|
HC SOM HYPOGLYCEMIC AGENT SCREEN
|
Facility
|
OP
|
$101.03
|
|
|
Service Code
|
CPT 80377
|
| Hospital Charge Code |
900912528
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.29 |
| Max. Negotiated Rate |
$196.94 |
| Rate for Payer: Adventist Health Commercial |
$20.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$62.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$85.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$55.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$75.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$196.94
|
| Rate for Payer: Cash Price |
$101.03
|
| Rate for Payer: Cash Price |
$101.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$65.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$85.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$85.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$59.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$62.54
|
| Rate for Payer: Heritage Provider Network Senior |
$62.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$48.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$70.72
|
| Rate for Payer: Multiplan Commercial |
$75.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$50.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$50.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$85.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$85.88
|
| Rate for Payer: Vantage Medical Group Senior |
$85.88
|
|
|
HC SOM IA2 AB
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
900914354
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$9.96 |
| Max. Negotiated Rate |
$41.25 |
| Rate for Payer: Adventist Health Commercial |
$11.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.42
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.23
|
| Rate for Payer: Heritage Provider Network Senior |
$37.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.75
|
| Rate for Payer: Multiplan Commercial |
$41.25
|
|
|
HC SOM IA2 AB
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
900914354
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$9.96 |
| Max. Negotiated Rate |
$146.00 |
| Rate for Payer: Adventist Health Commercial |
$11.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$35.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$23.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$146.00
|
| Rate for Payer: Blue Shield of California Commercial |
$133.75
|
| Rate for Payer: Blue Shield of California EPN |
$107.28
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$35.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.93
|
| Rate for Payer: Dignity Health Medicare Advantage |
$23.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$23.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.05
|
| Rate for Payer: Heritage Provider Network Senior |
$34.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$23.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$26.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$31.58
|
| Rate for Payer: Multiplan Commercial |
$41.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$23.57
|
| Rate for Payer: TriValley Medical Group Senior |
$23.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$25.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$25.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$35.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.93
|
| Rate for Payer: Vantage Medical Group Senior |
$23.57
|
|
|
HC SOM IGA SUBCLASSES IGA 1
|
Facility
|
OP
|
$31.19
|
|
|
Service Code
|
CPT 82787
|
| Hospital Charge Code |
900912703
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$316.29 |
| Rate for Payer: Adventist Health Commercial |
$6.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$316.29
|
| Rate for Payer: Blue Shield of California Commercial |
$64.51
|
| Rate for Payer: Blue Shield of California EPN |
$51.74
|
| Rate for Payer: Cash Price |
$31.19
|
| Rate for Payer: Cash Price |
$31.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.31
|
| Rate for Payer: Heritage Provider Network Senior |
$19.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$14.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.75
|
| Rate for Payer: Multiplan Commercial |
$23.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.02
|
| Rate for Payer: TriValley Medical Group Senior |
$8.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.82
|
| Rate for Payer: Vantage Medical Group Senior |
$8.02
|
|
|
HC SOM IGA SUBCLASSES IGA 1
|
Facility
|
IP
|
$31.19
|
|
|
Service Code
|
CPT 82787
|
| Hospital Charge Code |
900912703
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$23.39 |
| Rate for Payer: Adventist Health Commercial |
$6.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.09
|
| Rate for Payer: Cash Price |
$31.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.12
|
| Rate for Payer: Heritage Provider Network Senior |
$21.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.80
|
| Rate for Payer: Multiplan Commercial |
$23.39
|
|
|
HC SOM IGA SUBCLASSES IGA 2
|
Facility
|
IP
|
$31.19
|
|
|
Service Code
|
CPT 82787
|
| Hospital Charge Code |
900912704
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$23.39 |
| Rate for Payer: Adventist Health Commercial |
$6.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.09
|
| Rate for Payer: Cash Price |
$31.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.12
|
| Rate for Payer: Heritage Provider Network Senior |
$21.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.80
|
| Rate for Payer: Multiplan Commercial |
$23.39
|
|
|
HC SOM IGA SUBCLASSES IGA 2
|
Facility
|
OP
|
$31.19
|
|
|
Service Code
|
CPT 82787
|
| Hospital Charge Code |
900912704
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$316.29 |
| Rate for Payer: Adventist Health Commercial |
$6.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$316.29
|
| Rate for Payer: Blue Shield of California Commercial |
$64.51
|
| Rate for Payer: Blue Shield of California EPN |
$51.74
|
| Rate for Payer: Cash Price |
$31.19
|
| Rate for Payer: Cash Price |
$31.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.31
|
| Rate for Payer: Heritage Provider Network Senior |
$19.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$14.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.75
|
| Rate for Payer: Multiplan Commercial |
$23.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.02
|
| Rate for Payer: TriValley Medical Group Senior |
$8.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.82
|
| Rate for Payer: Vantage Medical Group Senior |
$8.02
|
|
|
HC SOM IGA SUBCLASSES TOTAL IGA
|
Facility
|
IP
|
$36.17
|
|
|
Service Code
|
CPT 82784
|
| Hospital Charge Code |
900912705
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.55 |
| Max. Negotiated Rate |
$27.13 |
| Rate for Payer: Adventist Health Commercial |
$7.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.29
|
| Rate for Payer: Cash Price |
$36.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.49
|
| Rate for Payer: Heritage Provider Network Senior |
$24.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.04
|
| Rate for Payer: Multiplan Commercial |
$27.13
|
|
|
HC SOM IGA SUBCLASSES TOTAL IGA
|
Facility
|
OP
|
$36.17
|
|
|
Service Code
|
CPT 82784
|
| Hospital Charge Code |
900912705
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.55 |
| Max. Negotiated Rate |
$74.82 |
| Rate for Payer: Adventist Health Commercial |
$7.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$73.57
|
| Rate for Payer: Blue Shield of California Commercial |
$74.82
|
| Rate for Payer: Blue Shield of California EPN |
$60.01
|
| Rate for Payer: Cash Price |
$36.17
|
| Rate for Payer: Cash Price |
$36.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.34
|
| Rate for Payer: EPIC Health Plan Medicare |
$9.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.39
|
| Rate for Payer: Heritage Provider Network Senior |
$22.39
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$17.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.46
|
| Rate for Payer: Multiplan Commercial |
$27.13
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.30
|
| Rate for Payer: TriValley Medical Group Senior |
$9.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.23
|
| Rate for Payer: Vantage Medical Group Senior |
$9.30
|
|
|
HC SOM IGF-BP3
|
Facility
|
IP
|
$17.27
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
900911428
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.13 |
| Max. Negotiated Rate |
$12.95 |
| Rate for Payer: Adventist Health Commercial |
$3.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.12
|
| Rate for Payer: Cash Price |
$17.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.69
|
| Rate for Payer: Heritage Provider Network Senior |
$11.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.32
|
| Rate for Payer: Multiplan Commercial |
$12.95
|
|
|
HC SOM IGF-BP3
|
Facility
|
OP
|
$17.27
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
900911428
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.13 |
| Max. Negotiated Rate |
$122.92 |
| Rate for Payer: Adventist Health Commercial |
$3.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.67
|
| 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 |
$17.27
|
| Rate for Payer: Cash Price |
$17.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.23
|
| 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 |
$10.19
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.69
|
| Rate for Payer: Heritage Provider Network Senior |
$10.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$23.14
|
| Rate for Payer: Multiplan Commercial |
$12.95
|
| 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 IGG FRAC. TOTAL IGG
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
CPT 82784
|
| Hospital Charge Code |
900912808
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$74.82 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$73.57
|
| Rate for Payer: Blue Shield of California Commercial |
$74.82
|
| Rate for Payer: Blue Shield of California EPN |
$60.01
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.54
|
| Rate for Payer: EPIC Health Plan Medicare |
$9.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.71
|
| Rate for Payer: Heritage Provider Network Senior |
$3.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.46
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.30
|
| Rate for Payer: TriValley Medical Group Senior |
$9.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.23
|
| Rate for Payer: Vantage Medical Group Senior |
$9.30
|
|
|
HC SOM IGG FRAC. TOTAL IGG
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
CPT 82784
|
| Hospital Charge Code |
900912808
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.86
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.06
|
| Rate for Payer: Heritage Provider Network Senior |
$4.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
|
|
HC SOM IGG SYNTHESIS INDEX-CSF
|
Facility
|
OP
|
$10.35
|
|
|
Service Code
|
CPT 82784
|
| Hospital Charge Code |
900911436
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$74.82 |
| Rate for Payer: Adventist Health Commercial |
$2.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$73.57
|
| Rate for Payer: Blue Shield of California Commercial |
$74.82
|
| Rate for Payer: Blue Shield of California EPN |
$60.01
|
| Rate for Payer: Cash Price |
$10.35
|
| Rate for Payer: Cash Price |
$10.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.11
|
| Rate for Payer: EPIC Health Plan Medicare |
$9.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.41
|
| Rate for Payer: Heritage Provider Network Senior |
$6.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.46
|
| Rate for Payer: Multiplan Commercial |
$7.76
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.30
|
| Rate for Payer: TriValley Medical Group Senior |
$9.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.23
|
| Rate for Payer: Vantage Medical Group Senior |
$9.30
|
|
|
HC SOM IGG SYNTHESIS INDEX-CSF
|
Facility
|
IP
|
$10.35
|
|
|
Service Code
|
CPT 82784
|
| Hospital Charge Code |
900911436
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Adventist Health Commercial |
$2.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.67
|
| Rate for Payer: Cash Price |
$10.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.01
|
| Rate for Payer: Heritage Provider Network Senior |
$7.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.59
|
| Rate for Payer: Multiplan Commercial |
$7.76
|
|
|
HC SOM IL 28 B POLYMORPHISM GENOT
|
Facility
|
IP
|
$312.70
|
|
|
Service Code
|
CPT 81400
|
| Hospital Charge Code |
900912991
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$56.60 |
| Max. Negotiated Rate |
$234.53 |
| Rate for Payer: Adventist Health Commercial |
$62.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$201.38
|
| Rate for Payer: Cash Price |
$312.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$211.70
|
| Rate for Payer: Heritage Provider Network Senior |
$211.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$56.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.17
|
| Rate for Payer: Multiplan Commercial |
$234.53
|
|
|
HC SOM IL 28 B POLYMORPHISM GENOT
|
Facility
|
OP
|
$312.70
|
|
|
Service Code
|
CPT 81400
|
| Hospital Charge Code |
900912991
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$56.60 |
| Max. Negotiated Rate |
$300.43 |
| Rate for Payer: Adventist Health Commercial |
$62.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$193.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$70.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$63.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$300.43
|
| Rate for Payer: Blue Shield of California Commercial |
$190.75
|
| Rate for Payer: Blue Shield of California EPN |
$152.60
|
| Rate for Payer: Cash Price |
$312.70
|
| Rate for Payer: Cash Price |
$312.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$203.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$70.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$63.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$203.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$63.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$193.56
|
| Rate for Payer: Heritage Provider Network Senior |
$193.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$63.96
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$149.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$56.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$73.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$85.71
|
| Rate for Payer: Multiplan Commercial |
$234.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$63.96
|
| Rate for Payer: TriValley Medical Group Senior |
$63.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$69.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$69.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$70.36
|
| Rate for Payer: Vantage Medical Group Senior |
$63.96
|
|
|
HC SOM IL-6
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
900913874
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$13.57 |
| Max. Negotiated Rate |
$56.25 |
| Rate for Payer: Adventist Health Commercial |
$15.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$48.30
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.77
|
| Rate for Payer: Heritage Provider Network Senior |
$50.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.75
|
| Rate for Payer: Multiplan Commercial |
$56.25
|
|
|
HC SOM IL-6
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
900913874
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$13.57 |
| Max. Negotiated Rate |
$122.92 |
| Rate for Payer: Adventist Health Commercial |
$15.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$46.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$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 |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$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 |
$44.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.42
|
| Rate for Payer: Heritage Provider Network Senior |
$46.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$35.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$23.14
|
| Rate for Payer: Multiplan Commercial |
$56.25
|
| 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 IMMUNOGLOBULIN IGD
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 82784
|
| Hospital Charge Code |
900910574
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$74.82 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$73.57
|
| Rate for Payer: Blue Shield of California Commercial |
$74.82
|
| Rate for Payer: Blue Shield of California EPN |
$60.01
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.70
|
| Rate for Payer: EPIC Health Plan Medicare |
$9.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.57
|
| Rate for Payer: Heritage Provider Network Senior |
$18.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$14.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.46
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.30
|
| Rate for Payer: TriValley Medical Group Senior |
$9.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.23
|
| Rate for Payer: Vantage Medical Group Senior |
$9.30
|
|
|
HC SOM IMMUNOGLOBULIN IGD
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT 82784
|
| Hospital Charge Code |
900910574
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.32
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.31
|
| Rate for Payer: Heritage Provider Network Senior |
$20.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
|
|
HC SOM IMMUNOGLOBULINS,IGC SUBCLASS 1
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
CPT 82787
|
| Hospital Charge Code |
900911271
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.86
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.06
|
| Rate for Payer: Heritage Provider Network Senior |
$4.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
|
|
HC SOM IMMUNOGLOBULINS,IGC SUBCLASS 1
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
CPT 82787
|
| Hospital Charge Code |
900911271
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$316.29 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$316.29
|
| Rate for Payer: Blue Shield of California Commercial |
$64.51
|
| Rate for Payer: Blue Shield of California EPN |
$51.74
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.54
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.71
|
| Rate for Payer: Heritage Provider Network Senior |
$3.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.75
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.02
|
| Rate for Payer: TriValley Medical Group Senior |
$8.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.82
|
| Rate for Payer: Vantage Medical Group Senior |
$8.02
|
|
|
HC SOM IMMUNOGLOBULINS,IGG SUBCLASS 2
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
CPT 82787
|
| Hospital Charge Code |
900911272
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.86
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.06
|
| Rate for Payer: Heritage Provider Network Senior |
$4.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
|
|
HC SOM IMMUNOGLOBULINS,IGG SUBCLASS 2
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
CPT 82787
|
| Hospital Charge Code |
900911272
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$316.29 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$316.29
|
| Rate for Payer: Blue Shield of California Commercial |
$64.51
|
| Rate for Payer: Blue Shield of California EPN |
$51.74
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.54
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.71
|
| Rate for Payer: Heritage Provider Network Senior |
$3.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.75
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.02
|
| Rate for Payer: TriValley Medical Group Senior |
$8.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.82
|
| Rate for Payer: Vantage Medical Group Senior |
$8.02
|
|
