|
HC SOM FISH MDS LOCUS ANOMALIES
|
Facility
OP
|
$150.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
900912610
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$21.25 |
| Max. Negotiated Rate |
$156.37 |
| Rate for Payer: Adventist Health Commercial |
$30.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$61.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$103.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$127.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$82.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$112.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$156.37
|
| Rate for Payer: Blue Shield of California Commercial |
$93.15
|
| Rate for Payer: Blue Shield of California EPN |
$88.05
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$97.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$127.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$127.50
|
| Rate for Payer: Dignity Health Senior |
$127.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$92.85
|
| Rate for Payer: Heritage Provider Network Senior |
$92.85
|
| Rate for Payer: IEHP Medi-Cal |
$21.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$72.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.50
|
| Rate for Payer: Multiplan Commercial |
$112.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$36.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$127.50
|
| Rate for Payer: Vantage Medical Group Senior |
$127.50
|
|
|
HC SOM FISH MDS LOCUS ANOMALIES
|
Facility
IP
|
$150.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
900912610
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$27.15 |
| Max. Negotiated Rate |
$112.50 |
| Rate for Payer: Adventist Health Commercial |
$30.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$103.05
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$101.55
|
| Rate for Payer: Heritage Provider Network Senior |
$101.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.50
|
| Rate for Payer: Multiplan Commercial |
$112.50
|
|
|
HC SOM FISH NEWBORN ANEUPLOIDY DETECT
|
Facility
IP
|
$200.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
900910685
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$36.20 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Adventist Health Commercial |
$40.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$137.40
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$135.40
|
| Rate for Payer: Heritage Provider Network Senior |
$135.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.00
|
| Rate for Payer: Multiplan Commercial |
$150.00
|
|
|
HC SOM FISH NEWBORN ANEUPLOIDY DETECT
|
Facility
OP
|
$200.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
900910685
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$21.25 |
| Max. Negotiated Rate |
$170.00 |
| Rate for Payer: Adventist Health Commercial |
$40.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$61.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$137.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$170.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$110.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$150.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$156.37
|
| Rate for Payer: Blue Shield of California Commercial |
$124.20
|
| Rate for Payer: Blue Shield of California EPN |
$117.40
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$130.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$170.00
|
| Rate for Payer: Dignity Health Senior |
$170.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$130.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$123.80
|
| Rate for Payer: Heritage Provider Network Senior |
$123.80
|
| Rate for Payer: IEHP Medi-Cal |
$21.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$96.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.00
|
| Rate for Payer: Multiplan Commercial |
$150.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$36.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$170.00
|
| Rate for Payer: Vantage Medical Group Senior |
$170.00
|
|
|
HC SOM FISH PRENATAL ANEUPLOIDY DETEC
|
Facility
OP
|
$225.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
900910689
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$21.25 |
| Max. Negotiated Rate |
$191.25 |
| Rate for Payer: Adventist Health Commercial |
$45.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$61.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$154.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$191.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$123.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$168.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$156.37
|
| Rate for Payer: Blue Shield of California Commercial |
$139.72
|
| Rate for Payer: Blue Shield of California EPN |
$132.08
|
| Rate for Payer: Cash Price |
$101.25
|
| Rate for Payer: Cash Price |
$101.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$146.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$191.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$191.25
|
| Rate for Payer: Dignity Health Senior |
$191.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$146.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$139.28
|
| Rate for Payer: Heritage Provider Network Senior |
$139.28
|
| Rate for Payer: IEHP Medi-Cal |
$21.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$108.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.25
|
| Rate for Payer: Multiplan Commercial |
$168.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$36.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$191.25
|
| Rate for Payer: Vantage Medical Group Senior |
$191.25
|
|
|
HC SOM FISH PRENATAL ANEUPLOIDY DETEC
|
Facility
IP
|
$225.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
900910689
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$40.72 |
| Max. Negotiated Rate |
$168.75 |
| Rate for Payer: Adventist Health Commercial |
$45.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$154.58
|
| Rate for Payer: Cash Price |
$101.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$152.32
|
| Rate for Payer: Heritage Provider Network Senior |
$152.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.25
|
| Rate for Payer: Multiplan Commercial |
$168.75
|
|
|
HC SOM FISH UROTHELIAL CANCER
|
Facility
IP
|
$440.00
|
|
|
Service Code
|
CPT 88120
|
| Hospital Charge Code |
900910694
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$79.64 |
| Max. Negotiated Rate |
$330.00 |
| Rate for Payer: Adventist Health Commercial |
$88.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$302.28
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$297.88
|
| Rate for Payer: Heritage Provider Network Senior |
$297.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$79.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$110.00
|
| Rate for Payer: Multiplan Commercial |
$330.00
|
|
|
HC SOM FISH UROTHELIAL CANCER
|
Facility
OP
|
$440.00
|
|
|
Service Code
|
CPT 88120
|
| Hospital Charge Code |
900910694
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$79.64 |
| Max. Negotiated Rate |
$2,426.36 |
| Rate for Payer: Adventist Health Commercial |
$88.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$899.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$302.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$320.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$234.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$213.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,426.36
|
| Rate for Payer: Blue Shield of California Commercial |
$273.24
|
| Rate for Payer: Blue Shield of California EPN |
$258.28
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$286.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$320.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$234.75
|
| Rate for Payer: Dignity Health Senior |
$213.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$286.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$213.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$272.36
|
| Rate for Payer: Heritage Provider Network Senior |
$272.36
|
| Rate for Payer: Humana Medicare |
$213.41
|
| Rate for Payer: IEHP Medi-Cal |
$566.92
|
| Rate for Payer: IEHP Medicare Advantage |
$213.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$405.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$79.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$251.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$110.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$268.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$268.90
|
| Rate for Payer: Multiplan Commercial |
$330.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$213.41
|
| Rate for Payer: TriValley Medical Group Senior |
$213.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$164.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$164.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$320.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$234.75
|
| Rate for Payer: Vantage Medical Group Senior |
$213.41
|
|
|
HC SOM FLECAINIDE ACETATE
|
Facility
OP
|
$50.00
|
|
|
Service Code
|
CPT 80181
|
| Hospital Charge Code |
900910551
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$104.20 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$38.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.35
|
| 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 |
$55.22
|
| Rate for Payer: Blue Shield of California Commercial |
$104.20
|
| Rate for Payer: Blue Shield of California EPN |
$81.46
|
| 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 |
$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 |
$32.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.95
|
| Rate for Payer: Heritage Provider Network Senior |
$30.95
|
| Rate for Payer: Humana Medicare |
$18.64
|
| Rate for Payer: IEHP Medi-Cal |
$23.26
|
| 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 |
$9.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.50
|
| 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 |
$37.50
|
| 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
|
|
|
HC SOM FLECAINIDE ACETATE
|
Facility
IP
|
$50.00
|
|
|
Service Code
|
CPT 80181
|
| Hospital Charge Code |
900910551
|
|
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 FLEXERIL
|
Facility
OP
|
$69.57
|
|
|
Service Code
|
CPT 80369
|
| Hospital Charge Code |
900911448
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$141.50 |
| Rate for Payer: Adventist Health Commercial |
$13.91
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$47.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$59.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$38.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$52.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$141.50
|
| Rate for Payer: Cash Price |
$31.31
|
| Rate for Payer: Cash Price |
$31.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$45.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$59.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$59.13
|
| Rate for Payer: Dignity Health Senior |
$59.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$43.06
|
| Rate for Payer: Heritage Provider Network Senior |
$43.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$33.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.39
|
| Rate for Payer: Multiplan Commercial |
$52.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$59.13
|
| Rate for Payer: Vantage Medical Group Senior |
$59.13
|
|
|
HC SOM FLEXERIL
|
Facility
IP
|
$69.57
|
|
|
Service Code
|
CPT 80369
|
| Hospital Charge Code |
900911448
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.59 |
| Max. Negotiated Rate |
$52.18 |
| Rate for Payer: Adventist Health Commercial |
$13.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$47.79
|
| Rate for Payer: Cash Price |
$31.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$47.10
|
| Rate for Payer: Heritage Provider Network Senior |
$47.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.39
|
| Rate for Payer: Multiplan Commercial |
$52.18
|
|
|
HC SOM FLT3 D835 INTERP
|
Facility
OP
|
$162.50
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
900914513
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$121.88 |
| Rate for Payer: Adventist Health Commercial |
$32.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$23.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$111.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$67.56
|
| Rate for Payer: Blue Shield of California Commercial |
$63.11
|
| Rate for Payer: Blue Shield of California EPN |
$49.34
|
| Rate for Payer: Cash Price |
$73.13
|
| Rate for Payer: Cash Price |
$73.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$105.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.89
|
| Rate for Payer: Dignity Health Senior |
$8.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$105.62
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$100.59
|
| Rate for Payer: Heritage Provider Network Senior |
$100.59
|
| Rate for Payer: Humana Medicare |
$8.08
|
| Rate for Payer: IEHP Medi-Cal |
$10.37
|
| Rate for Payer: IEHP Medicare Advantage |
$8.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.18
|
| Rate for Payer: Multiplan Commercial |
$121.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.08
|
| Rate for Payer: TriValley Medical Group Senior |
$8.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.89
|
| Rate for Payer: Vantage Medical Group Senior |
$8.08
|
|
|
HC SOM FLT3 D835 INTERP
|
Facility
IP
|
$162.50
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
900914513
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$29.41 |
| Max. Negotiated Rate |
$121.88 |
| Rate for Payer: Adventist Health Commercial |
$32.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$111.64
|
| Rate for Payer: Cash Price |
$73.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$110.01
|
| Rate for Payer: Heritage Provider Network Senior |
$110.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.62
|
| Rate for Payer: Multiplan Commercial |
$121.88
|
|
|
HC SOM FLT 3 & D835 VARIANT DET
|
Facility
IP
|
$165.00
|
|
|
Service Code
|
CPT 81245
|
| Hospital Charge Code |
900912984
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$29.86 |
| Max. Negotiated Rate |
$123.75 |
| Rate for Payer: Adventist Health Commercial |
$33.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$113.36
|
| Rate for Payer: Cash Price |
$74.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$111.70
|
| Rate for Payer: Heritage Provider Network Senior |
$111.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.25
|
| Rate for Payer: Multiplan Commercial |
$123.75
|
|
|
HC SOM FLT 3 & D835 VARIANT DET
|
Facility
OP
|
$165.00
|
|
|
Service Code
|
CPT 81245
|
| Hospital Charge Code |
900912984
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$29.86 |
| Max. Negotiated Rate |
$524.46 |
| Rate for Payer: Adventist Health Commercial |
$33.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$115.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$113.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$248.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$182.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$165.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$524.46
|
| Rate for Payer: Blue Shield of California Commercial |
$102.46
|
| Rate for Payer: Blue Shield of California EPN |
$96.86
|
| Rate for Payer: Cash Price |
$74.25
|
| Rate for Payer: Cash Price |
$74.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$107.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$248.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$182.06
|
| Rate for Payer: Dignity Health Senior |
$165.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$165.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$102.14
|
| Rate for Payer: Heritage Provider Network Senior |
$102.14
|
| Rate for Payer: Humana Medicare |
$165.51
|
| Rate for Payer: IEHP Medi-Cal |
$206.54
|
| Rate for Payer: IEHP Medicare Advantage |
$165.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$314.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$195.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$208.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$208.54
|
| Rate for Payer: Multiplan Commercial |
$123.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$165.51
|
| Rate for Payer: TriValley Medical Group Senior |
$165.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$178.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$178.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$248.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$182.06
|
| Rate for Payer: Vantage Medical Group Senior |
$165.51
|
|
|
HC SOM FLUORIDE BLOOD
|
Facility
OP
|
$59.35
|
|
|
Service Code
|
CPT 82735
|
| Hospital Charge Code |
900911276
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.74 |
| Max. Negotiated Rate |
$155.19 |
| Rate for Payer: Adventist Health Commercial |
$11.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$53.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$27.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.39
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$155.19
|
| Rate for Payer: Blue Shield of California Commercial |
$144.84
|
| Rate for Payer: Blue Shield of California EPN |
$113.23
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.39
|
| Rate for Payer: Dignity Health Senior |
$18.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.58
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$36.74
|
| Rate for Payer: Heritage Provider Network Senior |
$36.74
|
| Rate for Payer: Humana Medicare |
$18.54
|
| Rate for Payer: IEHP Medi-Cal |
$25.71
|
| Rate for Payer: IEHP Medicare Advantage |
$18.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$35.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.36
|
| Rate for Payer: Multiplan Commercial |
$44.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.54
|
| Rate for Payer: TriValley Medical Group Senior |
$18.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.39
|
| Rate for Payer: Vantage Medical Group Senior |
$18.54
|
|
|
HC SOM FLUORIDE BLOOD
|
Facility
IP
|
$59.35
|
|
|
Service Code
|
CPT 82735
|
| Hospital Charge Code |
900911276
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.74 |
| Max. Negotiated Rate |
$44.51 |
| Rate for Payer: Adventist Health Commercial |
$11.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.77
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.18
|
| Rate for Payer: Heritage Provider Network Senior |
$40.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.84
|
| Rate for Payer: Multiplan Commercial |
$44.51
|
|
|
HC SOM FLUOXETINE
|
Facility
OP
|
$55.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
900911433
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.96 |
| Max. Negotiated Rate |
$121.89 |
| Rate for Payer: Adventist Health Commercial |
$11.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$38.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.78
|
| 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 |
$24.75
|
| Rate for Payer: Cash Price |
$24.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$35.75
|
| 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 |
$35.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.04
|
| Rate for Payer: Heritage Provider Network Senior |
$34.04
|
| 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 |
$9.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.75
|
| 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 |
$41.25
|
| 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
|
|
|
HC SOM FLUOXETINE
|
Facility
IP
|
$55.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
900911433
|
|
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 FLUPHENAZINE
|
Facility
OP
|
$85.63
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
900911432
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$125.04 |
| Rate for Payer: Adventist Health Commercial |
$17.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$58.83
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$72.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$47.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$64.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$125.04
|
| Rate for Payer: Cash Price |
$38.53
|
| Rate for Payer: Cash Price |
$38.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$72.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$72.79
|
| Rate for Payer: Dignity Health Senior |
$72.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$55.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$53.00
|
| Rate for Payer: Heritage Provider Network Senior |
$53.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$41.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.41
|
| Rate for Payer: Multiplan Commercial |
$64.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$72.79
|
| Rate for Payer: Vantage Medical Group Senior |
$72.79
|
|
|
HC SOM FLUPHENAZINE
|
Facility
IP
|
$85.63
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
900911432
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$64.22 |
| Rate for Payer: Adventist Health Commercial |
$17.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$58.83
|
| Rate for Payer: Cash Price |
$38.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$57.97
|
| Rate for Payer: Heritage Provider Network Senior |
$57.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.41
|
| Rate for Payer: Multiplan Commercial |
$64.22
|
|
|
HC SOM FLURAZEPAM (DALMANE) LEVEL
|
Facility
IP
|
$25.00
|
|
|
Service Code
|
CPT 80346
|
| Hospital Charge Code |
900911084
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Adventist Health Commercial |
$5.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.18
|
| Rate for Payer: Cash Price |
$11.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.92
|
| Rate for Payer: Heritage Provider Network Senior |
$16.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.25
|
| Rate for Payer: Multiplan Commercial |
$18.75
|
|
|
HC SOM FLURAZEPAM (DALMANE) LEVEL
|
Facility
OP
|
$25.00
|
|
|
Service Code
|
CPT 80346
|
| Hospital Charge Code |
900911084
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$148.48 |
| Rate for Payer: Adventist Health Commercial |
$5.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$21.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$13.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$148.48
|
| Rate for Payer: Cash Price |
$11.25
|
| Rate for Payer: Cash Price |
$11.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.25
|
| Rate for Payer: Dignity Health Senior |
$21.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.48
|
| Rate for Payer: Heritage Provider Network Senior |
$15.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.25
|
| Rate for Payer: Multiplan Commercial |
$18.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.25
|
| Rate for Payer: Vantage Medical Group Senior |
$21.25
|
|
|
HC SOM FMGA 84181
|
Facility
IP
|
$125.00
|
|
|
Service Code
|
CPT 84181
|
| Hospital Charge Code |
900914770
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$22.62 |
| Max. Negotiated Rate |
$93.75 |
| Rate for Payer: Adventist Health Commercial |
$25.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$85.88
|
| Rate for Payer: Cash Price |
$56.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$84.62
|
| Rate for Payer: Heritage Provider Network Senior |
$84.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.25
|
| Rate for Payer: Multiplan Commercial |
$93.75
|
|
