|
HC SOM FMIS 83520
|
Facility
|
OP
|
$177.73
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
900914924
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.59 |
| Max. Negotiated Rate |
$133.30 |
| Rate for Payer: Adventist Health Commercial |
$35.55
|
| Rate for Payer: Aetna of CA Gatekeeper |
$95.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$122.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$118.19
|
| Rate for Payer: Blue Shield of California Commercial |
$104.20
|
| Rate for Payer: Blue Shield of California EPN |
$83.58
|
| Rate for Payer: Cash Price |
$177.73
|
| Rate for Payer: Cash Price |
$177.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$115.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.00
|
| Rate for Payer: Dignity Health Senior |
$17.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$115.52
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$110.01
|
| Rate for Payer: Heritage Provider Network Senior |
$110.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$84.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.76
|
| Rate for Payer: Multiplan Commercial |
$133.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.27
|
| Rate for Payer: TriValley Medical Group Senior |
$17.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.00
|
| Rate for Payer: Vantage Medical Group Senior |
$17.27
|
|
|
HC SOM FMIS 83520
|
Facility
|
IP
|
$177.73
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
900914924
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$32.17 |
| Max. Negotiated Rate |
$133.30 |
| Rate for Payer: Adventist Health Commercial |
$35.55
|
| Rate for Payer: Cash Price |
$177.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$120.32
|
| Rate for Payer: Heritage Provider Network Senior |
$120.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.43
|
| Rate for Payer: Multiplan Commercial |
$133.30
|
|
|
HC SOM FNTSM
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900914870
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.68 |
| Max. Negotiated Rate |
$131.25 |
| Rate for Payer: Adventist Health Commercial |
$35.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$118.47
|
| Rate for Payer: Heritage Provider Network Senior |
$118.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.75
|
| Rate for Payer: Multiplan Commercial |
$131.25
|
|
|
HC SOM FNTSM
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900914870
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$24.09 |
| Max. Negotiated Rate |
$164.17 |
| Rate for Payer: Adventist Health Commercial |
$35.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$93.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$120.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$164.17
|
| Rate for Payer: Blue Shield of California Commercial |
$145.32
|
| Rate for Payer: Blue Shield of California EPN |
$116.56
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$113.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.50
|
| Rate for Payer: Dignity Health Senior |
$24.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$113.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$24.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$108.33
|
| Rate for Payer: Heritage Provider Network Senior |
$108.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$24.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$83.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$27.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$30.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$30.35
|
| Rate for Payer: Multiplan Commercial |
$131.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.09
|
| Rate for Payer: TriValley Medical Group Senior |
$24.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Vantage Medical Group Senior |
$24.09
|
|
|
HC SOM FNTSM 82492A
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900914868
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.68 |
| Max. Negotiated Rate |
$131.25 |
| Rate for Payer: Adventist Health Commercial |
$35.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$118.47
|
| Rate for Payer: Heritage Provider Network Senior |
$118.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.75
|
| Rate for Payer: Multiplan Commercial |
$131.25
|
|
|
HC SOM FNTSM 82492A
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900914868
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$24.09 |
| Max. Negotiated Rate |
$164.17 |
| Rate for Payer: Adventist Health Commercial |
$35.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$93.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$120.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$164.17
|
| Rate for Payer: Blue Shield of California Commercial |
$145.32
|
| Rate for Payer: Blue Shield of California EPN |
$116.56
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$113.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.50
|
| Rate for Payer: Dignity Health Senior |
$24.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$113.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$24.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$108.33
|
| Rate for Payer: Heritage Provider Network Senior |
$108.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$24.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$83.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$27.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$30.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$30.35
|
| Rate for Payer: Multiplan Commercial |
$131.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.09
|
| Rate for Payer: TriValley Medical Group Senior |
$24.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Vantage Medical Group Senior |
$24.09
|
|
|
HC SOM FNTSM 82492B
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900914869
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$24.09 |
| Max. Negotiated Rate |
$164.17 |
| Rate for Payer: Adventist Health Commercial |
$35.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$93.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$120.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$164.17
|
| Rate for Payer: Blue Shield of California Commercial |
$145.32
|
| Rate for Payer: Blue Shield of California EPN |
$116.56
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$113.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.50
|
| Rate for Payer: Dignity Health Senior |
$24.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$113.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$24.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$108.33
|
| Rate for Payer: Heritage Provider Network Senior |
$108.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$24.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$83.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$27.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$30.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$30.35
|
| Rate for Payer: Multiplan Commercial |
$131.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.09
|
| Rate for Payer: TriValley Medical Group Senior |
$24.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Vantage Medical Group Senior |
$24.09
|
|
|
HC SOM FNTSM 82492B
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900914869
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.68 |
| Max. Negotiated Rate |
$131.25 |
| Rate for Payer: Adventist Health Commercial |
$35.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$118.47
|
| Rate for Payer: Heritage Provider Network Senior |
$118.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.75
|
| Rate for Payer: Multiplan Commercial |
$131.25
|
|
|
HC SOM FOLATE, RBC
|
Facility
|
OP
|
$52.50
|
|
|
Service Code
|
CPT 82747
|
| Hospital Charge Code |
900913862
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$163.92 |
| Rate for Payer: Adventist Health Commercial |
$10.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$28.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$36.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$163.92
|
| Rate for Payer: Blue Shield of California Commercial |
$139.39
|
| Rate for Payer: Blue Shield of California EPN |
$111.80
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$34.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.41
|
| Rate for Payer: Dignity Health Senior |
$17.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.12
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.50
|
| Rate for Payer: Heritage Provider Network Senior |
$32.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$25.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$20.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.24
|
| Rate for Payer: Multiplan Commercial |
$39.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.65
|
| Rate for Payer: TriValley Medical Group Senior |
$17.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.41
|
| Rate for Payer: Vantage Medical Group Senior |
$17.65
|
|
|
HC SOM FOLATE, RBC
|
Facility
|
IP
|
$52.50
|
|
|
Service Code
|
CPT 82747
|
| Hospital Charge Code |
900913862
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$39.38 |
| Rate for Payer: Adventist Health Commercial |
$10.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.54
|
| Rate for Payer: Heritage Provider Network Senior |
$35.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.12
|
| Rate for Payer: Multiplan Commercial |
$39.38
|
|
|
HC SOM FPRSG 84150
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
CPT 84150
|
| Hospital Charge Code |
900914777
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$63.35 |
| Max. Negotiated Rate |
$262.50 |
| Rate for Payer: Adventist Health Commercial |
$70.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$236.95
|
| Rate for Payer: Heritage Provider Network Senior |
$236.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$87.50
|
| Rate for Payer: Multiplan Commercial |
$262.50
|
|
|
HC SOM FPRSG 84150
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
CPT 84150
|
| Hospital Charge Code |
900914777
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$41.77 |
| Max. Negotiated Rate |
$262.50 |
| Rate for Payer: Adventist Health Commercial |
$70.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$187.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$240.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$62.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$41.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$227.84
|
| Rate for Payer: Blue Shield of California Commercial |
$200.91
|
| Rate for Payer: Blue Shield of California EPN |
$161.15
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$227.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$62.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$45.95
|
| Rate for Payer: Dignity Health Senior |
$41.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$227.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$41.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$216.65
|
| Rate for Payer: Heritage Provider Network Senior |
$216.65
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$44.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$41.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$166.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$48.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$87.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$52.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$52.63
|
| Rate for Payer: Multiplan Commercial |
$262.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$41.77
|
| Rate for Payer: TriValley Medical Group Senior |
$41.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$45.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$62.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$45.95
|
| Rate for Payer: Vantage Medical Group Senior |
$41.77
|
|
|
HC SOM FPSAP 84153
|
Facility
|
OP
|
$89.50
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
900914765
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.20 |
| Max. Negotiated Rate |
$167.92 |
| Rate for Payer: Adventist Health Commercial |
$17.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$47.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$61.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$167.92
|
| Rate for Payer: Blue Shield of California Commercial |
$148.03
|
| Rate for Payer: Blue Shield of California EPN |
$118.73
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$58.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.23
|
| Rate for Payer: Dignity Health Senior |
$18.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.17
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.40
|
| Rate for Payer: Heritage Provider Network Senior |
$55.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$26.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$42.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.17
|
| Rate for Payer: Multiplan Commercial |
$67.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.39
|
| Rate for Payer: TriValley Medical Group Senior |
$18.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.23
|
| Rate for Payer: Vantage Medical Group Senior |
$18.39
|
|
|
HC SOM FPSAP 84153
|
Facility
|
IP
|
$89.50
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
900914765
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.20 |
| Max. Negotiated Rate |
$67.12 |
| Rate for Payer: Adventist Health Commercial |
$17.90
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.59
|
| Rate for Payer: Heritage Provider Network Senior |
$60.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.38
|
| Rate for Payer: Multiplan Commercial |
$67.12
|
|
|
HC SOM FQUET 82491
|
Facility
|
OP
|
$66.16
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900914892
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.97 |
| Max. Negotiated Rate |
$164.17 |
| Rate for Payer: Adventist Health Commercial |
$13.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$35.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$45.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$164.17
|
| Rate for Payer: Blue Shield of California Commercial |
$145.32
|
| Rate for Payer: Blue Shield of California EPN |
$116.56
|
| Rate for Payer: Cash Price |
$66.16
|
| Rate for Payer: Cash Price |
$66.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$43.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.50
|
| Rate for Payer: Dignity Health Senior |
$24.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$24.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.95
|
| Rate for Payer: Heritage Provider Network Senior |
$40.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$24.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$31.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$27.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$30.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$30.35
|
| Rate for Payer: Multiplan Commercial |
$49.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.09
|
| Rate for Payer: TriValley Medical Group Senior |
$24.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Vantage Medical Group Senior |
$24.09
|
|
|
HC SOM FQUET 82491
|
Facility
|
IP
|
$66.16
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900914892
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.97 |
| Max. Negotiated Rate |
$49.62 |
| Rate for Payer: Adventist Health Commercial |
$13.23
|
| Rate for Payer: Cash Price |
$66.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.79
|
| Rate for Payer: Heritage Provider Network Senior |
$44.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.54
|
| Rate for Payer: Multiplan Commercial |
$49.62
|
|
|
HC SOM FRAGILE X FU ANALYSIS
|
Facility
|
IP
|
$216.50
|
|
|
Service Code
|
CPT 81244
|
| Hospital Charge Code |
900915280
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$39.19 |
| Max. Negotiated Rate |
$162.38 |
| Rate for Payer: Adventist Health Commercial |
$43.30
|
| Rate for Payer: Cash Price |
$216.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$146.57
|
| Rate for Payer: Heritage Provider Network Senior |
$146.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54.12
|
| Rate for Payer: Multiplan Commercial |
$162.38
|
|
|
HC SOM FRAGILE X FU ANALYSIS
|
Facility
|
OP
|
$216.50
|
|
|
Service Code
|
CPT 81244
|
| Hospital Charge Code |
900915280
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$39.19 |
| Max. Negotiated Rate |
$179.47 |
| Rate for Payer: Adventist Health Commercial |
$43.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$115.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$148.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$67.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$49.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$44.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$179.47
|
| Rate for Payer: Blue Shield of California Commercial |
$132.06
|
| Rate for Payer: Blue Shield of California EPN |
$105.65
|
| Rate for Payer: Cash Price |
$216.50
|
| Rate for Payer: Cash Price |
$216.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$140.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$67.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$49.38
|
| Rate for Payer: Dignity Health Senior |
$44.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$140.72
|
| Rate for Payer: EPIC Health Plan Medicare |
$44.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$134.01
|
| Rate for Payer: Heritage Provider Network Senior |
$134.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$58.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$44.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$103.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$51.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$56.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$56.56
|
| Rate for Payer: Multiplan Commercial |
$162.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$44.89
|
| Rate for Payer: TriValley Medical Group Senior |
$44.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$48.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$48.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$67.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$49.38
|
| Rate for Payer: Vantage Medical Group Senior |
$44.89
|
|
|
HC SOM FRAGILE X MOLECULAR ANALYSIS
|
Facility
|
IP
|
$450.00
|
|
|
Service Code
|
CPT 81243
|
| Hospital Charge Code |
900912503
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$81.45 |
| Max. Negotiated Rate |
$337.50 |
| Rate for Payer: Adventist Health Commercial |
$90.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$304.65
|
| Rate for Payer: Heritage Provider Network Senior |
$304.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$112.50
|
| Rate for Payer: Multiplan Commercial |
$337.50
|
|
|
HC SOM FRAGILE X MOLECULAR ANALYSIS
|
Facility
|
OP
|
$450.00
|
|
|
Service Code
|
CPT 81243
|
| Hospital Charge Code |
900912503
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$57.04 |
| Max. Negotiated Rate |
$446.77 |
| Rate for Payer: Adventist Health Commercial |
$90.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$240.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$309.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$85.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$62.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$57.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$446.77
|
| Rate for Payer: Blue Shield of California Commercial |
$274.50
|
| Rate for Payer: Blue Shield of California EPN |
$219.60
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$292.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$62.74
|
| Rate for Payer: Dignity Health Senior |
$57.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$292.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$57.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$278.55
|
| Rate for Payer: Heritage Provider Network Senior |
$278.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$73.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$57.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$214.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$65.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$112.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$71.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$71.87
|
| Rate for Payer: Multiplan Commercial |
$337.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$57.04
|
| Rate for Payer: TriValley Medical Group Senior |
$57.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$61.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$61.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$85.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$62.74
|
| Rate for Payer: Vantage Medical Group Senior |
$57.04
|
|
|
HC SOM FRANSICELLA AB
|
Facility
|
IP
|
$47.50
|
|
|
Service Code
|
CPT 86000
|
| Hospital Charge Code |
900911647
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.60 |
| Max. Negotiated Rate |
$35.62 |
| Rate for Payer: Adventist Health Commercial |
$9.50
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.16
|
| Rate for Payer: Heritage Provider Network Senior |
$32.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.88
|
| Rate for Payer: Multiplan Commercial |
$35.62
|
|
|
HC SOM FRANSICELLA AB
|
Facility
|
OP
|
$47.50
|
|
|
Service Code
|
CPT 86000
|
| Hospital Charge Code |
900911647
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.98 |
| Max. Negotiated Rate |
$57.53 |
| Rate for Payer: Adventist Health Commercial |
$9.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$57.53
|
| Rate for Payer: Blue Shield of California Commercial |
$56.16
|
| Rate for Payer: Blue Shield of California EPN |
$45.05
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.68
|
| Rate for Payer: Dignity Health Senior |
$6.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.88
|
| Rate for Payer: EPIC Health Plan Medicare |
$6.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.40
|
| Rate for Payer: Heritage Provider Network Senior |
$29.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.79
|
| Rate for Payer: Multiplan Commercial |
$35.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.98
|
| Rate for Payer: TriValley Medical Group Senior |
$6.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.68
|
| Rate for Payer: Vantage Medical Group Senior |
$6.98
|
|
|
HC SOM FREE FATTY ACIDS
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
CPT 82725
|
| Hospital Charge Code |
900914522
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Adventist Health Commercial |
$6.40
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.66
|
| Rate for Payer: Heritage Provider Network Senior |
$21.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.00
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
|
|
HC SOM FREE FATTY ACIDS
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
CPT 82725
|
| Hospital Charge Code |
900914522
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$121.57 |
| Rate for Payer: Adventist Health Commercial |
$6.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$121.57
|
| Rate for Payer: Blue Shield of California Commercial |
$107.14
|
| Rate for Payer: Blue Shield of California EPN |
$85.93
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.65
|
| Rate for Payer: Dignity Health Senior |
$18.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.81
|
| Rate for Payer: Heritage Provider Network Senior |
$19.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.65
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.77
|
| Rate for Payer: TriValley Medical Group Senior |
$18.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.65
|
| Rate for Payer: Vantage Medical Group Senior |
$18.77
|
|
|
HC SOM FR TYR IDX BIND CAP
|
Facility
|
IP
|
$9.27
|
|
|
Service Code
|
CPT 84479
|
| Hospital Charge Code |
900912805
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$6.95 |
| Rate for Payer: Adventist Health Commercial |
$1.85
|
| Rate for Payer: Cash Price |
$9.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.28
|
| Rate for Payer: Heritage Provider Network Senior |
$6.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.32
|
| Rate for Payer: Multiplan Commercial |
$6.95
|
|
