|
HC SOM ENS TRIM46 IFA
|
Facility
|
IP
|
$34.06
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915474
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$25.55 |
| Rate for Payer: Adventist Health Commercial |
$6.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.93
|
| Rate for Payer: Cash Price |
$34.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.06
|
| Rate for Payer: Heritage Provider Network Senior |
$23.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.52
|
| Rate for Payer: Multiplan Commercial |
$25.55
|
|
|
HC SOM ENTEROVIRUS PCR, BLOOD
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT 87498
|
| Hospital Charge Code |
900910691
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$326.00 |
| Rate for Payer: Adventist Health Commercial |
$9.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.81
|
| 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 |
$326.00
|
| 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 |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$35.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.55
|
| Rate for Payer: EPIC Health Plan Medicare |
$35.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.86
|
| Rate for Payer: Heritage Provider Network Senior |
$27.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$21.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$40.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$47.02
|
| Rate for Payer: Multiplan Commercial |
$33.75
|
| 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 ENTEROVIRUS PCR, BLOOD
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT 87498
|
| Hospital Charge Code |
900910691
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$33.75 |
| Rate for Payer: Adventist Health Commercial |
$9.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.98
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.46
|
| Rate for Payer: Heritage Provider Network Senior |
$30.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.25
|
| Rate for Payer: Multiplan Commercial |
$33.75
|
|
|
HC SOM ENTEROVIRUS PCR CSF
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT 87498
|
| Hospital Charge Code |
900910771
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$33.75 |
| Rate for Payer: Adventist Health Commercial |
$9.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.98
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.46
|
| Rate for Payer: Heritage Provider Network Senior |
$30.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.25
|
| Rate for Payer: Multiplan Commercial |
$33.75
|
|
|
HC SOM ENTEROVIRUS PCR CSF
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT 87498
|
| Hospital Charge Code |
900910771
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$326.00 |
| Rate for Payer: Adventist Health Commercial |
$9.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.81
|
| 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 |
$326.00
|
| 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 |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$35.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.55
|
| Rate for Payer: EPIC Health Plan Medicare |
$35.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.86
|
| Rate for Payer: Heritage Provider Network Senior |
$27.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$21.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$40.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$47.02
|
| Rate for Payer: Multiplan Commercial |
$33.75
|
| 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 ERYTHROPOIETIN
|
Facility
|
IP
|
$15.68
|
|
|
Service Code
|
CPT 82668
|
| Hospital Charge Code |
900911227
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$11.76 |
| Rate for Payer: Adventist Health Commercial |
$3.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.10
|
| Rate for Payer: Cash Price |
$15.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.62
|
| Rate for Payer: Heritage Provider Network Senior |
$10.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.92
|
| Rate for Payer: Multiplan Commercial |
$11.76
|
|
|
HC SOM ERYTHROPOIETIN
|
Facility
|
OP
|
$15.68
|
|
|
Service Code
|
CPT 82668
|
| Hospital Charge Code |
900911227
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$177.19 |
| Rate for Payer: Adventist Health Commercial |
$3.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$177.19
|
| Rate for Payer: Blue Shield of California Commercial |
$151.26
|
| Rate for Payer: Blue Shield of California EPN |
$121.32
|
| Rate for Payer: Cash Price |
$15.68
|
| Rate for Payer: Cash Price |
$15.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$18.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.71
|
| Rate for Payer: Heritage Provider Network Senior |
$9.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.18
|
| Rate for Payer: Multiplan Commercial |
$11.76
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.79
|
| Rate for Payer: TriValley Medical Group Senior |
$18.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.67
|
| Rate for Payer: Vantage Medical Group Senior |
$18.79
|
|
|
HC SOM ESTRADIOL
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
CPT 82671
|
| Hospital Charge Code |
900911014
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.88
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.54
|
| Rate for Payer: Heritage Provider Network Senior |
$13.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$15.00
|
|
|
HC SOM ESTRADIOL
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
CPT 82671
|
| Hospital Charge Code |
900911014
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$306.63 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$48.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$35.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$32.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$306.63
|
| Rate for Payer: Blue Shield of California Commercial |
$259.95
|
| Rate for Payer: Blue Shield of California EPN |
$208.50
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$32.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$32.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.38
|
| Rate for Payer: Heritage Provider Network Senior |
$12.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$32.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$9.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$37.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$43.28
|
| Rate for Payer: Multiplan Commercial |
$15.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$32.30
|
| Rate for Payer: TriValley Medical Group Senior |
$32.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$34.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$48.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.53
|
| Rate for Payer: Vantage Medical Group Senior |
$32.30
|
|
|
HC SOM ESTRIOL
|
Facility
|
IP
|
$19.88
|
|
|
Service Code
|
CPT 82677
|
| Hospital Charge Code |
900911036
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.60 |
| Max. Negotiated Rate |
$14.91 |
| Rate for Payer: Adventist Health Commercial |
$3.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.80
|
| Rate for Payer: Cash Price |
$19.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.46
|
| Rate for Payer: Heritage Provider Network Senior |
$13.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.97
|
| Rate for Payer: Multiplan Commercial |
$14.91
|
|
|
HC SOM ESTRIOL
|
Facility
|
OP
|
$19.88
|
|
|
Service Code
|
CPT 82677
|
| Hospital Charge Code |
900911036
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.60 |
| Max. Negotiated Rate |
$230.57 |
| Rate for Payer: Adventist Health Commercial |
$3.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$230.57
|
| Rate for Payer: Blue Shield of California Commercial |
$194.63
|
| Rate for Payer: Blue Shield of California EPN |
$156.11
|
| Rate for Payer: Cash Price |
$19.88
|
| Rate for Payer: Cash Price |
$19.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.73
|
| Rate for Payer: EPIC Health Plan Medicare |
$24.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.31
|
| Rate for Payer: Heritage Provider Network Senior |
$12.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$9.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32.40
|
| Rate for Payer: Multiplan Commercial |
$14.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.18
|
| Rate for Payer: TriValley Medical Group Senior |
$24.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.60
|
| Rate for Payer: Vantage Medical Group Senior |
$24.18
|
|
|
HC SOM ESTRONE
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
CPT 82679
|
| Hospital Charge Code |
900911482
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.53 |
| Max. Negotiated Rate |
$236.96 |
| Rate for Payer: Adventist Health Commercial |
$5.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$37.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$236.96
|
| Rate for Payer: Blue Shield of California Commercial |
$200.91
|
| Rate for Payer: Blue Shield of California EPN |
$161.15
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$37.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$24.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.47
|
| Rate for Payer: Heritage Provider Network Senior |
$15.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$28.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$33.43
|
| Rate for Payer: Multiplan Commercial |
$18.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.95
|
| Rate for Payer: TriValley Medical Group Senior |
$24.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$37.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.45
|
| Rate for Payer: Vantage Medical Group Senior |
$24.95
|
|
|
HC SOM ESTRONE
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
CPT 82679
|
| Hospital Charge Code |
900911482
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.53 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Adventist Health Commercial |
$5.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.10
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.93
|
| Rate for Payer: Heritage Provider Network Senior |
$16.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.25
|
| Rate for Payer: Multiplan Commercial |
$18.75
|
|
|
HC SOM ETHANOL, U
|
Facility
|
OP
|
$49.90
|
|
|
Service Code
|
CPT 80320
|
| Hospital Charge Code |
900912919
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.03 |
| Max. Negotiated Rate |
$98.44 |
| Rate for Payer: Adventist Health Commercial |
$9.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$98.44
|
| Rate for Payer: Cash Price |
$49.90
|
| Rate for Payer: Cash Price |
$49.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$42.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.89
|
| Rate for Payer: Heritage Provider Network Senior |
$30.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$23.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$34.93
|
| Rate for Payer: Multiplan Commercial |
$37.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$24.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.41
|
| Rate for Payer: Vantage Medical Group Senior |
$42.41
|
|
|
HC SOM ETHANOL, U
|
Facility
|
IP
|
$49.90
|
|
|
Service Code
|
CPT 80320
|
| Hospital Charge Code |
900912919
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.03 |
| Max. Negotiated Rate |
$37.42 |
| Rate for Payer: Adventist Health Commercial |
$9.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.14
|
| Rate for Payer: Cash Price |
$49.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.78
|
| Rate for Payer: Heritage Provider Network Senior |
$33.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.47
|
| Rate for Payer: Multiplan Commercial |
$37.42
|
|
|
HC SOM ETHCHLORVINYL (PLACIDYL)
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900910427
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.96 |
| Max. Negotiated Rate |
$41.25 |
| Rate for Payer: Adventist Health Commercial |
$11.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.42
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.23
|
| Rate for Payer: Heritage Provider Network Senior |
$37.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.75
|
| Rate for Payer: Multiplan Commercial |
$41.25
|
|
|
HC SOM ETHCHLORVINYL (PLACIDYL)
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900910427
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.96 |
| Max. Negotiated Rate |
$585.08 |
| Rate for Payer: Adventist Health Commercial |
$11.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$62.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$585.08
|
| Rate for Payer: Blue Shield of California Commercial |
$459.71
|
| Rate for Payer: Blue Shield of California EPN |
$368.72
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$35.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$93.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$62.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$62.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.05
|
| Rate for Payer: Heritage Provider Network Senior |
$34.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$62.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$26.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$71.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$83.27
|
| Rate for Payer: Multiplan Commercial |
$41.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$62.14
|
| Rate for Payer: TriValley Medical Group Senior |
$62.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$67.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$67.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: Vantage Medical Group Senior |
$62.14
|
|
|
HC SOM ETHOSUXIMIDE (ZARONTIN)
|
Facility
|
IP
|
$37.58
|
|
|
Service Code
|
CPT 80168
|
| Hospital Charge Code |
900910338
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$28.18 |
| Rate for Payer: Adventist Health Commercial |
$7.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.20
|
| Rate for Payer: Cash Price |
$37.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.44
|
| Rate for Payer: Heritage Provider Network Senior |
$25.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.39
|
| Rate for Payer: Multiplan Commercial |
$28.18
|
|
|
HC SOM ETHOSUXIMIDE (ZARONTIN)
|
Facility
|
OP
|
$37.58
|
|
|
Service Code
|
CPT 80168
|
| Hospital Charge Code |
900910338
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$155.14 |
| Rate for Payer: Adventist Health Commercial |
$7.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$155.14
|
| Rate for Payer: Blue Shield of California Commercial |
$131.50
|
| Rate for Payer: Blue Shield of California EPN |
$105.47
|
| Rate for Payer: Cash Price |
$37.58
|
| Rate for Payer: Cash Price |
$37.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.17
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.26
|
| Rate for Payer: Heritage Provider Network Senior |
$23.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$17.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$21.90
|
| Rate for Payer: Multiplan Commercial |
$28.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.34
|
| Rate for Payer: TriValley Medical Group Senior |
$16.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.97
|
| Rate for Payer: Vantage Medical Group Senior |
$16.34
|
|
|
HC SOM EVEROLIMUS B
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT 80169
|
| Hospital Charge Code |
900913810
|
|
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: Aetna of CA Non-Gatekeeper |
$19.32
|
| 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 Foundation Hospitals Medi-Cal |
$5.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
|
|
HC SOM EVEROLIMUS B
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 80169
|
| Hospital Charge Code |
900913810
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$107.88 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$78.37
|
| Rate for Payer: Blue Shield of California Commercial |
$107.88
|
| Rate for Payer: Blue Shield of California EPN |
$86.53
|
| 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 |
$20.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.70
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.73
|
| 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) Medicare Advantage |
$13.73
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$14.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18.40
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.73
|
| Rate for Payer: TriValley Medical Group Senior |
$13.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.10
|
| Rate for Payer: Vantage Medical Group Senior |
$13.73
|
|
|
HC SOM FACTOR IX BETHESDA UNITS
|
Facility
|
IP
|
$130.44
|
|
|
Service Code
|
CPT 85335
|
| Hospital Charge Code |
900915517
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.61 |
| Max. Negotiated Rate |
$97.83 |
| Rate for Payer: Adventist Health Commercial |
$26.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$84.00
|
| Rate for Payer: Cash Price |
$130.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$88.31
|
| Rate for Payer: Heritage Provider Network Senior |
$88.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.61
|
| Rate for Payer: Multiplan Commercial |
$97.83
|
|
|
HC SOM FACTOR IX BETHESDA UNITS
|
Facility
|
OP
|
$130.44
|
|
|
Service Code
|
CPT 85335
|
| Hospital Charge Code |
900915517
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.87 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: Adventist Health Commercial |
$26.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$122.22
|
| Rate for Payer: Blue Shield of California Commercial |
$103.62
|
| Rate for Payer: Blue Shield of California EPN |
$83.11
|
| Rate for Payer: Cash Price |
$130.44
|
| Rate for Payer: Cash Price |
$130.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$84.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.79
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$80.74
|
| Rate for Payer: Heritage Provider Network Senior |
$80.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$62.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$14.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17.25
|
| Rate for Payer: Multiplan Commercial |
$97.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.87
|
| Rate for Payer: TriValley Medical Group Senior |
$12.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.16
|
| Rate for Payer: Vantage Medical Group Senior |
$12.87
|
|
|
HC SOM FACTOR IX INHIB PROF INTERP
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
CPT 85390
|
| Hospital Charge Code |
900915516
|
|
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: Aetna of CA Non-Gatekeeper |
$48.30
|
| 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 Foundation Hospitals Medi-Cal |
$13.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.75
|
| Rate for Payer: Multiplan Commercial |
$56.25
|
|
|
HC SOM FACTOR IX INHIB PROF INTERP
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
CPT 85390
|
| Hospital Charge Code |
900915516
|
|
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: Aetna of CA Non-Gatekeeper |
$46.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.96
|
| Rate for Payer: Blue Shield of California Commercial |
$41.59
|
| Rate for Payer: Blue Shield of California EPN |
$33.36
|
| 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 |
$23.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$15.48
|
| 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) Medicare Advantage |
$15.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$35.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$20.74
|
| Rate for Payer: Multiplan Commercial |
$56.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.48
|
| Rate for Payer: TriValley Medical Group Senior |
$15.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.03
|
| Rate for Payer: Vantage Medical Group Senior |
$15.48
|
|
