|
HC SOM DESMOGLEIN 3
|
Facility
IP
|
$55.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
900914662
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.96 |
| Max. Negotiated Rate |
$41.25 |
| Rate for Payer: Adventist Health Commercial |
$11.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.78
|
| Rate for Payer: Cash Price |
$24.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.24
|
| Rate for Payer: Heritage Provider Network Senior |
$37.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.75
|
| Rate for Payer: Multiplan Commercial |
$41.25
|
|
|
HC SOM DESYREL (TRAZODONE)
|
Facility
OP
|
$24.45
|
|
|
Service Code
|
CPT 80338
|
| Hospital Charge Code |
900911223
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$143.70 |
| Rate for Payer: Adventist Health Commercial |
$4.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$20.78
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$13.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$143.70
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.78
|
| Rate for Payer: Dignity Health Senior |
$20.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.13
|
| Rate for Payer: Heritage Provider Network Senior |
$15.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.11
|
| Rate for Payer: Multiplan Commercial |
$18.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.78
|
| Rate for Payer: Vantage Medical Group Senior |
$20.78
|
|
|
HC SOM DESYREL (TRAZODONE)
|
Facility
IP
|
$24.45
|
|
|
Service Code
|
CPT 80338
|
| Hospital Charge Code |
900911223
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$18.34 |
| Rate for Payer: Adventist Health Commercial |
$4.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.80
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.55
|
| Rate for Payer: Heritage Provider Network Senior |
$16.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.11
|
| Rate for Payer: Multiplan Commercial |
$18.34
|
|
|
HC SOM DHEA
|
Facility
OP
|
$18.58
|
|
|
Service Code
|
CPT 82626
|
| Hospital Charge Code |
900911115
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.36 |
| Max. Negotiated Rate |
$211.54 |
| Rate for Payer: Adventist Health Commercial |
$3.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$73.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$37.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$27.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$211.54
|
| Rate for Payer: Blue Shield of California Commercial |
$197.38
|
| Rate for Payer: Blue Shield of California EPN |
$154.30
|
| Rate for Payer: Cash Price |
$8.36
|
| Rate for Payer: Cash Price |
$8.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$37.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.80
|
| Rate for Payer: Dignity Health Senior |
$25.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.08
|
| Rate for Payer: EPIC Health Plan Medicare |
$25.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.50
|
| Rate for Payer: Heritage Provider Network Senior |
$11.50
|
| Rate for Payer: Humana Medicare |
$25.27
|
| Rate for Payer: IEHP Medi-Cal |
$35.05
|
| Rate for Payer: IEHP Medicare Advantage |
$25.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$48.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$31.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$31.84
|
| Rate for Payer: Multiplan Commercial |
$13.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$25.27
|
| Rate for Payer: TriValley Medical Group Senior |
$25.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$37.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.80
|
| Rate for Payer: Vantage Medical Group Senior |
$25.27
|
|
|
HC SOM DHEA
|
Facility
IP
|
$18.58
|
|
|
Service Code
|
CPT 82626
|
| Hospital Charge Code |
900911115
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.36 |
| Max. Negotiated Rate |
$13.94 |
| Rate for Payer: Adventist Health Commercial |
$3.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.76
|
| Rate for Payer: Cash Price |
$8.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.58
|
| Rate for Payer: Heritage Provider Network Senior |
$12.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.64
|
| Rate for Payer: Multiplan Commercial |
$13.94
|
|
|
HC SOM DIABETES MELLITUS TYPE1 EV
|
Facility
OP
|
$16.00
|
|
|
Service Code
|
CPT 86337
|
| Hospital Charge Code |
900912904
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$167.25 |
| Rate for Payer: Adventist Health Commercial |
$3.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$62.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$32.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$23.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$21.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$152.15
|
| Rate for Payer: Blue Shield of California Commercial |
$167.25
|
| Rate for Payer: Blue Shield of California EPN |
$130.75
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.55
|
| Rate for Payer: Dignity Health Senior |
$21.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$21.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.90
|
| Rate for Payer: Heritage Provider Network Senior |
$9.90
|
| Rate for Payer: Humana Medicare |
$21.41
|
| Rate for Payer: IEHP Medi-Cal |
$29.69
|
| Rate for Payer: IEHP Medicare Advantage |
$21.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$40.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$25.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$26.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$26.98
|
| Rate for Payer: Multiplan Commercial |
$12.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$21.41
|
| Rate for Payer: TriValley Medical Group Senior |
$21.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$32.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.55
|
| Rate for Payer: Vantage Medical Group Senior |
$21.41
|
|
|
HC SOM DIABETES MELLITUS TYPE1 EV
|
Facility
IP
|
$16.00
|
|
|
Service Code
|
CPT 86337
|
| Hospital Charge Code |
900912904
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Adventist Health Commercial |
$3.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.99
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.83
|
| Rate for Payer: Heritage Provider Network Senior |
$10.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.00
|
| Rate for Payer: Multiplan Commercial |
$12.00
|
|
|
HC SOM DIAZEPAM (VALIUM)
|
Facility
IP
|
$26.49
|
|
|
Service Code
|
CPT 80346
|
| Hospital Charge Code |
900911088
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.79 |
| Max. Negotiated Rate |
$19.87 |
| Rate for Payer: Adventist Health Commercial |
$5.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.20
|
| Rate for Payer: Cash Price |
$11.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.93
|
| Rate for Payer: Heritage Provider Network Senior |
$17.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.62
|
| Rate for Payer: Multiplan Commercial |
$19.87
|
|
|
HC SOM DIAZEPAM (VALIUM)
|
Facility
OP
|
$26.49
|
|
|
Service Code
|
CPT 80346
|
| Hospital Charge Code |
900911088
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$148.48 |
| Rate for Payer: Adventist Health Commercial |
$5.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$22.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.57
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$19.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$148.48
|
| Rate for Payer: Cash Price |
$11.92
|
| Rate for Payer: Cash Price |
$11.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.52
|
| Rate for Payer: Dignity Health Senior |
$22.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.40
|
| Rate for Payer: Heritage Provider Network Senior |
$16.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.62
|
| Rate for Payer: Multiplan Commercial |
$19.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.52
|
| Rate for Payer: Vantage Medical Group Senior |
$22.52
|
|
|
HC SOM DIHYDROTESTERONE
|
Facility
IP
|
$41.00
|
|
|
Service Code
|
CPT 82642
|
| Hospital Charge Code |
900911013
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.42 |
| Max. Negotiated Rate |
$30.75 |
| Rate for Payer: Adventist Health Commercial |
$8.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.17
|
| Rate for Payer: Cash Price |
$18.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.76
|
| Rate for Payer: Heritage Provider Network Senior |
$27.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.25
|
| Rate for Payer: Multiplan Commercial |
$30.75
|
|
|
HC SOM DIHYDROTESTERONE
|
Facility
OP
|
$41.00
|
|
|
Service Code
|
CPT 82642
|
| Hospital Charge Code |
900911013
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.42 |
| Max. Negotiated Rate |
$181.84 |
| Rate for Payer: Adventist Health Commercial |
$8.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$67.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$43.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$32.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$29.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$169.28
|
| Rate for Payer: Blue Shield of California Commercial |
$181.84
|
| Rate for Payer: Blue Shield of California EPN |
$142.16
|
| Rate for Payer: Cash Price |
$18.45
|
| Rate for Payer: Cash Price |
$18.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$26.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$43.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.21
|
| Rate for Payer: Dignity Health Senior |
$29.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.65
|
| Rate for Payer: EPIC Health Plan Medicare |
$29.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.38
|
| Rate for Payer: Heritage Provider Network Senior |
$25.38
|
| Rate for Payer: Humana Medicare |
$29.28
|
| Rate for Payer: IEHP Medi-Cal |
$40.59
|
| Rate for Payer: IEHP Medicare Advantage |
$29.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$55.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$34.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$36.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$36.89
|
| Rate for Payer: Multiplan Commercial |
$30.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$29.28
|
| Rate for Payer: TriValley Medical Group Senior |
$29.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$31.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$43.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.21
|
| Rate for Payer: Vantage Medical Group Senior |
$29.28
|
|
|
HC SOM DILANTIN FREE
|
Facility
IP
|
$20.00
|
|
|
Service Code
|
CPT 80186
|
| Hospital Charge Code |
900911414
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.74
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.54
|
| Rate for Payer: Heritage Provider Network Senior |
$13.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$15.00
|
|
|
HC SOM DILANTIN FREE
|
Facility
OP
|
$20.00
|
|
|
Service Code
|
CPT 80186
|
| Hospital Charge Code |
900911414
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$117.32 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$40.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$20.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$117.32
|
| Rate for Payer: Blue Shield of California Commercial |
$107.50
|
| Rate for Payer: Blue Shield of California EPN |
$84.04
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.14
|
| Rate for Payer: Dignity Health Senior |
$13.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.38
|
| Rate for Payer: Heritage Provider Network Senior |
$12.38
|
| Rate for Payer: Humana Medicare |
$13.76
|
| Rate for Payer: IEHP Medi-Cal |
$19.08
|
| Rate for Payer: IEHP Medicare Advantage |
$13.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$26.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$16.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.34
|
| Rate for Payer: Multiplan Commercial |
$15.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.76
|
| Rate for Payer: TriValley Medical Group Senior |
$13.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.14
|
| Rate for Payer: Vantage Medical Group Senior |
$13.76
|
|
|
HC SOM DILANTIN LV FREE PHENY TOT
|
Facility
IP
|
$20.00
|
|
|
Service Code
|
CPT 80185
|
| Hospital Charge Code |
900912809
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.74
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.54
|
| Rate for Payer: Heritage Provider Network Senior |
$13.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$15.00
|
|
|
HC SOM DILANTIN LV FREE PHENY TOT
|
Facility
OP
|
$20.00
|
|
|
Service Code
|
CPT 80185
|
| Hospital Charge Code |
900912809
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$110.96 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$38.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$19.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$110.96
|
| Rate for Payer: Blue Shield of California Commercial |
$103.53
|
| Rate for Payer: Blue Shield of California EPN |
$80.93
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.58
|
| Rate for Payer: Dignity Health Senior |
$13.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.38
|
| Rate for Payer: Heritage Provider Network Senior |
$12.38
|
| Rate for Payer: Humana Medicare |
$13.25
|
| Rate for Payer: IEHP Medi-Cal |
$18.38
|
| Rate for Payer: IEHP Medicare Advantage |
$13.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$25.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.70
|
| Rate for Payer: Multiplan Commercial |
$15.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.25
|
| Rate for Payer: TriValley Medical Group Senior |
$13.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.58
|
| Rate for Payer: Vantage Medical Group Senior |
$13.25
|
|
|
HC SOM DIPHTHERIA ANTITOXOID (ELISA)
|
Facility
OP
|
$35.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
900911755
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.34 |
| Max. Negotiated Rate |
$125.49 |
| Rate for Payer: Adventist Health Commercial |
$7.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$22.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$16.49
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$125.49
|
| Rate for Payer: Blue Shield of California Commercial |
$117.11
|
| Rate for Payer: Blue Shield of California EPN |
$91.55
|
| Rate for Payer: Cash Price |
$15.75
|
| Rate for Payer: Cash Price |
$15.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.49
|
| Rate for Payer: Dignity Health Senior |
$14.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$14.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.66
|
| Rate for Payer: Heritage Provider Network Senior |
$21.66
|
| Rate for Payer: Humana Medicare |
$14.99
|
| Rate for Payer: IEHP Medi-Cal |
$16.36
|
| Rate for Payer: IEHP Medicare Advantage |
$14.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$28.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.89
|
| Rate for Payer: Multiplan Commercial |
$26.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.99
|
| Rate for Payer: TriValley Medical Group Senior |
$14.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.49
|
| Rate for Payer: Vantage Medical Group Senior |
$14.99
|
|
|
HC SOM DIPHTHERIA ANTITOXOID (ELISA)
|
Facility
IP
|
$35.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
900911755
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.34 |
| Max. Negotiated Rate |
$26.25 |
| Rate for Payer: Adventist Health Commercial |
$7.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.04
|
| Rate for Payer: Cash Price |
$15.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.70
|
| Rate for Payer: Heritage Provider Network Senior |
$23.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.75
|
| Rate for Payer: Multiplan Commercial |
$26.25
|
|
|
HC SOM DNA EXTRACTION
|
Facility
OP
|
$203.61
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
900910721
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$36.85 |
| Max. Negotiated Rate |
$264.85 |
| Rate for Payer: Adventist Health Commercial |
$40.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$94.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$139.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$205.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$150.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$137.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$264.85
|
| Rate for Payer: Blue Shield of California Commercial |
$126.44
|
| Rate for Payer: Blue Shield of California EPN |
$119.52
|
| Rate for Payer: Cash Price |
$91.62
|
| Rate for Payer: Cash Price |
$91.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$132.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$205.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$150.70
|
| Rate for Payer: Dignity Health Senior |
$137.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$132.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$137.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$126.03
|
| Rate for Payer: Heritage Provider Network Senior |
$126.03
|
| Rate for Payer: Humana Medicare |
$137.00
|
| Rate for Payer: IEHP Medi-Cal |
$213.72
|
| Rate for Payer: IEHP Medicare Advantage |
$137.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$260.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$161.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$172.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$172.62
|
| Rate for Payer: Multiplan Commercial |
$152.71
|
| Rate for Payer: TriValley Medical Group Commercial |
$137.00
|
| Rate for Payer: TriValley Medical Group Senior |
$137.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$147.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$147.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$205.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$150.70
|
| Rate for Payer: Vantage Medical Group Senior |
$137.00
|
|
|
HC SOM DNA EXTRACTION
|
Facility
IP
|
$203.61
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
900910721
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$36.85 |
| Max. Negotiated Rate |
$152.71 |
| Rate for Payer: Adventist Health Commercial |
$40.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$139.88
|
| Rate for Payer: Cash Price |
$91.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$137.84
|
| Rate for Payer: Heritage Provider Network Senior |
$137.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.90
|
| Rate for Payer: Multiplan Commercial |
$152.71
|
|
|
HC SOM DRUG SCREEN PRESCRIPTION/OTC U
|
Facility
IP
|
$47.95
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900912877
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$35.96 |
| Rate for Payer: Adventist Health Commercial |
$9.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.94
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.46
|
| Rate for Payer: Heritage Provider Network Senior |
$32.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$35.96
|
|
|
HC SOM DRUG SCREEN PRESCRIPTION/OTC U
|
Facility
OP
|
$47.95
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900912877
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$515.78 |
| Rate for Payer: Adventist Health Commercial |
$9.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$165.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$62.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$515.78
|
| Rate for Payer: Blue Shield of California Commercial |
$446.14
|
| Rate for Payer: Blue Shield of California EPN |
$348.77
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$93.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.35
|
| Rate for Payer: Dignity Health Senior |
$62.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.17
|
| Rate for Payer: EPIC Health Plan Medicare |
$62.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.68
|
| Rate for Payer: Heritage Provider Network Senior |
$29.68
|
| Rate for Payer: Humana Medicare |
$62.14
|
| Rate for Payer: IEHP Medi-Cal |
$67.86
|
| Rate for Payer: IEHP Medicare Advantage |
$62.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$118.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$73.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$78.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78.30
|
| Rate for Payer: Multiplan Commercial |
$35.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$62.14
|
| Rate for Payer: TriValley Medical Group Senior |
$62.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$67.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$67.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: Vantage Medical Group Senior |
$62.14
|
|
|
HC SOM DRUG SCRN MECONIUM AMPHETAMINE
|
Facility
IP
|
$50.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900911008
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$37.50 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.35
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.85
|
| Rate for Payer: Heritage Provider Network Senior |
$33.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.50
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
|
|
HC SOM DRUG SCRN MECONIUM AMPHETAMINE
|
Facility
OP
|
$50.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900911008
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$515.78 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$165.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$62.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$515.78
|
| Rate for Payer: Blue Shield of California Commercial |
$446.14
|
| Rate for Payer: Blue Shield of California EPN |
$348.77
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$93.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.35
|
| Rate for Payer: Dignity Health Senior |
$62.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$62.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.95
|
| Rate for Payer: Heritage Provider Network Senior |
$30.95
|
| Rate for Payer: Humana Medicare |
$62.14
|
| Rate for Payer: IEHP Medi-Cal |
$67.86
|
| Rate for Payer: IEHP Medicare Advantage |
$62.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$118.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$73.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$78.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78.30
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$62.14
|
| Rate for Payer: TriValley Medical Group Senior |
$62.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$67.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$67.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: Vantage Medical Group Senior |
$62.14
|
|
|
HC SOM DULOX 80299
|
Facility
IP
|
$45.63
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
900914748
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.26 |
| Max. Negotiated Rate |
$34.22 |
| Rate for Payer: Adventist Health Commercial |
$9.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.35
|
| Rate for Payer: Cash Price |
$20.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.89
|
| Rate for Payer: Heritage Provider Network Senior |
$30.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.41
|
| Rate for Payer: Multiplan Commercial |
$34.22
|
|
|
HC SOM DULOX 80299
|
Facility
OP
|
$45.63
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
900914748
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.26 |
| Max. Negotiated Rate |
$121.89 |
| Rate for Payer: Adventist Health Commercial |
$9.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$38.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$27.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$121.89
|
| Rate for Payer: Blue Shield of California Commercial |
$106.94
|
| Rate for Payer: Blue Shield of California EPN |
$83.60
|
| Rate for Payer: Cash Price |
$20.53
|
| Rate for Payer: Cash Price |
$20.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.50
|
| Rate for Payer: Dignity Health Senior |
$18.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.66
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.24
|
| Rate for Payer: Heritage Provider Network Senior |
$28.24
|
| Rate for Payer: Humana Medicare |
$18.64
|
| Rate for Payer: IEHP Medi-Cal |
$19.64
|
| Rate for Payer: IEHP Medicare Advantage |
$18.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$35.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.49
|
| Rate for Payer: Multiplan Commercial |
$34.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.64
|
| Rate for Payer: TriValley Medical Group Senior |
$18.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.50
|
| Rate for Payer: Vantage Medical Group Senior |
$18.64
|
|
