|
HC SOM FLURAZEPAM (DALMANE) LEVEL
|
Facility
|
IP
|
$67.52
|
|
|
Service Code
|
CPT 80346
|
| Hospital Charge Code |
900911084
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.22 |
| Max. Negotiated Rate |
$50.64 |
| Rate for Payer: Adventist Health Commercial |
$13.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$43.48
|
| Rate for Payer: Cash Price |
$67.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$45.71
|
| Rate for Payer: Heritage Provider Network Senior |
$45.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.88
|
| Rate for Payer: Multiplan Commercial |
$50.64
|
|
|
HC SOM FLURAZEPAM (DALMANE) LEVEL
|
Facility
|
OP
|
$67.52
|
|
|
Service Code
|
CPT 80346
|
| Hospital Charge Code |
900911084
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.22 |
| Max. Negotiated Rate |
$168.43 |
| Rate for Payer: Adventist Health Commercial |
$13.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$57.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$37.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$50.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$168.43
|
| Rate for Payer: Cash Price |
$67.52
|
| Rate for Payer: Cash Price |
$67.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$43.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$57.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$57.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$57.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.79
|
| Rate for Payer: Heritage Provider Network Senior |
$41.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$32.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$47.26
|
| Rate for Payer: Multiplan Commercial |
$50.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$33.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$33.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$57.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$57.39
|
| Rate for Payer: Vantage Medical Group Senior |
$57.39
|
|
|
HC SOM FMGA 84181
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
CPT 84181
|
| Hospital Charge Code |
900914770
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$22.62 |
| Max. Negotiated Rate |
$93.75 |
| Rate for Payer: Adventist Health Commercial |
$25.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.50
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$84.62
|
| Rate for Payer: Heritage Provider Network Senior |
$84.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$22.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.25
|
| Rate for Payer: Multiplan Commercial |
$93.75
|
|
|
HC SOM FMGA 84181
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
CPT 84181
|
| Hospital Charge Code |
900914770
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$17.03 |
| Max. Negotiated Rate |
$161.72 |
| Rate for Payer: Adventist Health Commercial |
$25.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$161.72
|
| Rate for Payer: Blue Shield of California Commercial |
$137.09
|
| Rate for Payer: Blue Shield of California EPN |
$109.96
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$81.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.73
|
| Rate for Payer: Dignity Health Medicare Advantage |
$17.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$77.38
|
| Rate for Payer: Heritage Provider Network Senior |
$77.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$59.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$22.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22.82
|
| Rate for Payer: Multiplan Commercial |
$93.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.03
|
| Rate for Payer: TriValley Medical Group Senior |
$17.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.73
|
| Rate for Payer: Vantage Medical Group Senior |
$17.03
|
|
|
HC SOM FMGS 83520A
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
900914771
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$122.92 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$67.98
|
| Rate for Payer: Adventist Health Commercial |
$22.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$122.92
|
| Rate for Payer: Blue Shield of California Commercial |
$104.20
|
| Rate for Payer: Blue Shield of California EPN |
$83.58
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$71.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$17.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$68.09
|
| Rate for Payer: Heritage Provider Network Senior |
$68.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$52.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$23.14
|
| Rate for Payer: Multiplan Commercial |
$82.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.27
|
| Rate for Payer: TriValley Medical Group Senior |
$17.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.00
|
| Rate for Payer: Vantage Medical Group Senior |
$17.27
|
|
|
HC SOM FMGS 83520A
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
900914771
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$19.91 |
| Max. Negotiated Rate |
$82.50 |
| Rate for Payer: Adventist Health Commercial |
$22.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$70.84
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$74.47
|
| Rate for Payer: Heritage Provider Network Senior |
$74.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.50
|
| Rate for Payer: Multiplan Commercial |
$82.50
|
|
|
HC SOM FMGS 83520B
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
900914772
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$19.91 |
| Max. Negotiated Rate |
$82.50 |
| Rate for Payer: Adventist Health Commercial |
$22.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$70.84
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$74.47
|
| Rate for Payer: Heritage Provider Network Senior |
$74.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.50
|
| Rate for Payer: Multiplan Commercial |
$82.50
|
|
|
HC SOM FMGS 83520B
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
900914772
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$122.92 |
| Rate for Payer: Adventist Health Commercial |
$22.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$67.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$122.92
|
| Rate for Payer: Blue Shield of California Commercial |
$104.20
|
| Rate for Payer: Blue Shield of California EPN |
$83.58
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$71.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$17.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$68.09
|
| Rate for Payer: Heritage Provider Network Senior |
$68.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$52.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$23.14
|
| Rate for Payer: Multiplan Commercial |
$82.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.27
|
| Rate for Payer: TriValley Medical Group Senior |
$17.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.00
|
| Rate for Payer: Vantage Medical Group Senior |
$17.27
|
|
|
HC SOM FMIS 83520
|
Facility
|
OP
|
$177.73
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
900914924
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$133.30 |
| Rate for Payer: Adventist Health Commercial |
$35.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$109.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$122.92
|
| Rate for Payer: Blue Shield of California Commercial |
$104.20
|
| Rate for Payer: Blue Shield of California EPN |
$83.58
|
| Rate for Payer: Cash Price |
$177.73
|
| Rate for Payer: Cash Price |
$177.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$115.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$17.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$104.86
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$110.01
|
| Rate for Payer: Heritage Provider Network Senior |
$110.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$84.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$32.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$23.14
|
| Rate for Payer: Multiplan Commercial |
$133.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.27
|
| Rate for Payer: TriValley Medical Group Senior |
$17.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.00
|
| Rate for Payer: Vantage Medical Group Senior |
$17.27
|
|
|
HC SOM FMIS 83520
|
Facility
|
IP
|
$177.73
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
900914924
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$32.17 |
| Max. Negotiated Rate |
$133.30 |
| Rate for Payer: Adventist Health Commercial |
$35.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$114.46
|
| Rate for Payer: Cash Price |
$177.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$120.32
|
| Rate for Payer: Heritage Provider Network Senior |
$120.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$32.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.43
|
| Rate for Payer: Multiplan Commercial |
$133.30
|
|
|
HC SOM FNTSM
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900914870
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$24.09 |
| Max. Negotiated Rate |
$170.74 |
| Rate for Payer: Adventist Health Commercial |
$35.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$108.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.09
|
| 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 |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$113.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$103.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$24.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$108.33
|
| Rate for Payer: Heritage Provider Network Senior |
$108.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$83.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$31.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32.28
|
| Rate for Payer: Multiplan Commercial |
$131.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.09
|
| Rate for Payer: TriValley Medical Group Senior |
$24.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Vantage Medical Group Senior |
$24.09
|
|
|
HC SOM FNTSM
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900914870
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.68 |
| Max. Negotiated Rate |
$131.25 |
| Rate for Payer: Adventist Health Commercial |
$35.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$112.70
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$118.47
|
| Rate for Payer: Heritage Provider Network Senior |
$118.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$31.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.75
|
| Rate for Payer: Multiplan Commercial |
$131.25
|
|
|
HC SOM FNTSM 82492A
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900914868
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$24.09 |
| Max. Negotiated Rate |
$170.74 |
| Rate for Payer: Adventist Health Commercial |
$35.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$108.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.09
|
| 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 |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$113.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$103.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$24.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$108.33
|
| Rate for Payer: Heritage Provider Network Senior |
$108.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$83.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$31.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32.28
|
| Rate for Payer: Multiplan Commercial |
$131.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.09
|
| Rate for Payer: TriValley Medical Group Senior |
$24.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Vantage Medical Group Senior |
$24.09
|
|
|
HC SOM FNTSM 82492A
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900914868
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.68 |
| Max. Negotiated Rate |
$131.25 |
| Rate for Payer: Adventist Health Commercial |
$35.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$112.70
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$118.47
|
| Rate for Payer: Heritage Provider Network Senior |
$118.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$31.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.75
|
| Rate for Payer: Multiplan Commercial |
$131.25
|
|
|
HC SOM FNTSM 82492B
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900914869
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$24.09 |
| Max. Negotiated Rate |
$170.74 |
| Rate for Payer: Adventist Health Commercial |
$35.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$108.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.09
|
| 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 |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$113.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$103.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$24.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$108.33
|
| Rate for Payer: Heritage Provider Network Senior |
$108.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$83.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$31.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32.28
|
| Rate for Payer: Multiplan Commercial |
$131.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.09
|
| Rate for Payer: TriValley Medical Group Senior |
$24.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Vantage Medical Group Senior |
$24.09
|
|
|
HC SOM FNTSM 82492B
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900914869
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.68 |
| Max. Negotiated Rate |
$131.25 |
| Rate for Payer: Adventist Health Commercial |
$35.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$112.70
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$118.47
|
| Rate for Payer: Heritage Provider Network Senior |
$118.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$31.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.75
|
| Rate for Payer: Multiplan Commercial |
$131.25
|
|
|
HC SOM FOLATE, RBC
|
Facility
|
IP
|
$52.50
|
|
|
Service Code
|
CPT 82747
|
| Hospital Charge Code |
900913862
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$39.38 |
| Rate for Payer: Adventist Health Commercial |
$10.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33.81
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.54
|
| Rate for Payer: Heritage Provider Network Senior |
$35.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.12
|
| Rate for Payer: Multiplan Commercial |
$39.38
|
|
|
HC SOM FOLATE, RBC
|
Facility
|
OP
|
$52.50
|
|
|
Service Code
|
CPT 82747
|
| Hospital Charge Code |
900913862
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$170.48 |
| Rate for Payer: Adventist Health Commercial |
$10.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$170.48
|
| Rate for Payer: Blue Shield of California Commercial |
$139.39
|
| Rate for Payer: Blue Shield of California EPN |
$111.80
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$34.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$17.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.98
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.50
|
| Rate for Payer: Heritage Provider Network Senior |
$32.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$25.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$20.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$23.65
|
| Rate for Payer: Multiplan Commercial |
$39.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.65
|
| Rate for Payer: TriValley Medical Group Senior |
$17.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.41
|
| Rate for Payer: Vantage Medical Group Senior |
$17.65
|
|
|
HC SOM FPRSG 84150
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
CPT 84150
|
| Hospital Charge Code |
900914777
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$41.77 |
| Max. Negotiated Rate |
$262.50 |
| Rate for Payer: Adventist Health Commercial |
$70.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$216.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$62.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$41.77
|
| 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 |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$227.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$62.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$45.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$41.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$206.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$41.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$216.65
|
| Rate for Payer: Heritage Provider Network Senior |
$216.65
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$41.77
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$166.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$63.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$48.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$87.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$55.97
|
| Rate for Payer: Multiplan Commercial |
$262.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$41.77
|
| Rate for Payer: TriValley Medical Group Senior |
$41.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$45.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$62.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$45.95
|
| Rate for Payer: Vantage Medical Group Senior |
$41.77
|
|
|
HC SOM FPRSG 84150
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
CPT 84150
|
| Hospital Charge Code |
900914777
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$63.35 |
| Max. Negotiated Rate |
$262.50 |
| Rate for Payer: Adventist Health Commercial |
$70.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$225.40
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$236.95
|
| Rate for Payer: Heritage Provider Network Senior |
$236.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$63.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$87.50
|
| Rate for Payer: Multiplan Commercial |
$262.50
|
|
|
HC SOM FPSAP 84153
|
Facility
|
IP
|
$89.50
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
900914765
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.20 |
| Max. Negotiated Rate |
$67.12 |
| Rate for Payer: Adventist Health Commercial |
$17.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$57.64
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.59
|
| Rate for Payer: Heritage Provider Network Senior |
$60.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.38
|
| Rate for Payer: Multiplan Commercial |
$67.12
|
|
|
HC SOM FPSAP 84153
|
Facility
|
OP
|
$89.50
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
900914765
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.20 |
| Max. Negotiated Rate |
$174.63 |
| Rate for Payer: Adventist Health Commercial |
$17.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$55.31
|
| 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 |
$174.63
|
| 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 |
$89.50
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$58.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$18.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.40
|
| Rate for Payer: Heritage Provider Network Senior |
$55.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$42.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$24.64
|
| Rate for Payer: Multiplan Commercial |
$67.12
|
| 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 FQUET 82491
|
Facility
|
IP
|
$66.16
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900914892
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.97 |
| Max. Negotiated Rate |
$49.62 |
| Rate for Payer: Adventist Health Commercial |
$13.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$42.61
|
| Rate for Payer: Cash Price |
$66.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.79
|
| Rate for Payer: Heritage Provider Network Senior |
$44.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.54
|
| Rate for Payer: Multiplan Commercial |
$49.62
|
|
|
HC SOM FQUET 82491
|
Facility
|
OP
|
$66.16
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900914892
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.97 |
| Max. Negotiated Rate |
$170.74 |
| Rate for Payer: Adventist Health Commercial |
$13.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.09
|
| 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 |
$66.16
|
| Rate for Payer: Cash Price |
$66.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$43.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.03
|
| Rate for Payer: EPIC Health Plan Medicare |
$24.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.95
|
| Rate for Payer: Heritage Provider Network Senior |
$40.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$31.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32.28
|
| Rate for Payer: Multiplan Commercial |
$49.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.09
|
| Rate for Payer: TriValley Medical Group Senior |
$24.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Vantage Medical Group Senior |
$24.09
|
|
|
HC SOM FRAGILE X FU ANALYSIS
|
Facility
|
IP
|
$216.50
|
|
|
Service Code
|
CPT 81244
|
| Hospital Charge Code |
900915280
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$39.19 |
| Max. Negotiated Rate |
$162.38 |
| Rate for Payer: Adventist Health Commercial |
$43.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$139.43
|
| Rate for Payer: Cash Price |
$216.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$146.57
|
| Rate for Payer: Heritage Provider Network Senior |
$146.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$39.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54.12
|
| Rate for Payer: Multiplan Commercial |
$162.38
|
|
