|
HC SOM PCDES GFAP IFA
|
Facility
|
IP
|
$48.65
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915499
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$36.49 |
| Rate for Payer: Adventist Health Commercial |
$9.73
|
| Rate for Payer: Cash Price |
$48.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.94
|
| Rate for Payer: Heritage Provider Network Senior |
$32.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.16
|
| Rate for Payer: Multiplan Commercial |
$36.49
|
|
|
HC SOM PCDES LGI1 IGG CBA
|
Facility
|
IP
|
$48.65
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915494
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$36.49 |
| Rate for Payer: Adventist Health Commercial |
$9.73
|
| Rate for Payer: Cash Price |
$48.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.94
|
| Rate for Payer: Heritage Provider Network Senior |
$32.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.16
|
| Rate for Payer: Multiplan Commercial |
$36.49
|
|
|
HC SOM PCDES LGI1 IGG CBA
|
Facility
|
OP
|
$48.65
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915494
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$110.08 |
| Rate for Payer: Adventist Health Commercial |
$9.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$110.08
|
| Rate for Payer: Blue Shield of California Commercial |
$97.00
|
| Rate for Payer: Blue Shield of California EPN |
$77.80
|
| Rate for Payer: Cash Price |
$48.65
|
| Rate for Payer: Cash Price |
$48.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Senior |
$12.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.62
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.11
|
| Rate for Payer: Heritage Provider Network Senior |
$30.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.18
|
| Rate for Payer: Multiplan Commercial |
$36.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| 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 |
$18.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$12.05
|
|
|
HC SOM PCDES MGLUR1 AB IFA
|
Facility
|
IP
|
$48.66
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915497
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$36.49 |
| Rate for Payer: Adventist Health Commercial |
$9.73
|
| Rate for Payer: Cash Price |
$48.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.94
|
| Rate for Payer: Heritage Provider Network Senior |
$32.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.16
|
| Rate for Payer: Multiplan Commercial |
$36.49
|
|
|
HC SOM PCDES MGLUR1 AB IFA
|
Facility
|
OP
|
$48.66
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915497
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$110.08 |
| Rate for Payer: Adventist Health Commercial |
$9.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$110.08
|
| Rate for Payer: Blue Shield of California Commercial |
$97.00
|
| Rate for Payer: Blue Shield of California EPN |
$77.80
|
| Rate for Payer: Cash Price |
$48.66
|
| Rate for Payer: Cash Price |
$48.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Senior |
$12.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.63
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.12
|
| Rate for Payer: Heritage Provider Network Senior |
$30.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.18
|
| Rate for Payer: Multiplan Commercial |
$36.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| 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 |
$18.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$12.05
|
|
|
HC SOM PCDES MOG FACS
|
Facility
|
IP
|
$152.33
|
|
|
Service Code
|
CPT 86363
|
| Hospital Charge Code |
900915496
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.57 |
| Max. Negotiated Rate |
$114.25 |
| Rate for Payer: Adventist Health Commercial |
$30.47
|
| Rate for Payer: Cash Price |
$152.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$103.13
|
| Rate for Payer: Heritage Provider Network Senior |
$103.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.08
|
| Rate for Payer: Multiplan Commercial |
$114.25
|
|
|
HC SOM PCDES MOG FACS
|
Facility
|
OP
|
$152.33
|
|
|
Service Code
|
CPT 86363
|
| Hospital Charge Code |
900915496
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.02 |
| Max. Negotiated Rate |
$114.25 |
| Rate for Payer: Adventist Health Commercial |
$30.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$81.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$104.65
|
| 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 |
$152.33
|
| Rate for Payer: Cash Price |
$152.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$99.01
|
| 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 |
$99.01
|
| Rate for Payer: EPIC Health Plan Medicare |
$37.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$94.29
|
| Rate for Payer: Heritage Provider Network Senior |
$94.29
|
| 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 |
$72.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$43.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.08
|
| 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 |
$114.25
|
| 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 PCDES NEUROCONDRIN IFA
|
Facility
|
IP
|
$48.66
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915500
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$36.49 |
| Rate for Payer: Adventist Health Commercial |
$9.73
|
| Rate for Payer: Cash Price |
$48.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.94
|
| Rate for Payer: Heritage Provider Network Senior |
$32.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.16
|
| Rate for Payer: Multiplan Commercial |
$36.49
|
|
|
HC SOM PCDES NEUROCONDRIN IFA
|
Facility
|
OP
|
$48.66
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915500
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$110.08 |
| Rate for Payer: Adventist Health Commercial |
$9.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$110.08
|
| Rate for Payer: Blue Shield of California Commercial |
$97.00
|
| Rate for Payer: Blue Shield of California EPN |
$77.80
|
| Rate for Payer: Cash Price |
$48.66
|
| Rate for Payer: Cash Price |
$48.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Senior |
$12.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.63
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.12
|
| Rate for Payer: Heritage Provider Network Senior |
$30.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.18
|
| Rate for Payer: Multiplan Commercial |
$36.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| 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 |
$18.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$12.05
|
|
|
HC SOM PCDES NMDA-R AB CBA
|
Facility
|
IP
|
$48.65
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915490
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$36.49 |
| Rate for Payer: Adventist Health Commercial |
$9.73
|
| Rate for Payer: Cash Price |
$48.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.94
|
| Rate for Payer: Heritage Provider Network Senior |
$32.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.16
|
| Rate for Payer: Multiplan Commercial |
$36.49
|
|
|
HC SOM PCDES NMDA-R AB CBA
|
Facility
|
OP
|
$48.65
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915490
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$110.08 |
| Rate for Payer: Adventist Health Commercial |
$9.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$110.08
|
| Rate for Payer: Blue Shield of California Commercial |
$97.00
|
| Rate for Payer: Blue Shield of California EPN |
$77.80
|
| Rate for Payer: Cash Price |
$48.65
|
| Rate for Payer: Cash Price |
$48.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Senior |
$12.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.62
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.11
|
| Rate for Payer: Heritage Provider Network Senior |
$30.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.18
|
| Rate for Payer: Multiplan Commercial |
$36.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| 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 |
$18.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$12.05
|
|
|
HC SOM PCDES NMO/AQP4 FACS
|
Facility
|
IP
|
$152.34
|
|
|
Service Code
|
CPT 86053
|
| Hospital Charge Code |
900915493
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.57 |
| Max. Negotiated Rate |
$114.25 |
| Rate for Payer: Adventist Health Commercial |
$30.47
|
| Rate for Payer: Cash Price |
$152.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$103.13
|
| Rate for Payer: Heritage Provider Network Senior |
$103.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.09
|
| Rate for Payer: Multiplan Commercial |
$114.25
|
|
|
HC SOM PCDES NMO/AQP4 FACS
|
Facility
|
OP
|
$152.34
|
|
|
Service Code
|
CPT 86053
|
| Hospital Charge Code |
900915493
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.02 |
| Max. Negotiated Rate |
$114.25 |
| Rate for Payer: Adventist Health Commercial |
$30.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$81.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$104.66
|
| 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 |
$152.34
|
| Rate for Payer: Cash Price |
$152.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$99.02
|
| 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 |
$99.02
|
| Rate for Payer: EPIC Health Plan Medicare |
$37.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$94.30
|
| Rate for Payer: Heritage Provider Network Senior |
$94.30
|
| 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 |
$72.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$43.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.09
|
| 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 |
$114.25
|
| 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 PCDES PCA-TR
|
Facility
|
OP
|
$48.66
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915488
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$110.08 |
| Rate for Payer: Adventist Health Commercial |
$9.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$110.08
|
| Rate for Payer: Blue Shield of California Commercial |
$97.00
|
| Rate for Payer: Blue Shield of California EPN |
$77.80
|
| Rate for Payer: Cash Price |
$48.66
|
| Rate for Payer: Cash Price |
$48.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Senior |
$12.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.63
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.12
|
| Rate for Payer: Heritage Provider Network Senior |
$30.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.18
|
| Rate for Payer: Multiplan Commercial |
$36.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| 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 |
$18.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$12.05
|
|
|
HC SOM PCDES PCA-TR
|
Facility
|
IP
|
$48.66
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915488
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$36.49 |
| Rate for Payer: Adventist Health Commercial |
$9.73
|
| Rate for Payer: Cash Price |
$48.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.94
|
| Rate for Payer: Heritage Provider Network Senior |
$32.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.16
|
| Rate for Payer: Multiplan Commercial |
$36.49
|
|
|
HC SOM PENICILLIN G IGE
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
900912843
|
|
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 PENICILLIN G IGE
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
900912843
|
|
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 PENICILLIN V IGE
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
900912842
|
|
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 PENICILLIN V IGE
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
900912842
|
|
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 PERNIC ANEM CASC B12
|
Facility
|
OP
|
$79.28
|
|
|
Service Code
|
CPT 82607
|
| Hospital Charge Code |
900914690
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.35 |
| Max. Negotiated Rate |
$137.62 |
| Rate for Payer: Adventist Health Commercial |
$15.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$42.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$54.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$137.62
|
| Rate for Payer: Blue Shield of California Commercial |
$121.31
|
| Rate for Payer: Blue Shield of California EPN |
$97.30
|
| Rate for Payer: Cash Price |
$79.28
|
| Rate for Payer: Cash Price |
$79.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$51.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.59
|
| Rate for Payer: Dignity Health Senior |
$15.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.53
|
| Rate for Payer: EPIC Health Plan Medicare |
$15.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$49.07
|
| Rate for Payer: Heritage Provider Network Senior |
$49.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$37.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$19.00
|
| Rate for Payer: Multiplan Commercial |
$59.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.08
|
| Rate for Payer: TriValley Medical Group Senior |
$15.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.59
|
| Rate for Payer: Vantage Medical Group Senior |
$15.08
|
|
|
HC SOM PERNIC ANEM CASC B12
|
Facility
|
IP
|
$79.28
|
|
|
Service Code
|
CPT 82607
|
| Hospital Charge Code |
900914690
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.35 |
| Max. Negotiated Rate |
$59.46 |
| Rate for Payer: Adventist Health Commercial |
$15.86
|
| Rate for Payer: Cash Price |
$79.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$53.67
|
| Rate for Payer: Heritage Provider Network Senior |
$53.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.82
|
| Rate for Payer: Multiplan Commercial |
$59.46
|
|
|
HC SOM PHENCYCLIDINE CONFIRM, U
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
CPT 83992
|
| Hospital Charge Code |
900912920
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.04 |
| Max. Negotiated Rate |
$45.75 |
| Rate for Payer: Adventist Health Commercial |
$12.20
|
| Rate for Payer: Cash Price |
$61.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.30
|
| Rate for Payer: Heritage Provider Network Senior |
$41.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.25
|
| Rate for Payer: Multiplan Commercial |
$45.75
|
|
|
HC SOM PHENCYCLIDINE CONFIRM, U
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
CPT 83992
|
| Hospital Charge Code |
900912920
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.04 |
| Max. Negotiated Rate |
$117.82 |
| Rate for Payer: Adventist Health Commercial |
$12.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$32.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$33.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$117.82
|
| Rate for Payer: Blue Shield of California Commercial |
$112.26
|
| Rate for Payer: Blue Shield of California EPN |
$90.04
|
| Rate for Payer: Cash Price |
$61.00
|
| Rate for Payer: Cash Price |
$61.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$39.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.85
|
| Rate for Payer: Dignity Health Senior |
$51.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.76
|
| Rate for Payer: Heritage Provider Network Senior |
$37.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$29.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$42.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$42.70
|
| Rate for Payer: Multiplan Commercial |
$45.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$40.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$51.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.85
|
| Rate for Payer: Vantage Medical Group Senior |
$51.85
|
|
|
HC SOM PHENOBARBITAL LEVEL
|
Facility
|
OP
|
$23.99
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
900912658
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$104.36 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$104.36
|
| Rate for Payer: Blue Shield of California Commercial |
$92.22
|
| Rate for Payer: Blue Shield of California EPN |
$73.97
|
| Rate for Payer: Cash Price |
$23.99
|
| Rate for Payer: Cash Price |
$23.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.83
|
| Rate for Payer: Dignity Health Senior |
$15.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.59
|
| Rate for Payer: EPIC Health Plan Medicare |
$15.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.85
|
| Rate for Payer: Heritage Provider Network Senior |
$14.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$19.28
|
| Rate for Payer: Multiplan Commercial |
$17.99
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.30
|
| Rate for Payer: TriValley Medical Group Senior |
$15.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.83
|
| Rate for Payer: Vantage Medical Group Senior |
$15.30
|
|
|
HC SOM PHENOBARBITAL LEVEL
|
Facility
|
IP
|
$23.99
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
900912658
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$17.99 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Cash Price |
$23.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.24
|
| Rate for Payer: Heritage Provider Network Senior |
$16.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$17.99
|
|
