|
HC SOM FACTOR IX INH. SCREEN
|
Facility
|
OP
|
$58.82
|
|
|
Service Code
|
CPT 85335
|
| Hospital Charge Code |
900915515
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.65 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: Adventist Health Commercial |
$11.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$36.35
|
| 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 |
$58.82
|
| Rate for Payer: Cash Price |
$58.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.23
|
| 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 |
$38.23
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$36.41
|
| Rate for Payer: Heritage Provider Network Senior |
$36.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$28.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$14.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17.25
|
| Rate for Payer: Multiplan Commercial |
$44.12
|
| 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 INH. SCREEN
|
Facility
|
IP
|
$58.82
|
|
|
Service Code
|
CPT 85335
|
| Hospital Charge Code |
900915515
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.65 |
| Max. Negotiated Rate |
$44.12 |
| Rate for Payer: Adventist Health Commercial |
$11.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.88
|
| Rate for Payer: Cash Price |
$58.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$39.82
|
| Rate for Payer: Heritage Provider Network Senior |
$39.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.71
|
| Rate for Payer: Multiplan Commercial |
$44.12
|
|
|
HC SOM FACTOR VIII BETHESDA UNITS
|
Facility
|
OP
|
$130.44
|
|
|
Service Code
|
CPT 85335
|
| Hospital Charge Code |
900915511
|
|
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 VIII BETHESDA UNITS
|
Facility
|
IP
|
$130.44
|
|
|
Service Code
|
CPT 85335
|
| Hospital Charge Code |
900915511
|
|
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 VIII INHIB PROF INTERP
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
CPT 85390
|
| Hospital Charge Code |
900915510
|
|
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 VIII INHIB PROF INTERP
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
CPT 85390
|
| Hospital Charge Code |
900915510
|
|
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
|
|
|
HC SOM FACTOR VIII INH. SCREEN
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
CPT 85335
|
| Hospital Charge Code |
900912803
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$27.15 |
| Max. Negotiated Rate |
$112.50 |
| Rate for Payer: Adventist Health Commercial |
$30.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$96.60
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$101.55
|
| Rate for Payer: Heritage Provider Network Senior |
$101.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$27.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.50
|
| Rate for Payer: Multiplan Commercial |
$112.50
|
|
|
HC SOM FACTOR VIII INH. SCREEN
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
CPT 85335
|
| Hospital Charge Code |
900912803
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$12.87 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: Adventist Health Commercial |
$30.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$92.70
|
| 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 |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$97.50
|
| 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 |
$88.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$92.85
|
| Rate for Payer: Heritage Provider Network Senior |
$92.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$71.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$27.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$14.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17.25
|
| Rate for Payer: Multiplan Commercial |
$112.50
|
| 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 V LEIDEN
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT 81241
|
| Hospital Charge Code |
900915371
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$37.50 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.20
|
| 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 Foundation Hospitals Medi-Cal |
$9.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.50
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
|
|
HC SOM FACTOR V LEIDEN
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT 81241
|
| Hospital Charge Code |
900915371
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$382.57 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$110.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$80.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$73.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$382.57
|
| Rate for Payer: Blue Shield of California Commercial |
$30.50
|
| Rate for Payer: Blue Shield of California EPN |
$24.40
|
| 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 |
$110.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$80.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$73.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$73.37
|
| 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) Medicare Advantage |
$73.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$23.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$84.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$98.32
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$73.37
|
| Rate for Payer: TriValley Medical Group Senior |
$73.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$79.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$79.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$110.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$80.71
|
| Rate for Payer: Vantage Medical Group Senior |
$73.37
|
|
|
HC SOM FANBF 86038
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
CPT 86038
|
| Hospital Charge Code |
900914925
|
|
Hospital Revenue Code
|
301
|
| 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 FANBF 86038
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
CPT 86038
|
| Hospital Charge Code |
900914925
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.09 |
| Max. Negotiated Rate |
$114.74 |
| 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 |
$18.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$114.74
|
| Rate for Payer: Blue Shield of California Commercial |
$97.29
|
| Rate for Payer: Blue Shield of California EPN |
$78.03
|
| 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 |
$18.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.09
|
| 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 |
$12.09
|
| 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 |
$13.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.20
|
| Rate for Payer: Multiplan Commercial |
$56.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.09
|
| Rate for Payer: TriValley Medical Group Senior |
$12.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.30
|
| Rate for Payer: Vantage Medical Group Senior |
$12.09
|
|
|
HC SOM FAP KNOWN MUT EXTRACT
|
Facility
|
OP
|
$318.21
|
|
|
Service Code
|
CPT 81202
|
| Hospital Charge Code |
900914620
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Adventist Health Commercial |
$63.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$196.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$420.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$308.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$280.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$124.39
|
| Rate for Payer: Blue Shield of California Commercial |
$194.11
|
| Rate for Payer: Blue Shield of California EPN |
$155.29
|
| Rate for Payer: Cash Price |
$318.21
|
| Rate for Payer: Cash Price |
$318.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$206.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$420.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$308.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$280.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$206.84
|
| Rate for Payer: EPIC Health Plan Medicare |
$280.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$196.97
|
| Rate for Payer: Heritage Provider Network Senior |
$196.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$280.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$151.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$57.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$322.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$79.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$375.20
|
| Rate for Payer: Multiplan Commercial |
$238.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$280.00
|
| Rate for Payer: TriValley Medical Group Senior |
$280.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$302.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$302.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$420.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$308.00
|
| Rate for Payer: Vantage Medical Group Senior |
$280.00
|
|
|
HC SOM FAP KNOWN MUT EXTRACT
|
Facility
|
IP
|
$318.21
|
|
|
Service Code
|
CPT 81202
|
| Hospital Charge Code |
900914620
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$238.66 |
| Rate for Payer: Adventist Health Commercial |
$63.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$204.93
|
| Rate for Payer: Cash Price |
$318.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$215.43
|
| Rate for Payer: Heritage Provider Network Senior |
$215.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$57.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$79.55
|
| Rate for Payer: Multiplan Commercial |
$238.66
|
|
|
HC SOM FASP 86606
|
Facility
|
IP
|
$77.80
|
|
|
Service Code
|
CPT 86606
|
| Hospital Charge Code |
900914727
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$14.08 |
| Max. Negotiated Rate |
$58.35 |
| Rate for Payer: Adventist Health Commercial |
$15.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$50.10
|
| Rate for Payer: Cash Price |
$77.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.67
|
| Rate for Payer: Heritage Provider Network Senior |
$52.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.45
|
| Rate for Payer: Multiplan Commercial |
$58.35
|
|
|
HC SOM FASP 86606
|
Facility
|
OP
|
$77.80
|
|
|
Service Code
|
CPT 86606
|
| Hospital Charge Code |
900914727
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$14.08 |
| Max. Negotiated Rate |
$142.93 |
| Rate for Payer: Adventist Health Commercial |
$15.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$48.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$142.93
|
| Rate for Payer: Blue Shield of California Commercial |
$121.13
|
| Rate for Payer: Blue Shield of California EPN |
$97.16
|
| Rate for Payer: Cash Price |
$77.80
|
| Rate for Payer: Cash Price |
$77.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$50.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$15.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.16
|
| Rate for Payer: Heritage Provider Network Senior |
$48.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$37.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$20.17
|
| Rate for Payer: Multiplan Commercial |
$58.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.05
|
| Rate for Payer: TriValley Medical Group Senior |
$15.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.55
|
| Rate for Payer: Vantage Medical Group Senior |
$15.05
|
|
|
HC SOM FAT FECAL QUANT
|
Facility
|
OP
|
$28.02
|
|
|
Service Code
|
CPT 82710
|
| Hospital Charge Code |
900911139
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.07 |
| Max. Negotiated Rate |
$159.55 |
| Rate for Payer: Adventist Health Commercial |
$5.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$159.55
|
| Rate for Payer: Blue Shield of California Commercial |
$135.19
|
| Rate for Payer: Blue Shield of California EPN |
$108.43
|
| Rate for Payer: Cash Price |
$28.02
|
| Rate for Payer: Cash Price |
$28.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.53
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.34
|
| Rate for Payer: Heritage Provider Network Senior |
$17.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$13.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22.51
|
| Rate for Payer: Multiplan Commercial |
$21.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.80
|
| Rate for Payer: TriValley Medical Group Senior |
$16.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.48
|
| Rate for Payer: Vantage Medical Group Senior |
$16.80
|
|
|
HC SOM FAT FECAL QUANT
|
Facility
|
IP
|
$28.02
|
|
|
Service Code
|
CPT 82710
|
| Hospital Charge Code |
900911139
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.07 |
| Max. Negotiated Rate |
$21.02 |
| Rate for Payer: Adventist Health Commercial |
$5.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.04
|
| Rate for Payer: Cash Price |
$28.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.97
|
| Rate for Payer: Heritage Provider Network Senior |
$18.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.00
|
| Rate for Payer: Multiplan Commercial |
$21.02
|
|
|
HC SOM FATTY ACIDS FREE
|
Facility
|
IP
|
$128.82
|
|
|
Service Code
|
CPT 82725
|
| Hospital Charge Code |
900910286
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.32 |
| Max. Negotiated Rate |
$96.61 |
| Rate for Payer: Adventist Health Commercial |
$25.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.96
|
| Rate for Payer: Cash Price |
$128.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$87.21
|
| Rate for Payer: Heritage Provider Network Senior |
$87.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.20
|
| Rate for Payer: Multiplan Commercial |
$96.61
|
|
|
HC SOM FATTY ACIDS FREE
|
Facility
|
OP
|
$128.82
|
|
|
Service Code
|
CPT 82725
|
| Hospital Charge Code |
900910286
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.77 |
| Max. Negotiated Rate |
$126.44 |
| Rate for Payer: Adventist Health Commercial |
$25.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$79.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$126.44
|
| Rate for Payer: Blue Shield of California Commercial |
$107.14
|
| Rate for Payer: Blue Shield of California EPN |
$85.93
|
| Rate for Payer: Cash Price |
$128.82
|
| Rate for Payer: Cash Price |
$128.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$83.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$18.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$79.74
|
| Rate for Payer: Heritage Provider Network Senior |
$79.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.77
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$61.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.15
|
| Rate for Payer: Multiplan Commercial |
$96.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.77
|
| Rate for Payer: TriValley Medical Group Senior |
$18.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.65
|
| Rate for Payer: Vantage Medical Group Senior |
$18.77
|
|
|
HC SOM FATTY ACIDS PEROXISOMAL
|
Facility
|
OP
|
$94.37
|
|
|
Service Code
|
CPT 82726
|
| Hospital Charge Code |
900911471
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.08 |
| Max. Negotiated Rate |
$170.74 |
| Rate for Payer: EPIC Health Plan Commercial |
$55.68
|
| Rate for Payer: Adventist Health Commercial |
$18.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$58.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$170.74
|
| Rate for Payer: Blue Shield of California Commercial |
$145.32
|
| Rate for Payer: Blue Shield of California EPN |
$116.56
|
| Rate for Payer: Cash Price |
$94.37
|
| Rate for Payer: Cash Price |
$94.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$61.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.73
|
| Rate for Payer: Dignity Health Medicare Advantage |
$19.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$19.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.42
|
| Rate for Payer: Heritage Provider Network Senior |
$58.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$45.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$26.46
|
| Rate for Payer: Multiplan Commercial |
$70.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.75
|
| Rate for Payer: TriValley Medical Group Senior |
$19.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$21.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.73
|
| Rate for Payer: Vantage Medical Group Senior |
$19.75
|
|
|
HC SOM FATTY ACIDS PEROXISOMAL
|
Facility
|
IP
|
$94.37
|
|
|
Service Code
|
CPT 82726
|
| Hospital Charge Code |
900911471
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.08 |
| Max. Negotiated Rate |
$70.78 |
| Rate for Payer: Adventist Health Commercial |
$18.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$60.77
|
| Rate for Payer: Cash Price |
$94.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$63.89
|
| Rate for Payer: Heritage Provider Network Senior |
$63.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.59
|
| Rate for Payer: Multiplan Commercial |
$70.78
|
|
|
HC SOM FBIOT 84591
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 84591
|
| Hospital Charge Code |
900914760
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.06 |
| Max. Negotiated Rate |
$110.01 |
| Rate for Payer: EPIC Health Plan Commercial |
$59.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.06
|
| Rate for Payer: Adventist Health Commercial |
$20.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$61.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$110.01
|
| Rate for Payer: Blue Shield of California Commercial |
$93.31
|
| Rate for Payer: Blue Shield of California EPN |
$74.84
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$65.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$17.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$61.90
|
| Rate for Payer: Heritage Provider Network Senior |
$61.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$47.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22.86
|
| Rate for Payer: Multiplan Commercial |
$75.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.06
|
| Rate for Payer: TriValley Medical Group Senior |
$17.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.77
|
| Rate for Payer: Vantage Medical Group Senior |
$17.06
|
|
|
HC SOM FBIOT 84591
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 84591
|
| Hospital Charge Code |
900914760
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.10 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Adventist Health Commercial |
$20.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$64.40
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$67.70
|
| Rate for Payer: Heritage Provider Network Senior |
$67.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.00
|
| Rate for Payer: Multiplan Commercial |
$75.00
|
|
|
HC SOM FBP1 88273
|
Facility
|
IP
|
$84.86
|
|
|
Service Code
|
CPT 88273
|
| Hospital Charge Code |
900914874
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$15.36 |
| Max. Negotiated Rate |
$63.65 |
| Rate for Payer: Adventist Health Commercial |
$16.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$54.65
|
| Rate for Payer: Cash Price |
$84.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$57.45
|
| Rate for Payer: Heritage Provider Network Senior |
$57.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.21
|
| Rate for Payer: Multiplan Commercial |
$63.65
|
|
