|
HC SOM VDER 87798
|
Facility
|
IP
|
$50.27
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
900913966
|
|
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
|
|
|
HC SOM VDER 87798
|
Facility
|
OP
|
$50.27
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
900913966
|
|
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 |
$48.84
|
| 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 VEDOLIZUMAB AB
|
Facility
|
OP
|
$62.98
|
|
|
Service Code
|
CPT 82397
|
| Hospital Charge Code |
900915325
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$11.40 |
| Max. Negotiated Rate |
$129.01 |
| Rate for Payer: Adventist Health Commercial |
$12.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$33.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$43.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$129.01
|
| Rate for Payer: Blue Shield of California Commercial |
$113.70
|
| Rate for Payer: Blue Shield of California EPN |
$91.20
|
| Rate for Payer: Cash Price |
$62.98
|
| Rate for Payer: Cash Price |
$62.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.53
|
| Rate for Payer: Dignity Health Senior |
$14.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.94
|
| Rate for Payer: EPIC Health Plan Medicare |
$14.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.98
|
| Rate for Payer: Heritage Provider Network Senior |
$38.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$20.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$30.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$16.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.79
|
| Rate for Payer: Multiplan Commercial |
$47.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.12
|
| Rate for Payer: TriValley Medical Group Senior |
$14.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.53
|
| Rate for Payer: Vantage Medical Group Senior |
$14.12
|
|
|
HC SOM VEDOLIZUMAB AB
|
Facility
|
IP
|
$62.98
|
|
|
Service Code
|
CPT 82397
|
| Hospital Charge Code |
900915325
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$11.40 |
| Max. Negotiated Rate |
$47.23 |
| Rate for Payer: Adventist Health Commercial |
$12.60
|
| Rate for Payer: Cash Price |
$62.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$42.64
|
| Rate for Payer: Heritage Provider Network Senior |
$42.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.74
|
| Rate for Payer: Multiplan Commercial |
$47.23
|
|
|
HC SOM VEDOLIZUMAB QN
|
Facility
|
IP
|
$172.02
|
|
|
Service Code
|
CPT 80280
|
| Hospital Charge Code |
900915324
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.14 |
| Max. Negotiated Rate |
$129.01 |
| Rate for Payer: Adventist Health Commercial |
$34.40
|
| Rate for Payer: Cash Price |
$172.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$116.46
|
| Rate for Payer: Heritage Provider Network Senior |
$116.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.01
|
| Rate for Payer: Multiplan Commercial |
$129.01
|
|
|
HC SOM VEDOLIZUMAB QN
|
Facility
|
OP
|
$172.02
|
|
|
Service Code
|
CPT 80280
|
| Hospital Charge Code |
900915324
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.14 |
| Max. Negotiated Rate |
$222.16 |
| Rate for Payer: Adventist Health Commercial |
$34.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$91.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$118.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$57.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$42.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$38.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$124.77
|
| Rate for Payer: Blue Shield of California Commercial |
$222.16
|
| Rate for Payer: Blue Shield of California EPN |
$178.19
|
| Rate for Payer: Cash Price |
$172.02
|
| Rate for Payer: Cash Price |
$172.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$111.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$57.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.43
|
| Rate for Payer: Dignity Health Senior |
$38.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$111.81
|
| Rate for Payer: EPIC Health Plan Medicare |
$38.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$106.48
|
| Rate for Payer: Heritage Provider Network Senior |
$106.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$49.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$38.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$82.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$44.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$48.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$48.60
|
| Rate for Payer: Multiplan Commercial |
$129.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$38.57
|
| Rate for Payer: TriValley Medical Group Senior |
$38.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$41.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$41.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$57.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.43
|
| Rate for Payer: Vantage Medical Group Senior |
$38.57
|
|
|
HC SOM VITAMIN A
|
Facility
|
IP
|
$17.90
|
|
|
Service Code
|
CPT 84590
|
| Hospital Charge Code |
900911173
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$13.43 |
| Rate for Payer: Adventist Health Commercial |
$3.58
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.12
|
| Rate for Payer: Heritage Provider Network Senior |
$12.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.47
|
| Rate for Payer: Multiplan Commercial |
$13.43
|
|
|
HC SOM VITAMIN A
|
Facility
|
OP
|
$17.90
|
|
|
Service Code
|
CPT 84590
|
| Hospital Charge Code |
900911173
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$105.84 |
| Rate for Payer: Adventist Health Commercial |
$3.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$105.84
|
| 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 |
$17.90
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.77
|
| Rate for Payer: Dignity Health Senior |
$11.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.63
|
| Rate for Payer: EPIC Health Plan Medicare |
$11.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.08
|
| Rate for Payer: Heritage Provider Network Senior |
$11.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.63
|
| Rate for Payer: Multiplan Commercial |
$13.43
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.61
|
| Rate for Payer: TriValley Medical Group Senior |
$11.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.77
|
| Rate for Payer: Vantage Medical Group Senior |
$11.61
|
|
|
HC SOM VITAMIN B1 (THIAMINE)
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 84425
|
| Hospital Charge Code |
900911048
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.98 |
| Max. Negotiated Rate |
$16.50 |
| Rate for Payer: Adventist Health Commercial |
$4.40
|
| Rate for Payer: Cash Price |
$22.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.89
|
| Rate for Payer: Heritage Provider Network Senior |
$14.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.50
|
| Rate for Payer: Multiplan Commercial |
$16.50
|
|
|
HC SOM VITAMIN B1 (THIAMINE)
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 84425
|
| Hospital Charge Code |
900911048
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.98 |
| Max. Negotiated Rate |
$170.90 |
| Rate for Payer: Adventist Health Commercial |
$4.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$164.66
|
| Rate for Payer: Blue Shield of California Commercial |
$170.90
|
| Rate for Payer: Blue Shield of California EPN |
$137.08
|
| Rate for Payer: Cash Price |
$22.00
|
| Rate for Payer: Cash Price |
$22.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.35
|
| Rate for Payer: Dignity Health Senior |
$21.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.30
|
| Rate for Payer: EPIC Health Plan Medicare |
$21.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.62
|
| Rate for Payer: Heritage Provider Network Senior |
$13.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$30.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$21.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$24.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$26.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$26.75
|
| Rate for Payer: Multiplan Commercial |
$16.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$21.23
|
| Rate for Payer: TriValley Medical Group Senior |
$21.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.35
|
| Rate for Payer: Vantage Medical Group Senior |
$21.23
|
|
|
HC SOM VITAMIN B6
|
Facility
|
IP
|
$28.25
|
|
|
Service Code
|
CPT 84207
|
| Hospital Charge Code |
900911400
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.11 |
| Max. Negotiated Rate |
$21.19 |
| Rate for Payer: Adventist Health Commercial |
$5.65
|
| Rate for Payer: Cash Price |
$28.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.13
|
| Rate for Payer: Heritage Provider Network Senior |
$19.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.06
|
| Rate for Payer: Multiplan Commercial |
$21.19
|
|
|
HC SOM VITAMIN B6
|
Facility
|
OP
|
$28.25
|
|
|
Service Code
|
CPT 84207
|
| Hospital Charge Code |
900911400
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.11 |
| Max. Negotiated Rate |
$226.08 |
| Rate for Payer: Adventist Health Commercial |
$5.65
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$30.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$28.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$217.70
|
| Rate for Payer: Blue Shield of California Commercial |
$226.08
|
| Rate for Payer: Blue Shield of California EPN |
$181.34
|
| Rate for Payer: Cash Price |
$28.25
|
| Rate for Payer: Cash Price |
$28.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.91
|
| Rate for Payer: Dignity Health Senior |
$28.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.36
|
| Rate for Payer: EPIC Health Plan Medicare |
$28.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.49
|
| Rate for Payer: Heritage Provider Network Senior |
$17.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$40.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$28.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$32.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$35.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$35.41
|
| Rate for Payer: Multiplan Commercial |
$21.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$28.10
|
| Rate for Payer: TriValley Medical Group Senior |
$28.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$30.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$30.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.91
|
| Rate for Payer: Vantage Medical Group Senior |
$28.10
|
|
|
HC SOM VITAMIN D 25-HYDROXY
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
CPT 82306
|
| Hospital Charge Code |
900911032
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$6.00 |
| Rate for Payer: Adventist Health Commercial |
$1.60
|
| Rate for Payer: Cash Price |
$8.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.42
|
| Rate for Payer: Heritage Provider Network Senior |
$5.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.00
|
| Rate for Payer: Multiplan Commercial |
$6.00
|
|
|
HC SOM VITAMIN D 25-HYDROXY
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
CPT 82306
|
| Hospital Charge Code |
900911032
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$270.25 |
| Rate for Payer: Adventist Health Commercial |
$1.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$44.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$29.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$270.25
|
| Rate for Payer: Blue Shield of California Commercial |
$238.23
|
| Rate for Payer: Blue Shield of California EPN |
$191.08
|
| Rate for Payer: Cash Price |
$8.00
|
| Rate for Payer: Cash Price |
$8.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$44.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.56
|
| Rate for Payer: Dignity Health Senior |
$29.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$29.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.95
|
| Rate for Payer: Heritage Provider Network Senior |
$4.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$33.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$29.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$34.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$37.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$37.30
|
| Rate for Payer: Multiplan Commercial |
$6.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$29.60
|
| Rate for Payer: TriValley Medical Group Senior |
$29.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$31.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$44.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.56
|
| Rate for Payer: Vantage Medical Group Senior |
$29.60
|
|
|
HC SOM VITAMIN E
|
Facility
|
OP
|
$19.57
|
|
|
Service Code
|
CPT 84446
|
| Hospital Charge Code |
900911174
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$129.38 |
| Rate for Payer: Adventist Health Commercial |
$3.91
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$129.38
|
| Rate for Payer: Blue Shield of California Commercial |
$114.11
|
| Rate for Payer: Blue Shield of California EPN |
$91.52
|
| Rate for Payer: Cash Price |
$19.57
|
| Rate for Payer: Cash Price |
$19.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.60
|
| Rate for Payer: Dignity Health Senior |
$14.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.72
|
| Rate for Payer: EPIC Health Plan Medicare |
$14.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.11
|
| Rate for Payer: Heritage Provider Network Senior |
$12.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$16.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.87
|
| Rate for Payer: Multiplan Commercial |
$14.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.18
|
| Rate for Payer: TriValley Medical Group Senior |
$14.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.60
|
| Rate for Payer: Vantage Medical Group Senior |
$14.18
|
|
|
HC SOM VITAMIN E
|
Facility
|
IP
|
$19.57
|
|
|
Service Code
|
CPT 84446
|
| Hospital Charge Code |
900911174
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$14.68 |
| Rate for Payer: Adventist Health Commercial |
$3.91
|
| Rate for Payer: Cash Price |
$19.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.25
|
| Rate for Payer: Heritage Provider Network Senior |
$13.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.89
|
| Rate for Payer: Multiplan Commercial |
$14.68
|
|
|
HC SOM VITAMIN K
|
Facility
|
OP
|
$45.65
|
|
|
Service Code
|
CPT 84597
|
| Hospital Charge Code |
900911429
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.26 |
| Max. Negotiated Rate |
$121.08 |
| Rate for Payer: Adventist Health Commercial |
$9.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$121.08
|
| Rate for Payer: Blue Shield of California Commercial |
$110.30
|
| Rate for Payer: Blue Shield of California EPN |
$88.47
|
| Rate for Payer: Cash Price |
$45.65
|
| Rate for Payer: Cash Price |
$45.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.09
|
| Rate for Payer: Dignity Health Senior |
$13.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.67
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.26
|
| Rate for Payer: Heritage Provider Network Senior |
$28.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.29
|
| Rate for Payer: Multiplan Commercial |
$34.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.72
|
| Rate for Payer: TriValley Medical Group Senior |
$13.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.09
|
| Rate for Payer: Vantage Medical Group Senior |
$13.72
|
|
|
HC SOM VITAMIN K
|
Facility
|
IP
|
$45.65
|
|
|
Service Code
|
CPT 84597
|
| Hospital Charge Code |
900911429
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.26 |
| Max. Negotiated Rate |
$34.24 |
| Rate for Payer: Adventist Health Commercial |
$9.13
|
| Rate for Payer: Cash Price |
$45.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.91
|
| Rate for Payer: Heritage Provider Network Senior |
$30.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.41
|
| Rate for Payer: Multiplan Commercial |
$34.24
|
|
|
HC SOM VOLATILES BLOOD
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT 80320
|
| Hospital Charge Code |
900910583
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$94.65 |
| Rate for Payer: Adventist Health Commercial |
$9.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$33.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$94.65
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.25
|
| Rate for Payer: Dignity Health Senior |
$38.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.86
|
| Rate for Payer: Heritage Provider Network Senior |
$27.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$31.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$33.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.25
|
| Rate for Payer: Vantage Medical Group Senior |
$38.25
|
|
|
HC SOM VOLATILES BLOOD
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT 80320
|
| Hospital Charge Code |
900910583
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$33.75 |
| Rate for Payer: Adventist Health Commercial |
$9.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.46
|
| Rate for Payer: Heritage Provider Network Senior |
$30.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.25
|
| Rate for Payer: Multiplan Commercial |
$33.75
|
|
|
HC SOM VOLATILES URINE
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT 80320
|
| Hospital Charge Code |
900910584
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$33.75 |
| Rate for Payer: Adventist Health Commercial |
$9.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.46
|
| Rate for Payer: Heritage Provider Network Senior |
$30.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.25
|
| Rate for Payer: Multiplan Commercial |
$33.75
|
|
|
HC SOM VOLATILES URINE
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT 80320
|
| Hospital Charge Code |
900910584
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$94.65 |
| Rate for Payer: Adventist Health Commercial |
$9.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$33.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$94.65
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.25
|
| Rate for Payer: Dignity Health Senior |
$38.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.86
|
| Rate for Payer: Heritage Provider Network Senior |
$27.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$31.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$33.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.25
|
| Rate for Payer: Vantage Medical Group Senior |
$38.25
|
|
|
HC SOM VONWILLEBRAND AG
|
Facility
|
IP
|
$25.34
|
|
|
Service Code
|
CPT 85246
|
| Hospital Charge Code |
900910112
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Adventist Health Commercial |
$5.07
|
| Rate for Payer: Cash Price |
$25.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.16
|
| Rate for Payer: Heritage Provider Network Senior |
$17.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.33
|
| Rate for Payer: Multiplan Commercial |
$19.00
|
|
|
HC SOM VONWILLEBRAND AG
|
Facility
|
OP
|
$25.34
|
|
|
Service Code
|
CPT 85246
|
| Hospital Charge Code |
900910112
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$209.47 |
| Rate for Payer: Adventist Health Commercial |
$5.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$34.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$209.47
|
| Rate for Payer: Blue Shield of California Commercial |
$184.67
|
| Rate for Payer: Blue Shield of California EPN |
$148.12
|
| Rate for Payer: Cash Price |
$25.34
|
| Rate for Payer: Cash Price |
$25.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$34.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.23
|
| Rate for Payer: Dignity Health Senior |
$22.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.47
|
| Rate for Payer: EPIC Health Plan Medicare |
$22.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.69
|
| Rate for Payer: Heritage Provider Network Senior |
$15.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$33.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$22.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$26.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$28.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$28.90
|
| Rate for Payer: Multiplan Commercial |
$19.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$22.94
|
| Rate for Payer: TriValley Medical Group Senior |
$22.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$24.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$34.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.23
|
| Rate for Payer: Vantage Medical Group Senior |
$22.94
|
|
|
HC SOM VON WILLEBRAND FACTOR ACTIVITY
|
Facility
|
IP
|
$74.20
|
|
|
Service Code
|
CPT 85397
|
| Hospital Charge Code |
900912874
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$13.43 |
| Max. Negotiated Rate |
$55.65 |
| Rate for Payer: Adventist Health Commercial |
$14.84
|
| Rate for Payer: Cash Price |
$74.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.23
|
| Rate for Payer: Heritage Provider Network Senior |
$50.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.55
|
| Rate for Payer: Multiplan Commercial |
$55.65
|
|
