|
HC SOM PHI 2PROPSA
|
Facility
|
OP
|
$29.20
|
|
|
Service Code
|
CPT 86316
|
| Hospital Charge Code |
900915520
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.29 |
| Max. Negotiated Rate |
$189.98 |
| Rate for Payer: Adventist Health Commercial |
$5.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$22.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$189.98
|
| Rate for Payer: Blue Shield of California Commercial |
$167.44
|
| Rate for Payer: Blue Shield of California EPN |
$134.30
|
| Rate for Payer: Cash Price |
$29.20
|
| Rate for Payer: Cash Price |
$29.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.89
|
| Rate for Payer: Dignity Health Senior |
$20.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.98
|
| Rate for Payer: EPIC Health Plan Medicare |
$20.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.07
|
| Rate for Payer: Heritage Provider Network Senior |
$18.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$29.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$23.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$26.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$26.22
|
| Rate for Payer: Multiplan Commercial |
$21.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$20.81
|
| Rate for Payer: TriValley Medical Group Senior |
$20.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.89
|
| Rate for Payer: Vantage Medical Group Senior |
$20.81
|
|
|
HC SOM PHI 2PROPSA
|
Facility
|
IP
|
$29.20
|
|
|
Service Code
|
CPT 86316
|
| Hospital Charge Code |
900915520
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.29 |
| Max. Negotiated Rate |
$21.90 |
| Rate for Payer: Adventist Health Commercial |
$5.84
|
| Rate for Payer: Cash Price |
$29.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.77
|
| Rate for Payer: Heritage Provider Network Senior |
$19.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.30
|
| Rate for Payer: Multiplan Commercial |
$21.90
|
|
|
HC SOM PHI FREE PSA
|
Facility
|
IP
|
$25.80
|
|
|
Service Code
|
CPT 84154
|
| Hospital Charge Code |
900915519
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.67 |
| Max. Negotiated Rate |
$19.35 |
| Rate for Payer: Adventist Health Commercial |
$5.16
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.47
|
| Rate for Payer: Heritage Provider Network Senior |
$17.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.45
|
| Rate for Payer: Multiplan Commercial |
$19.35
|
|
|
HC SOM PHI FREE PSA
|
Facility
|
OP
|
$25.80
|
|
|
Service Code
|
CPT 84154
|
| Hospital Charge Code |
900915519
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.67 |
| Max. Negotiated Rate |
$167.18 |
| Rate for Payer: Adventist Health Commercial |
$5.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$167.18
|
| Rate for Payer: Blue Shield of California Commercial |
$148.03
|
| Rate for Payer: Blue Shield of California EPN |
$118.73
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.23
|
| Rate for Payer: Dignity Health Senior |
$18.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.77
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.97
|
| Rate for Payer: Heritage Provider Network Senior |
$15.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$20.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.17
|
| Rate for Payer: Multiplan Commercial |
$19.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.39
|
| Rate for Payer: TriValley Medical Group Senior |
$18.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.23
|
| Rate for Payer: Vantage Medical Group Senior |
$18.39
|
|
|
HC SOM PHOSPHOLIPID AB IGA
|
Facility
|
OP
|
$24.10
|
|
|
Service Code
|
CPT 86147
|
| Hospital Charge Code |
900914172
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$147.97 |
| Rate for Payer: Adventist Health Commercial |
$4.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.56
|
| 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 |
$131.84
|
| Rate for Payer: Blue Shield of California Commercial |
$147.97
|
| Rate for Payer: Blue Shield of California EPN |
$118.69
|
| Rate for Payer: Cash Price |
$24.10
|
| Rate for Payer: Cash Price |
$24.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.66
|
| 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 |
$15.66
|
| Rate for Payer: EPIC Health Plan Medicare |
$25.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.92
|
| Rate for Payer: Heritage Provider Network Senior |
$14.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$28.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$25.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.03
|
| 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 |
$18.07
|
| 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 PHOSPHOLIPID AB IGA
|
Facility
|
IP
|
$24.10
|
|
|
Service Code
|
CPT 86147
|
| Hospital Charge Code |
900914172
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$18.07 |
| Rate for Payer: Adventist Health Commercial |
$4.82
|
| Rate for Payer: Cash Price |
$24.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.32
|
| Rate for Payer: Heritage Provider Network Senior |
$16.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.03
|
| Rate for Payer: Multiplan Commercial |
$18.07
|
|
|
HC SOM PI-LINKD AG FLOW EA ADD'L
|
Facility
|
IP
|
$79.46
|
|
|
Service Code
|
CPT 88185
|
| Hospital Charge Code |
900914176
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$14.38 |
| Max. Negotiated Rate |
$59.59 |
| Rate for Payer: Adventist Health Commercial |
$15.89
|
| Rate for Payer: Cash Price |
$79.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$53.79
|
| Rate for Payer: Heritage Provider Network Senior |
$53.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.86
|
| Rate for Payer: Multiplan Commercial |
$59.59
|
|
|
HC SOM PI-LINKD AG FLOW EA ADD'L
|
Facility
|
OP
|
$79.46
|
|
|
Service Code
|
CPT 88185
|
| Hospital Charge Code |
900914176
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$14.38 |
| Max. Negotiated Rate |
$174.99 |
| Rate for Payer: Adventist Health Commercial |
$15.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$42.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$54.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$67.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$43.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$59.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$174.99
|
| Rate for Payer: Blue Shield of California Commercial |
$132.14
|
| Rate for Payer: Blue Shield of California EPN |
$106.27
|
| Rate for Payer: Cash Price |
$79.46
|
| Rate for Payer: Cash Price |
$79.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$51.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$67.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$67.54
|
| Rate for Payer: Dignity Health Senior |
$67.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$49.19
|
| Rate for Payer: Heritage Provider Network Senior |
$49.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$33.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$37.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$55.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$55.62
|
| Rate for Payer: Multiplan Commercial |
$59.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$67.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$67.54
|
| Rate for Payer: Vantage Medical Group Senior |
$67.54
|
|
|
HC SOM PI-LINKD AG FLOW TC 1 MRKR
|
Facility
|
OP
|
$70.54
|
|
|
Service Code
|
CPT 88184
|
| Hospital Charge Code |
900914173
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$685.59 |
| Rate for Payer: Adventist Health Commercial |
$14.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$37.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$48.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$685.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$502.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$457.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$356.12
|
| Rate for Payer: Blue Shield of California Commercial |
$269.52
|
| Rate for Payer: Blue Shield of California EPN |
$216.74
|
| Rate for Payer: Cash Price |
$70.54
|
| Rate for Payer: Cash Price |
$70.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$45.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$685.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$502.77
|
| Rate for Payer: Dignity Health Senior |
$457.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$457.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$43.66
|
| Rate for Payer: Heritage Provider Network Senior |
$43.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$68.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$457.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$33.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$525.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$575.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$575.90
|
| Rate for Payer: Multiplan Commercial |
$52.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$457.06
|
| Rate for Payer: TriValley Medical Group Senior |
$457.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$321.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$321.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$685.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$502.77
|
| Rate for Payer: Vantage Medical Group Senior |
$457.06
|
|
|
HC SOM PI-LINKD AG FLOW TC 1 MRKR
|
Facility
|
IP
|
$70.54
|
|
|
Service Code
|
CPT 88184
|
| Hospital Charge Code |
900914173
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$52.91 |
| Rate for Payer: Adventist Health Commercial |
$14.11
|
| Rate for Payer: Cash Price |
$70.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$47.76
|
| Rate for Payer: Heritage Provider Network Senior |
$47.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.64
|
| Rate for Payer: Multiplan Commercial |
$52.91
|
|
|
HC SOM PIPERACILLIN LEVEL BA
|
Facility
|
OP
|
$106.40
|
|
|
Service Code
|
CPT 84999
|
| Hospital Charge Code |
900914693
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.26 |
| Max. Negotiated Rate |
$90.44 |
| Rate for Payer: Adventist Health Commercial |
$21.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$56.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$73.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$58.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$79.80
|
| Rate for Payer: Blue Shield of California Commercial |
$64.90
|
| Rate for Payer: Blue Shield of California EPN |
$51.92
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$90.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$90.44
|
| Rate for Payer: Dignity Health Senior |
$90.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.86
|
| Rate for Payer: Heritage Provider Network Senior |
$65.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$50.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$74.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$74.48
|
| Rate for Payer: Multiplan Commercial |
$79.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$53.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$53.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$90.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$90.44
|
| Rate for Payer: Vantage Medical Group Senior |
$90.44
|
|
|
HC SOM PIPERACILLIN LEVEL BA
|
Facility
|
IP
|
$106.40
|
|
|
Service Code
|
CPT 84999
|
| Hospital Charge Code |
900914693
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.26 |
| Max. Negotiated Rate |
$79.80 |
| Rate for Payer: Adventist Health Commercial |
$21.28
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$72.03
|
| Rate for Payer: Heritage Provider Network Senior |
$72.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.60
|
| Rate for Payer: Multiplan Commercial |
$79.80
|
|
|
HC SOM PKHD1 GENE
|
Facility
|
OP
|
$1,525.00
|
|
|
Service Code
|
CPT 84999
|
| Hospital Charge Code |
900914705
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$276.02 |
| Max. Negotiated Rate |
$1,296.25 |
| Rate for Payer: Adventist Health Commercial |
$305.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$815.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,047.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,296.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$838.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,143.75
|
| Rate for Payer: Blue Shield of California Commercial |
$930.25
|
| Rate for Payer: Blue Shield of California EPN |
$744.20
|
| Rate for Payer: Cash Price |
$1,525.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$991.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,296.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,296.25
|
| Rate for Payer: Dignity Health Senior |
$1,296.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$991.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$943.98
|
| Rate for Payer: Heritage Provider Network Senior |
$943.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$727.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$276.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$381.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,067.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,067.50
|
| Rate for Payer: Multiplan Commercial |
$1,143.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$762.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$762.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,296.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,296.25
|
| Rate for Payer: Vantage Medical Group Senior |
$1,296.25
|
|
|
HC SOM PKHD1 GENE
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
CPT 84999
|
| Hospital Charge Code |
900914705
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$276.02 |
| Max. Negotiated Rate |
$1,143.75 |
| Rate for Payer: Adventist Health Commercial |
$305.00
|
| Rate for Payer: Cash Price |
$1,525.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,032.42
|
| Rate for Payer: Heritage Provider Network Senior |
$1,032.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$276.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$381.25
|
| Rate for Payer: Multiplan Commercial |
$1,143.75
|
|
|
HC SOM PLASMINOGEN ACTIVITY
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT 85420
|
| Hospital Charge Code |
900911325
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$37.50 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Cash Price |
$50.00
|
| 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 PLASMINOGEN ACTIVITY
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT 85420
|
| Hospital Charge Code |
900911325
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$6.53 |
| Max. Negotiated Rate |
$59.74 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$59.74
|
| Rate for Payer: Blue Shield of California Commercial |
$52.59
|
| Rate for Payer: Blue Shield of California EPN |
$42.18
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.18
|
| Rate for Payer: Dignity Health Senior |
$6.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$6.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.95
|
| Rate for Payer: Heritage Provider Network Senior |
$30.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.23
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.53
|
| Rate for Payer: TriValley Medical Group Senior |
$6.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.18
|
| Rate for Payer: Vantage Medical Group Senior |
$6.53
|
|
|
HC SOM PML/RARA QUANT, PCR
|
Facility
|
IP
|
$255.94
|
|
|
Service Code
|
CPT 81315
|
| Hospital Charge Code |
900913891
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$46.33 |
| Max. Negotiated Rate |
$191.96 |
| Rate for Payer: Adventist Health Commercial |
$51.19
|
| Rate for Payer: Cash Price |
$255.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$173.27
|
| Rate for Payer: Heritage Provider Network Senior |
$173.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.98
|
| Rate for Payer: Multiplan Commercial |
$191.96
|
|
|
HC SOM PML/RARA QUANT, PCR
|
Facility
|
OP
|
$255.94
|
|
|
Service Code
|
CPT 81315
|
| Hospital Charge Code |
900913891
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$46.33 |
| Max. Negotiated Rate |
$487.46 |
| Rate for Payer: Adventist Health Commercial |
$51.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$136.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$175.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$310.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$228.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$207.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$487.46
|
| Rate for Payer: Blue Shield of California Commercial |
$156.12
|
| Rate for Payer: Blue Shield of California EPN |
$124.90
|
| Rate for Payer: Cash Price |
$255.94
|
| Rate for Payer: Cash Price |
$255.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$166.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$310.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.04
|
| Rate for Payer: Dignity Health Senior |
$207.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$166.36
|
| Rate for Payer: EPIC Health Plan Medicare |
$207.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$158.43
|
| Rate for Payer: Heritage Provider Network Senior |
$158.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$152.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$207.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$122.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$238.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$261.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$261.21
|
| Rate for Payer: Multiplan Commercial |
$191.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$207.31
|
| Rate for Payer: TriValley Medical Group Senior |
$207.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$223.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$223.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$310.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.04
|
| Rate for Payer: Vantage Medical Group Senior |
$207.31
|
|
|
HC SOM PNEUMOCYSTIS PCR
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
900915467
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.82
|
| Rate for Payer: Heritage Provider Network Senior |
$75.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
|
|
HC SOM PNEUMOCYSTIS PCR
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
900915467
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$310.02 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$59.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$52.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$310.02
|
| Rate for Payer: Blue Shield of California Commercial |
$282.47
|
| Rate for Payer: Blue Shield of California EPN |
$226.56
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.60
|
| Rate for Payer: Dignity Health Senior |
$35.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$35.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.33
|
| Rate for Payer: Heritage Provider Network Senior |
$69.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$48.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$53.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$40.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$44.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$44.21
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$35.09
|
| Rate for Payer: TriValley Medical Group Senior |
$35.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$37.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$52.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Vantage Medical Group Senior |
$35.09
|
|
|
HC SOM PORPHOBILINOGEN QUANT.
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 84110
|
| Hospital Charge Code |
900912570
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$77.14 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$77.14
|
| Rate for Payer: Blue Shield of California Commercial |
$67.97
|
| Rate for Payer: Blue Shield of California EPN |
$54.52
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.28
|
| Rate for Payer: Dignity Health Senior |
$8.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.57
|
| Rate for Payer: Heritage Provider Network Senior |
$18.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.63
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.44
|
| Rate for Payer: TriValley Medical Group Senior |
$8.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.28
|
| Rate for Payer: Vantage Medical Group Senior |
$8.44
|
|
|
HC SOM PORPHOBILINOGEN QUANT.
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT 84110
|
| Hospital Charge Code |
900912570
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.31
|
| Rate for Payer: Heritage Provider Network Senior |
$20.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
|
|
HC SOM PORPHYRINS FRAC RND U
|
Facility
|
IP
|
$21.08
|
|
|
Service Code
|
CPT 84120
|
| Hospital Charge Code |
900914687
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$15.81 |
| Rate for Payer: Adventist Health Commercial |
$4.22
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.27
|
| Rate for Payer: Heritage Provider Network Senior |
$14.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.27
|
| Rate for Payer: Multiplan Commercial |
$15.81
|
|
|
HC SOM PORPHYRINS FRAC RND U
|
Facility
|
OP
|
$21.08
|
|
|
Service Code
|
CPT 84120
|
| Hospital Charge Code |
900914687
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$134.30 |
| Rate for Payer: Adventist Health Commercial |
$4.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$134.30
|
| Rate for Payer: Blue Shield of California Commercial |
$118.37
|
| Rate for Payer: Blue Shield of California EPN |
$94.94
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.18
|
| Rate for Payer: Dignity Health Senior |
$14.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.70
|
| Rate for Payer: EPIC Health Plan Medicare |
$14.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.05
|
| Rate for Payer: Heritage Provider Network Senior |
$13.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.82
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$16.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.53
|
| Rate for Payer: Multiplan Commercial |
$15.81
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.71
|
| Rate for Payer: TriValley Medical Group Senior |
$14.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.18
|
| Rate for Payer: Vantage Medical Group Senior |
$14.71
|
|
|
HC SOM PORPHYRINS QN RND U
|
Facility
|
IP
|
$12.09
|
|
|
Service Code
|
CPT 84110
|
| Hospital Charge Code |
900914686
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$9.07 |
| Rate for Payer: Adventist Health Commercial |
$2.42
|
| Rate for Payer: Cash Price |
$12.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.18
|
| Rate for Payer: Heritage Provider Network Senior |
$8.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.02
|
| Rate for Payer: Multiplan Commercial |
$9.07
|
|
