|
HC SOM TRYPTASE
|
Facility
|
IP
|
$37.70
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
900910734
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.82 |
| Max. Negotiated Rate |
$28.27 |
| Rate for Payer: Adventist Health Commercial |
$7.54
|
| Rate for Payer: Cash Price |
$37.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.52
|
| Rate for Payer: Heritage Provider Network Senior |
$25.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.43
|
| Rate for Payer: Multiplan Commercial |
$28.27
|
|
|
HC SOM TSH SENSITIVE, SERUM
|
Facility
|
IP
|
$24.06
|
|
|
Service Code
|
CPT 84443
|
| Hospital Charge Code |
900913813
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$18.05 |
| Rate for Payer: Adventist Health Commercial |
$4.81
|
| Rate for Payer: Cash Price |
$24.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.29
|
| Rate for Payer: Heritage Provider Network Senior |
$16.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.01
|
| Rate for Payer: Multiplan Commercial |
$18.05
|
|
|
HC SOM TSH SENSITIVE, SERUM
|
Facility
|
OP
|
$24.06
|
|
|
Service Code
|
CPT 84443
|
| Hospital Charge Code |
900913813
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$153.41 |
| Rate for Payer: Adventist Health Commercial |
$4.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.53
|
| 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 |
$153.41
|
| 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 |
$24.06
|
| Rate for Payer: Cash Price |
$24.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.48
|
| Rate for Payer: Dignity Health Senior |
$16.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.64
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.89
|
| Rate for Payer: Heritage Provider Network Senior |
$14.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23.91
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.17
|
| Rate for Payer: Multiplan Commercial |
$18.05
|
| 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 TTFB 84402A
|
Facility
|
OP
|
$81.10
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
900914762
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.68 |
| Max. Negotiated Rate |
$237.43 |
| Rate for Payer: Adventist Health Commercial |
$16.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$55.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$28.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$237.43
|
| Rate for Payer: Blue Shield of California Commercial |
$204.88
|
| Rate for Payer: Blue Shield of California EPN |
$164.33
|
| Rate for Payer: Cash Price |
$81.10
|
| Rate for Payer: Cash Price |
$81.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.02
|
| Rate for Payer: Dignity Health Senior |
$25.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.72
|
| Rate for Payer: EPIC Health Plan Medicare |
$25.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.20
|
| Rate for Payer: Heritage Provider Network Senior |
$50.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$36.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$25.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.09
|
| Rate for Payer: Multiplan Commercial |
$60.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$25.47
|
| Rate for Payer: TriValley Medical Group Senior |
$25.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.02
|
| Rate for Payer: Vantage Medical Group Senior |
$25.47
|
|
|
HC SOM TTFB 84402A
|
Facility
|
IP
|
$81.10
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
900914762
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.68 |
| Max. Negotiated Rate |
$60.83 |
| Rate for Payer: Adventist Health Commercial |
$16.22
|
| Rate for Payer: Cash Price |
$81.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.90
|
| Rate for Payer: Heritage Provider Network Senior |
$54.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.27
|
| Rate for Payer: Multiplan Commercial |
$60.83
|
|
|
HC SOM TTFB 84402B
|
Facility
|
OP
|
$81.10
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
900914763
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.68 |
| Max. Negotiated Rate |
$237.43 |
| Rate for Payer: Adventist Health Commercial |
$16.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$55.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$28.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$237.43
|
| Rate for Payer: Blue Shield of California Commercial |
$204.88
|
| Rate for Payer: Blue Shield of California EPN |
$164.33
|
| Rate for Payer: Cash Price |
$81.10
|
| Rate for Payer: Cash Price |
$81.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.02
|
| Rate for Payer: Dignity Health Senior |
$25.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.72
|
| Rate for Payer: EPIC Health Plan Medicare |
$25.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.20
|
| Rate for Payer: Heritage Provider Network Senior |
$50.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$36.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$25.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.09
|
| Rate for Payer: Multiplan Commercial |
$60.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$25.47
|
| Rate for Payer: TriValley Medical Group Senior |
$25.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.02
|
| Rate for Payer: Vantage Medical Group Senior |
$25.47
|
|
|
HC SOM TTFB 84402B
|
Facility
|
IP
|
$81.10
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
900914763
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.68 |
| Max. Negotiated Rate |
$60.83 |
| Rate for Payer: Adventist Health Commercial |
$16.22
|
| Rate for Payer: Cash Price |
$81.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.90
|
| Rate for Payer: Heritage Provider Network Senior |
$54.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.27
|
| Rate for Payer: Multiplan Commercial |
$60.83
|
|
|
HC SOM TTFB 84403
|
Facility
|
OP
|
$82.23
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
900914764
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.88 |
| Max. Negotiated Rate |
$235.65 |
| Rate for Payer: Adventist Health Commercial |
$16.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$28.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$235.65
|
| Rate for Payer: Blue Shield of California Commercial |
$207.82
|
| Rate for Payer: Blue Shield of California EPN |
$166.69
|
| Rate for Payer: Cash Price |
$82.23
|
| Rate for Payer: Cash Price |
$82.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.39
|
| Rate for Payer: Dignity Health Senior |
$25.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$25.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.90
|
| Rate for Payer: Heritage Provider Network Senior |
$50.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$36.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$25.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$39.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.88
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.52
|
| Rate for Payer: Multiplan Commercial |
$61.67
|
| Rate for Payer: TriValley Medical Group Commercial |
$25.81
|
| Rate for Payer: TriValley Medical Group Senior |
$25.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.39
|
| Rate for Payer: Vantage Medical Group Senior |
$25.81
|
|
|
HC SOM TTFB 84403
|
Facility
|
IP
|
$82.23
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
900914764
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.88 |
| Max. Negotiated Rate |
$61.67 |
| Rate for Payer: Adventist Health Commercial |
$16.45
|
| Rate for Payer: Cash Price |
$82.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.67
|
| Rate for Payer: Heritage Provider Network Senior |
$55.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.56
|
| Rate for Payer: Multiplan Commercial |
$61.67
|
|
|
HC SOM UBEMS 81406
|
Facility
|
IP
|
$967.50
|
|
|
Service Code
|
CPT 81406
|
| Hospital Charge Code |
900914886
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$175.12 |
| Max. Negotiated Rate |
$725.62 |
| Rate for Payer: Adventist Health Commercial |
$193.50
|
| Rate for Payer: Cash Price |
$967.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$655.00
|
| Rate for Payer: Heritage Provider Network Senior |
$655.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$175.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$241.88
|
| Rate for Payer: Multiplan Commercial |
$725.62
|
|
|
HC SOM UBEMS 81406
|
Facility
|
OP
|
$967.50
|
|
|
Service Code
|
CPT 81406
|
| Hospital Charge Code |
900914886
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$175.12 |
| Max. Negotiated Rate |
$2,194.72 |
| Rate for Payer: Adventist Health Commercial |
$193.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$517.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$664.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$424.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$311.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$282.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,194.72
|
| Rate for Payer: Blue Shield of California Commercial |
$590.17
|
| Rate for Payer: Blue Shield of California EPN |
$472.14
|
| Rate for Payer: Cash Price |
$967.50
|
| Rate for Payer: Cash Price |
$967.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$628.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$424.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$311.17
|
| Rate for Payer: Dignity Health Senior |
$282.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$628.88
|
| Rate for Payer: EPIC Health Plan Medicare |
$282.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$598.88
|
| Rate for Payer: Heritage Provider Network Senior |
$598.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$458.27
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$282.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$461.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$175.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$325.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$241.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$356.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$356.43
|
| Rate for Payer: Multiplan Commercial |
$725.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$282.88
|
| Rate for Payer: TriValley Medical Group Senior |
$282.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$305.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$305.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$424.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$311.17
|
| Rate for Payer: Vantage Medical Group Senior |
$282.88
|
|
|
HC SOM UNFRACT HEPARIN DEP PLT
|
Facility
|
IP
|
$357.00
|
|
|
Service Code
|
CPT 86022
|
| Hospital Charge Code |
900914710
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$64.62 |
| Max. Negotiated Rate |
$267.75 |
| Rate for Payer: Adventist Health Commercial |
$71.40
|
| Rate for Payer: Cash Price |
$357.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$241.69
|
| Rate for Payer: Heritage Provider Network Senior |
$241.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$64.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.25
|
| Rate for Payer: Multiplan Commercial |
$267.75
|
|
|
HC SOM UNFRACT HEPARIN DEP PLT
|
Facility
|
OP
|
$357.00
|
|
|
Service Code
|
CPT 86022
|
| Hospital Charge Code |
900914710
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$18.37 |
| Max. Negotiated Rate |
$267.75 |
| Rate for Payer: Adventist Health Commercial |
$71.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$190.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$245.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$142.29
|
| Rate for Payer: Blue Shield of California Commercial |
$147.80
|
| Rate for Payer: Blue Shield of California EPN |
$118.55
|
| Rate for Payer: Cash Price |
$357.00
|
| Rate for Payer: Cash Price |
$357.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$232.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.21
|
| Rate for Payer: Dignity Health Senior |
$18.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$232.05
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$220.98
|
| Rate for Payer: Heritage Provider Network Senior |
$220.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$26.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$170.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$64.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.15
|
| Rate for Payer: Multiplan Commercial |
$267.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.37
|
| Rate for Payer: TriValley Medical Group Senior |
$18.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.21
|
| Rate for Payer: Vantage Medical Group Senior |
$18.37
|
|
|
HC SOM UNIPARENTAL DISOMY AMP
|
Facility
|
OP
|
$275.48
|
|
|
Service Code
|
CPT 81402
|
| Hospital Charge Code |
900914445
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$49.86 |
| Max. Negotiated Rate |
$679.04 |
| Rate for Payer: Adventist Health Commercial |
$55.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$147.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$189.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$225.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$165.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$150.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$679.04
|
| Rate for Payer: Blue Shield of California Commercial |
$168.04
|
| Rate for Payer: Blue Shield of California EPN |
$134.43
|
| Rate for Payer: Cash Price |
$275.48
|
| Rate for Payer: Cash Price |
$275.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$179.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$225.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$165.36
|
| Rate for Payer: Dignity Health Senior |
$150.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$179.06
|
| Rate for Payer: EPIC Health Plan Medicare |
$150.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$170.52
|
| Rate for Payer: Heritage Provider Network Senior |
$170.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$243.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$150.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$131.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$172.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$189.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$189.42
|
| Rate for Payer: Multiplan Commercial |
$206.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$150.33
|
| Rate for Payer: TriValley Medical Group Senior |
$150.33
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$162.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$162.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$225.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$165.36
|
| Rate for Payer: Vantage Medical Group Senior |
$150.33
|
|
|
HC SOM UNIPARENTAL DISOMY AMP
|
Facility
|
IP
|
$275.48
|
|
|
Service Code
|
CPT 81402
|
| Hospital Charge Code |
900914445
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$49.86 |
| Max. Negotiated Rate |
$206.61 |
| Rate for Payer: Adventist Health Commercial |
$55.10
|
| Rate for Payer: Cash Price |
$275.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$186.50
|
| Rate for Payer: Heritage Provider Network Senior |
$186.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.87
|
| Rate for Payer: Multiplan Commercial |
$206.61
|
|
|
HC SOM UREAPLASMA PCR
|
Facility
|
IP
|
$37.50
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
900912878
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$6.79 |
| Max. Negotiated Rate |
$28.12 |
| Rate for Payer: Adventist Health Commercial |
$7.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.39
|
| Rate for Payer: Heritage Provider Network Senior |
$25.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.38
|
| Rate for Payer: Multiplan Commercial |
$28.12
|
|
|
HC SOM UREAPLASMA PCR
|
Facility
|
OP
|
$37.50
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
900912878
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$6.79 |
| Max. Negotiated Rate |
$310.02 |
| Rate for Payer: Adventist Health Commercial |
$7.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$20.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$52.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$310.02
|
| Rate for Payer: Blue Shield of California Commercial |
$282.47
|
| Rate for Payer: Blue Shield of California EPN |
$226.56
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.60
|
| Rate for Payer: Dignity Health Senior |
$35.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.38
|
| Rate for Payer: EPIC Health Plan Medicare |
$35.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.21
|
| Rate for Payer: Heritage Provider Network Senior |
$23.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$48.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$40.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$44.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$44.21
|
| Rate for Payer: Multiplan Commercial |
$28.12
|
| 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 VARICELLA ZOSTER ANTIBODY
|
Facility
|
OP
|
$14.17
|
|
|
Service Code
|
CPT 86787
|
| Hospital Charge Code |
900912868
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$117.64 |
| Rate for Payer: Adventist Health Commercial |
$2.83
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$117.64
|
| Rate for Payer: Blue Shield of California Commercial |
$103.68
|
| Rate for Payer: Blue Shield of California EPN |
$83.16
|
| Rate for Payer: Cash Price |
$14.17
|
| Rate for Payer: Cash Price |
$14.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.17
|
| Rate for Payer: Dignity Health Senior |
$12.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.21
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.77
|
| Rate for Payer: Heritage Provider Network Senior |
$8.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.23
|
| Rate for Payer: Multiplan Commercial |
$10.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.88
|
| Rate for Payer: TriValley Medical Group Senior |
$12.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.17
|
| Rate for Payer: Vantage Medical Group Senior |
$12.88
|
|
|
HC SOM VARICELLA ZOSTER ANTIBODY
|
Facility
|
IP
|
$14.17
|
|
|
Service Code
|
CPT 86787
|
| Hospital Charge Code |
900912868
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$10.63 |
| Rate for Payer: Adventist Health Commercial |
$2.83
|
| Rate for Payer: Cash Price |
$14.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.59
|
| Rate for Payer: Heritage Provider Network Senior |
$9.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.54
|
| Rate for Payer: Multiplan Commercial |
$10.63
|
|
|
HC SOM VASCULITIS PANEL P3 AB
|
Facility
|
IP
|
$17.50
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
900912702
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$13.12 |
| Rate for Payer: Adventist Health Commercial |
$3.50
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.85
|
| Rate for Payer: Heritage Provider Network Senior |
$11.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$13.12
|
|
|
HC SOM VASCULITIS PANEL P3 AB
|
Facility
|
OP
|
$17.50
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
900912702
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$213.58 |
| Rate for Payer: Adventist Health Commercial |
$3.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$213.58
|
| Rate for Payer: Blue Shield of California Commercial |
$74.76
|
| Rate for Payer: Blue Shield of California EPN |
$59.97
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.68
|
| Rate for Payer: Dignity Health Senior |
$11.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.38
|
| Rate for Payer: EPIC Health Plan Medicare |
$11.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.83
|
| Rate for Payer: Heritage Provider Network Senior |
$10.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.53
|
| Rate for Payer: Multiplan Commercial |
$13.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.53
|
| Rate for Payer: TriValley Medical Group Senior |
$11.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.68
|
| Rate for Payer: Vantage Medical Group Senior |
$11.53
|
|
|
HC SOM VASOACTIVE INTESTINAL PEPTIDE
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT 84586
|
| Hospital Charge Code |
900911186
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$106.88 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$52.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$106.88
|
| Rate for Payer: Blue Shield of California Commercial |
$101.84
|
| Rate for Payer: Blue Shield of California EPN |
$81.68
|
| 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 |
$52.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.86
|
| Rate for Payer: Dignity Health Senior |
$35.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$35.33
|
| 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 |
$35.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$40.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$44.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$44.52
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$35.33
|
| Rate for Payer: TriValley Medical Group Senior |
$35.33
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$38.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$52.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.86
|
| Rate for Payer: Vantage Medical Group Senior |
$35.33
|
|
|
HC SOM VASOACTIVE INTESTINAL PEPTIDE
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT 84586
|
| Hospital Charge Code |
900911186
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$37.50 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.85
|
| Rate for Payer: Heritage Provider Network Senior |
$33.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.50
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
|
|
HC SOM VDER 87529
|
Facility
|
OP
|
$50.27
|
|
|
Service Code
|
CPT 87529
|
| Hospital Charge Code |
900913965
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$310.02 |
| Rate for Payer: Adventist Health Commercial |
$10.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$52.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$310.02
|
| Rate for Payer: Blue Shield of California Commercial |
$282.47
|
| Rate for Payer: Blue Shield of California EPN |
$226.56
|
| Rate for Payer: Cash Price |
$50.27
|
| Rate for Payer: Cash Price |
$50.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.60
|
| Rate for Payer: Dignity Health Senior |
$35.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.68
|
| Rate for Payer: EPIC Health Plan Medicare |
$35.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.12
|
| Rate for Payer: Heritage Provider Network Senior |
$31.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$39.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$40.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$44.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$44.21
|
| Rate for Payer: Multiplan Commercial |
$37.70
|
| 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 VDER 87529
|
Facility
|
IP
|
$50.27
|
|
|
Service Code
|
CPT 87529
|
| Hospital Charge Code |
900913965
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$37.70 |
| Rate for Payer: Adventist Health Commercial |
$10.05
|
| Rate for Payer: Cash Price |
$50.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.03
|
| Rate for Payer: Heritage Provider Network Senior |
$34.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.57
|
| Rate for Payer: Multiplan Commercial |
$37.70
|
|
