|
HC SOM MGLES 83520
|
Facility
|
OP
|
$121.17
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
900914810
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$16.59 |
| Max. Negotiated Rate |
$118.19 |
| Rate for Payer: Adventist Health Commercial |
$24.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$64.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$83.24
|
| 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 |
$121.17
|
| Rate for Payer: Cash Price |
$121.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$78.76
|
| 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 |
$78.76
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.00
|
| Rate for Payer: Heritage Provider Network Senior |
$75.00
|
| 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 |
$57.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.93
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.29
|
| 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 |
$90.88
|
| 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 MGLES 83520
|
Facility
|
IP
|
$121.17
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
900914810
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$21.93 |
| Max. Negotiated Rate |
$90.88 |
| Rate for Payer: Adventist Health Commercial |
$24.23
|
| Rate for Payer: Cash Price |
$121.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$82.03
|
| Rate for Payer: Heritage Provider Network Senior |
$82.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.29
|
| Rate for Payer: Multiplan Commercial |
$90.88
|
|
|
HC SOM MICROSPORIDIA CULTURE
|
Facility
|
IP
|
$206.40
|
|
|
Service Code
|
CPT 87015
|
| Hospital Charge Code |
900912827
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$37.36 |
| Max. Negotiated Rate |
$154.80 |
| Rate for Payer: Adventist Health Commercial |
$41.28
|
| Rate for Payer: Cash Price |
$206.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$139.73
|
| Rate for Payer: Heritage Provider Network Senior |
$139.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$37.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.60
|
| Rate for Payer: Multiplan Commercial |
$154.80
|
|
|
HC SOM MICROSPORIDIA CULTURE
|
Facility
|
OP
|
$206.40
|
|
|
Service Code
|
CPT 87015
|
| Hospital Charge Code |
900912827
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$6.68 |
| Max. Negotiated Rate |
$154.80 |
| Rate for Payer: Adventist Health Commercial |
$41.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$110.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$141.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.97
|
| Rate for Payer: Blue Shield of California Commercial |
$53.74
|
| Rate for Payer: Blue Shield of California EPN |
$43.10
|
| Rate for Payer: Cash Price |
$206.40
|
| Rate for Payer: Cash Price |
$206.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$134.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.35
|
| Rate for Payer: Dignity Health Senior |
$6.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$134.16
|
| Rate for Payer: EPIC Health Plan Medicare |
$6.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$127.76
|
| Rate for Payer: Heritage Provider Network Senior |
$127.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$98.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$37.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.42
|
| Rate for Payer: Multiplan Commercial |
$154.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.68
|
| Rate for Payer: TriValley Medical Group Senior |
$6.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.35
|
| Rate for Payer: Vantage Medical Group Senior |
$6.68
|
|
|
HC SOM MICROSPORIDIA DETECTION
|
Facility
|
OP
|
$89.72
|
|
|
Service Code
|
CPT 87207
|
| Hospital Charge Code |
900911588
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$5.99 |
| Max. Negotiated Rate |
$67.29 |
| Rate for Payer: Adventist Health Commercial |
$17.94
|
| Rate for Payer: Aetna of CA Gatekeeper |
$47.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$61.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$54.70
|
| Rate for Payer: Blue Shield of California Commercial |
$48.21
|
| Rate for Payer: Blue Shield of California EPN |
$38.67
|
| Rate for Payer: Cash Price |
$89.72
|
| Rate for Payer: Cash Price |
$89.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$58.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.59
|
| Rate for Payer: Dignity Health Senior |
$5.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.32
|
| Rate for Payer: EPIC Health Plan Medicare |
$5.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.54
|
| Rate for Payer: Heritage Provider Network Senior |
$55.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$42.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.55
|
| Rate for Payer: Multiplan Commercial |
$67.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.99
|
| Rate for Payer: TriValley Medical Group Senior |
$5.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.59
|
| Rate for Payer: Vantage Medical Group Senior |
$5.99
|
|
|
HC SOM MICROSPORIDIA DETECTION
|
Facility
|
IP
|
$89.72
|
|
|
Service Code
|
CPT 87207
|
| Hospital Charge Code |
900911588
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$16.24 |
| Max. Negotiated Rate |
$67.29 |
| Rate for Payer: Adventist Health Commercial |
$17.94
|
| Rate for Payer: Cash Price |
$89.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.74
|
| Rate for Payer: Heritage Provider Network Senior |
$60.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.43
|
| Rate for Payer: Multiplan Commercial |
$67.29
|
|
|
HC SOM MILK PROCESSED IGE
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
900914157
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.22
|
| Rate for Payer: Heritage Provider Network Senior |
$3.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$3.56
|
|
|
HC SOM MILK PROCESSED IGE
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
900914157
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$144.32 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$144.32
|
| Rate for Payer: Blue Shield of California Commercial |
$42.05
|
| Rate for Payer: Blue Shield of California EPN |
$33.73
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.74
|
| Rate for Payer: Dignity Health Senior |
$5.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.09
|
| Rate for Payer: EPIC Health Plan Medicare |
$5.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.94
|
| Rate for Payer: Heritage Provider Network Senior |
$2.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.58
|
| Rate for Payer: Multiplan Commercial |
$3.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.22
|
| Rate for Payer: TriValley Medical Group Senior |
$5.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.74
|
| Rate for Payer: Vantage Medical Group Senior |
$5.22
|
|
|
HC SOM MIRA VISTA HC HISTOPLASMA AG
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
CPT 87385
|
| Hospital Charge Code |
900913883
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$25.34 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Adventist Health Commercial |
$28.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$94.78
|
| Rate for Payer: Heritage Provider Network Senior |
$94.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.00
|
| Rate for Payer: Multiplan Commercial |
$105.00
|
|
|
HC SOM MIRA VISTA HC HISTOPLASMA AG
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
CPT 87385
|
| Hospital Charge Code |
900913883
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Adventist Health Commercial |
$28.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$74.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$96.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$82.05
|
| Rate for Payer: Blue Shield of California Commercial |
$74.76
|
| Rate for Payer: Blue Shield of California EPN |
$59.97
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$91.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.57
|
| Rate for Payer: Dignity Health Senior |
$13.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$91.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$86.66
|
| Rate for Payer: Heritage Provider Network Senior |
$86.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$66.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.00
|
| 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 |
$105.00
|
| 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 |
$14.57
|
| Rate for Payer: Vantage Medical Group Senior |
$13.25
|
|
|
HC SOM MITOCHONDRIAL ANTIBO
|
Facility
|
OP
|
$10.82
|
|
|
Service Code
|
CPT 86381
|
| Hospital Charge Code |
900911178
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$146.59 |
| Rate for Payer: Adventist Health Commercial |
$2.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$28.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$92.81
|
| Rate for Payer: Blue Shield of California Commercial |
$146.59
|
| Rate for Payer: Blue Shield of California EPN |
$117.58
|
| Rate for Payer: Cash Price |
$10.82
|
| Rate for Payer: Cash Price |
$10.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.00
|
| Rate for Payer: Dignity Health Senior |
$25.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.03
|
| Rate for Payer: EPIC Health Plan Medicare |
$25.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.70
|
| Rate for Payer: Heritage Provider Network Senior |
$6.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$41.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$25.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.07
|
| Rate for Payer: Multiplan Commercial |
$8.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$25.45
|
| Rate for Payer: TriValley Medical Group Senior |
$25.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.00
|
| Rate for Payer: Vantage Medical Group Senior |
$25.45
|
|
|
HC SOM MITOCHONDRIAL ANTIBO
|
Facility
|
IP
|
$10.82
|
|
|
Service Code
|
CPT 86381
|
| Hospital Charge Code |
900911178
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$8.12 |
| Rate for Payer: Adventist Health Commercial |
$2.16
|
| Rate for Payer: Cash Price |
$10.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.33
|
| Rate for Payer: Heritage Provider Network Senior |
$7.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.71
|
| Rate for Payer: Multiplan Commercial |
$8.12
|
|
|
HC SOM MMRV 86735
|
Facility
|
OP
|
$100.43
|
|
|
Service Code
|
CPT 86735
|
| Hospital Charge Code |
900914957
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$120.41 |
| Rate for Payer: Adventist Health Commercial |
$20.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$53.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$120.41
|
| Rate for Payer: Blue Shield of California Commercial |
$105.00
|
| Rate for Payer: Blue Shield of California EPN |
$84.22
|
| Rate for Payer: Cash Price |
$100.43
|
| Rate for Payer: Cash Price |
$100.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$65.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.36
|
| Rate for Payer: Dignity Health Senior |
$13.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.28
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$62.17
|
| Rate for Payer: Heritage Provider Network Senior |
$62.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$47.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.18
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.44
|
| Rate for Payer: Multiplan Commercial |
$75.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.05
|
| Rate for Payer: TriValley Medical Group Senior |
$13.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.36
|
| Rate for Payer: Vantage Medical Group Senior |
$13.05
|
|
|
HC SOM MMRV 86735
|
Facility
|
IP
|
$100.43
|
|
|
Service Code
|
CPT 86735
|
| Hospital Charge Code |
900914957
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$18.18 |
| Max. Negotiated Rate |
$75.32 |
| Rate for Payer: Adventist Health Commercial |
$20.09
|
| Rate for Payer: Cash Price |
$100.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$67.99
|
| Rate for Payer: Heritage Provider Network Senior |
$67.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.11
|
| Rate for Payer: Multiplan Commercial |
$75.32
|
|
|
HC SOM MMRV 86762
|
Facility
|
OP
|
$70.05
|
|
|
Service Code
|
CPT 86762
|
| Hospital Charge Code |
900914958
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.68 |
| Max. Negotiated Rate |
$130.98 |
| Rate for Payer: Adventist Health Commercial |
$14.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$37.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$48.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$130.98
|
| Rate for Payer: Blue Shield of California Commercial |
$115.83
|
| Rate for Payer: Blue Shield of California EPN |
$92.91
|
| Rate for Payer: Cash Price |
$70.05
|
| Rate for Payer: Cash Price |
$70.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$45.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.83
|
| Rate for Payer: Dignity Health Senior |
$14.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.53
|
| Rate for Payer: EPIC Health Plan Medicare |
$14.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$43.36
|
| Rate for Payer: Heritage Provider Network Senior |
$43.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$20.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$33.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$16.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.13
|
| Rate for Payer: Multiplan Commercial |
$52.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.39
|
| Rate for Payer: TriValley Medical Group Senior |
$14.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.83
|
| Rate for Payer: Vantage Medical Group Senior |
$14.39
|
|
|
HC SOM MMRV 86762
|
Facility
|
IP
|
$70.05
|
|
|
Service Code
|
CPT 86762
|
| Hospital Charge Code |
900914958
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.68 |
| Max. Negotiated Rate |
$52.54 |
| Rate for Payer: Adventist Health Commercial |
$14.01
|
| Rate for Payer: Cash Price |
$70.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$47.42
|
| Rate for Payer: Heritage Provider Network Senior |
$47.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.51
|
| Rate for Payer: Multiplan Commercial |
$52.54
|
|
|
HC SOM MMRV 86765
|
Facility
|
IP
|
$17.90
|
|
|
Service Code
|
CPT 86765
|
| Hospital Charge Code |
900914956
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$13.43 |
| Rate for Payer: Adventist Health Commercial |
$3.58
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.12
|
| Rate for Payer: Heritage Provider Network Senior |
$12.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.47
|
| Rate for Payer: Multiplan Commercial |
$13.43
|
|
|
HC SOM MMRV 86765
|
Facility
|
OP
|
$17.90
|
|
|
Service Code
|
CPT 86765
|
| Hospital Charge Code |
900914956
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$117.64 |
| Rate for Payer: Adventist Health Commercial |
$3.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$117.64
|
| Rate for Payer: Blue Shield of California Commercial |
$103.68
|
| Rate for Payer: Blue Shield of California EPN |
$83.16
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.17
|
| Rate for Payer: Dignity Health Senior |
$12.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.63
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.08
|
| Rate for Payer: Heritage Provider Network Senior |
$11.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.23
|
| Rate for Payer: Multiplan Commercial |
$13.43
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.88
|
| Rate for Payer: TriValley Medical Group Senior |
$12.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.17
|
| Rate for Payer: Vantage Medical Group Senior |
$12.88
|
|
|
HC SOM MMRV 86787
|
Facility
|
IP
|
$29.73
|
|
|
Service Code
|
CPT 86787
|
| Hospital Charge Code |
900914959
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.38 |
| Max. Negotiated Rate |
$22.30 |
| Rate for Payer: Adventist Health Commercial |
$5.95
|
| Rate for Payer: Cash Price |
$29.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.13
|
| Rate for Payer: Heritage Provider Network Senior |
$20.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.43
|
| Rate for Payer: Multiplan Commercial |
$22.30
|
|
|
HC SOM MMRV 86787
|
Facility
|
OP
|
$29.73
|
|
|
Service Code
|
CPT 86787
|
| Hospital Charge Code |
900914959
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.38 |
| Max. Negotiated Rate |
$117.64 |
| Rate for Payer: Adventist Health Commercial |
$5.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$117.64
|
| Rate for Payer: Blue Shield of California Commercial |
$103.68
|
| Rate for Payer: Blue Shield of California EPN |
$83.16
|
| Rate for Payer: Cash Price |
$29.73
|
| Rate for Payer: Cash Price |
$29.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.17
|
| Rate for Payer: Dignity Health Senior |
$12.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.32
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.40
|
| Rate for Payer: Heritage Provider Network Senior |
$18.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.23
|
| Rate for Payer: Multiplan Commercial |
$22.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.88
|
| Rate for Payer: TriValley Medical Group Senior |
$12.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.17
|
| Rate for Payer: Vantage Medical Group Senior |
$12.88
|
|
|
HC SOM MOGS FACS
|
Facility
|
OP
|
$450.00
|
|
|
Service Code
|
CPT 86363
|
| Hospital Charge Code |
900915461
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.02 |
| Max. Negotiated Rate |
$337.50 |
| 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 |
$56.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$41.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.98
|
| Rate for Payer: Blue Shield of California Commercial |
$69.41
|
| Rate for Payer: Blue Shield of California EPN |
$55.67
|
| 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 |
$56.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$41.50
|
| Rate for Payer: Dignity Health Senior |
$37.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$292.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$37.73
|
| 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 |
$19.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$37.73
|
| 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 |
$43.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$112.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$47.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$47.54
|
| Rate for Payer: Multiplan Commercial |
$337.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$37.73
|
| Rate for Payer: TriValley Medical Group Senior |
$37.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$56.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$41.50
|
| Rate for Payer: Vantage Medical Group Senior |
$37.73
|
|
|
HC SOM MOGS FACS
|
Facility
|
IP
|
$450.00
|
|
|
Service Code
|
CPT 86363
|
| Hospital Charge Code |
900915461
|
|
Hospital Revenue Code
|
300
|
| 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 MOGS FACS TITER
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
CPT 86363
|
| Hospital Charge Code |
900915462
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.57 |
| Max. Negotiated Rate |
$56.25 |
| Rate for Payer: Adventist Health Commercial |
$15.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.77
|
| Rate for Payer: Heritage Provider Network Senior |
$50.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.75
|
| Rate for Payer: Multiplan Commercial |
$56.25
|
|
|
HC SOM MOGS FACS TITER
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
CPT 86363
|
| Hospital Charge Code |
900915462
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.02 |
| Max. Negotiated Rate |
$69.41 |
| Rate for Payer: Adventist Health Commercial |
$15.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$40.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$56.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$41.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.98
|
| Rate for Payer: Blue Shield of California Commercial |
$69.41
|
| Rate for Payer: Blue Shield of California EPN |
$55.67
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$56.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$41.50
|
| Rate for Payer: Dignity Health Senior |
$37.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$37.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.42
|
| Rate for Payer: Heritage Provider Network Senior |
$46.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$37.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$35.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$43.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$47.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$47.54
|
| Rate for Payer: Multiplan Commercial |
$56.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$37.73
|
| Rate for Payer: TriValley Medical Group Senior |
$37.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$56.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$41.50
|
| Rate for Payer: Vantage Medical Group Senior |
$37.73
|
|
|
HC SOM MONKEYPOX DNA PCR
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 87593
|
| Hospital Charge Code |
900915425
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.72 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.24
|
| Rate for Payer: Heritage Provider Network Senior |
$81.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
|
