|
HC SOM NMHIN 83789
|
Facility
|
IP
|
$162.45
|
|
|
Service Code
|
CPT 83789
|
| Hospital Charge Code |
900914806
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$121.84 |
| Rate for Payer: Adventist Health Commercial |
$32.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$104.62
|
| Rate for Payer: Cash Price |
$162.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$109.98
|
| Rate for Payer: Heritage Provider Network Senior |
$109.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$29.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.61
|
| Rate for Payer: Multiplan Commercial |
$121.84
|
|
|
HC SOM NMO/AQP4 FACS
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
CPT 86053
|
| Hospital Charge Code |
900915463
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$61.54 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Adventist Health Commercial |
$68.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$218.96
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$230.18
|
| Rate for Payer: Heritage Provider Network Senior |
$230.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$61.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.00
|
| Rate for Payer: Multiplan Commercial |
$255.00
|
|
|
HC SOM NMO/AQP4 FACS
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
CPT 86053
|
| Hospital Charge Code |
900915463
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.02 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: EPIC Health Plan Medicare |
$37.73
|
| Rate for Payer: Adventist Health Commercial |
$68.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$210.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$56.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$41.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.22
|
| Rate for Payer: Blue Shield of California Commercial |
$69.41
|
| Rate for Payer: Blue Shield of California EPN |
$55.67
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$221.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$56.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$41.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$37.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$221.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$210.46
|
| Rate for Payer: Heritage Provider Network Senior |
$210.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$37.73
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$162.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$61.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$43.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$50.56
|
| Rate for Payer: Multiplan Commercial |
$255.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$37.73
|
| Rate for Payer: TriValley Medical Group Senior |
$37.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$56.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$41.50
|
| Rate for Payer: Vantage Medical Group Senior |
$37.73
|
|
|
HC SOM NMO/AQP4 FACS TITER
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
CPT 86053
|
| Hospital Charge Code |
900915464
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.02 |
| Max. Negotiated Rate |
$69.41 |
| 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 |
$56.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$41.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.22
|
| Rate for Payer: Blue Shield of California Commercial |
$69.41
|
| Rate for Payer: Blue Shield of California EPN |
$55.67
|
| 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 |
$56.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$41.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$37.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$37.73
|
| 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 |
$37.73
|
| 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 |
$43.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$50.56
|
| Rate for Payer: Multiplan Commercial |
$56.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$37.73
|
| Rate for Payer: TriValley Medical Group Senior |
$37.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$56.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$41.50
|
| Rate for Payer: Vantage Medical Group Senior |
$37.73
|
|
|
HC SOM NMO/AQP4 FACS TITER
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
CPT 86053
|
| Hospital Charge Code |
900915464
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.57 |
| Max. Negotiated Rate |
$56.25 |
| Rate for Payer: Adventist Health Commercial |
$15.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$48.30
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.77
|
| Rate for Payer: Heritage Provider Network Senior |
$50.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.75
|
| Rate for Payer: Multiplan Commercial |
$56.25
|
|
|
HC SOMN NC05 CSF P-5-P 82491
|
Facility
|
OP
|
$185.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900914867
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$24.09 |
| Max. Negotiated Rate |
$170.74 |
| Rate for Payer: Adventist Health Commercial |
$37.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$114.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$170.74
|
| Rate for Payer: Blue Shield of California Commercial |
$145.32
|
| Rate for Payer: Blue Shield of California EPN |
$116.56
|
| Rate for Payer: Cash Price |
$83.25
|
| Rate for Payer: Cash Price |
$83.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$120.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$109.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$24.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$114.52
|
| Rate for Payer: Heritage Provider Network Senior |
$114.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$88.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$33.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32.28
|
| Rate for Payer: Multiplan Commercial |
$138.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.09
|
| Rate for Payer: TriValley Medical Group Senior |
$24.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Vantage Medical Group Senior |
$24.09
|
|
|
HC SOMN NC05 CSF P-5-P 82491
|
Facility
|
IP
|
$185.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900914867
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$33.48 |
| Max. Negotiated Rate |
$138.75 |
| Rate for Payer: Adventist Health Commercial |
$37.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$119.14
|
| Rate for Payer: Cash Price |
$83.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$125.25
|
| Rate for Payer: Heritage Provider Network Senior |
$125.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$33.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.25
|
| Rate for Payer: Multiplan Commercial |
$138.75
|
|
|
HC SOMN NC07 CSF SIALIC 82017
|
Facility
|
IP
|
$205.00
|
|
|
Service Code
|
CPT 82017
|
| Hospital Charge Code |
900914735
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$153.75 |
| Rate for Payer: Adventist Health Commercial |
$41.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$132.02
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$138.78
|
| Rate for Payer: Heritage Provider Network Senior |
$138.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$37.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.25
|
| Rate for Payer: Multiplan Commercial |
$153.75
|
|
|
HC SOMN NC07 CSF SIALIC 82017
|
Facility
|
OP
|
$205.00
|
|
|
Service Code
|
CPT 82017
|
| Hospital Charge Code |
900914735
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.87 |
| Max. Negotiated Rate |
$159.42 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$126.69
|
| Rate for Payer: Adventist Health Commercial |
$41.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$159.42
|
| Rate for Payer: Blue Shield of California Commercial |
$135.76
|
| Rate for Payer: Blue Shield of California EPN |
$108.89
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$133.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$120.95
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$126.89
|
| Rate for Payer: Heritage Provider Network Senior |
$126.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$97.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$37.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22.61
|
| Rate for Payer: Multiplan Commercial |
$153.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.87
|
| Rate for Payer: TriValley Medical Group Senior |
$16.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.56
|
| Rate for Payer: Vantage Medical Group Senior |
$16.87
|
|
|
HC SOMN NC08 CSF A-AMIN 82017
|
Facility
|
IP
|
$205.00
|
|
|
Service Code
|
CPT 82017
|
| Hospital Charge Code |
900914733
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$153.75 |
| Rate for Payer: Adventist Health Commercial |
$41.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$132.02
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$138.78
|
| Rate for Payer: Heritage Provider Network Senior |
$138.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$37.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.25
|
| Rate for Payer: Multiplan Commercial |
$153.75
|
|
|
HC SOMN NC08 CSF A-AMIN 82017
|
Facility
|
OP
|
$205.00
|
|
|
Service Code
|
CPT 82017
|
| Hospital Charge Code |
900914733
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$16.87 |
| Max. Negotiated Rate |
$159.42 |
| Rate for Payer: Adventist Health Commercial |
$41.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$126.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$159.42
|
| Rate for Payer: Blue Shield of California Commercial |
$135.76
|
| Rate for Payer: Blue Shield of California EPN |
$108.89
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$133.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$133.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$126.89
|
| Rate for Payer: Heritage Provider Network Senior |
$126.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$97.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$37.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22.61
|
| Rate for Payer: Multiplan Commercial |
$153.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.87
|
| Rate for Payer: TriValley Medical Group Senior |
$16.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.56
|
| Rate for Payer: Vantage Medical Group Senior |
$16.87
|
|
|
HC SOM NORCLOZAPINE LEVEL
|
Facility
|
OP
|
$15.80
|
|
|
Service Code
|
CPT 80159
|
| Hospital Charge Code |
900912685
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$145.32 |
| Rate for Payer: Adventist Health Commercial |
$3.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$22.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$105.66
|
| Rate for Payer: Blue Shield of California Commercial |
$145.32
|
| Rate for Payer: Blue Shield of California EPN |
$116.56
|
| Rate for Payer: Cash Price |
$15.80
|
| Rate for Payer: Cash Price |
$15.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$20.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.32
|
| Rate for Payer: EPIC Health Plan Medicare |
$20.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.78
|
| Rate for Payer: Heritage Provider Network Senior |
$9.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$23.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$11.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$20.15
|
| Rate for Payer: TriValley Medical Group Senior |
$20.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$21.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.16
|
| Rate for Payer: Vantage Medical Group Senior |
$20.15
|
|
|
HC SOM NORCLOZAPINE LEVEL
|
Facility
|
IP
|
$15.80
|
|
|
Service Code
|
CPT 80159
|
| Hospital Charge Code |
900912685
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$11.85 |
| Rate for Payer: Adventist Health Commercial |
$3.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.18
|
| Rate for Payer: Cash Price |
$15.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.70
|
| Rate for Payer: Heritage Provider Network Senior |
$10.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.95
|
| Rate for Payer: Multiplan Commercial |
$11.85
|
|
|
HC SOM NORDOXEPIN LEVEL
|
Facility
|
OP
|
$42.72
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
900912562
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.73 |
| Max. Negotiated Rate |
$138.26 |
| Rate for Payer: Adventist Health Commercial |
$8.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$138.26
|
| Rate for Payer: Blue Shield of California Commercial |
$110.19
|
| Rate for Payer: Blue Shield of California EPN |
$88.38
|
| Rate for Payer: Cash Price |
$42.72
|
| Rate for Payer: Cash Price |
$42.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$18.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.44
|
| Rate for Payer: Heritage Provider Network Senior |
$26.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.64
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$20.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$24.98
|
| Rate for Payer: Multiplan Commercial |
$32.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.64
|
| Rate for Payer: TriValley Medical Group Senior |
$18.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.50
|
| Rate for Payer: Vantage Medical Group Senior |
$18.64
|
|
|
HC SOM NORDOXEPIN LEVEL
|
Facility
|
IP
|
$42.72
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
900912562
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.73 |
| Max. Negotiated Rate |
$32.04 |
| Rate for Payer: Adventist Health Commercial |
$8.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.51
|
| Rate for Payer: Cash Price |
$42.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.92
|
| Rate for Payer: Heritage Provider Network Senior |
$28.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.68
|
| Rate for Payer: Multiplan Commercial |
$32.04
|
|
|
HC SOM NOROVIRUS AG
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
CPT 87449
|
| Hospital Charge Code |
900914127
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$22.81 |
| Max. Negotiated Rate |
$94.50 |
| Rate for Payer: Adventist Health Commercial |
$25.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$81.14
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$85.30
|
| Rate for Payer: Heritage Provider Network Senior |
$85.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$22.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$94.50
|
|
|
HC SOM NOROVIRUS AG
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
CPT 87449
|
| Hospital Charge Code |
900914127
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$94.50 |
| Rate for Payer: Adventist Health Commercial |
$25.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$85.34
|
| 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 |
$126.00
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$81.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$74.34
|
| Rate for Payer: EPIC Health Plan Medicare |
$11.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$77.99
|
| Rate for Payer: Heritage Provider Network Senior |
$77.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11.98
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$60.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$22.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.05
|
| Rate for Payer: Multiplan Commercial |
$94.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.98
|
| Rate for Payer: TriValley Medical Group Senior |
$11.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.18
|
| Rate for Payer: Vantage Medical Group Senior |
$11.98
|
|
|
HC SOM NOROVIRUS RNA
|
Facility
|
OP
|
$245.52
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
900913809
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$322.42 |
| Rate for Payer: Adventist Health Commercial |
$49.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$151.73
|
| 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 |
$322.42
|
| 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 |
$245.52
|
| Rate for Payer: Cash Price |
$245.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$159.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$35.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$159.59
|
| Rate for Payer: EPIC Health Plan Medicare |
$35.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$151.98
|
| Rate for Payer: Heritage Provider Network Senior |
$151.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$117.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$44.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$40.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$47.02
|
| Rate for Payer: Multiplan Commercial |
$184.14
|
| 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 NOROVIRUS RNA
|
Facility
|
IP
|
$245.52
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
900913809
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$44.44 |
| Max. Negotiated Rate |
$184.14 |
| Rate for Payer: Adventist Health Commercial |
$49.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$158.11
|
| Rate for Payer: Cash Price |
$245.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$166.22
|
| Rate for Payer: Heritage Provider Network Senior |
$166.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$44.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.38
|
| Rate for Payer: Multiplan Commercial |
$184.14
|
|
|
HC SOM N-TELOPEPTIDE CREATININE URINE
|
Facility
|
IP
|
$5.33
|
|
|
Service Code
|
CPT 82570
|
| Hospital Charge Code |
900915361
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Adventist Health Commercial |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.43
|
| Rate for Payer: Cash Price |
$5.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.61
|
| Rate for Payer: Heritage Provider Network Senior |
$3.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
|
|
HC SOM N-TELOPEPTIDE CREATININE URINE
|
Facility
|
OP
|
$5.33
|
|
|
Service Code
|
CPT 82570
|
| Hospital Charge Code |
900915361
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$49.09 |
| Rate for Payer: Adventist Health Commercial |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$49.09
|
| Rate for Payer: Blue Shield of California Commercial |
$41.64
|
| Rate for Payer: Blue Shield of California EPN |
$33.40
|
| Rate for Payer: Cash Price |
$5.33
|
| Rate for Payer: Cash Price |
$5.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.14
|
| Rate for Payer: EPIC Health Plan Medicare |
$5.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.30
|
| Rate for Payer: Heritage Provider Network Senior |
$3.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.94
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.18
|
| Rate for Payer: TriValley Medical Group Senior |
$5.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.70
|
| Rate for Payer: Vantage Medical Group Senior |
$5.18
|
|
|
HC SOM N-TELOPEPTIDE URINE
|
Facility
|
IP
|
$19.23
|
|
|
Service Code
|
CPT 82523
|
| Hospital Charge Code |
900911412
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$14.42 |
| Rate for Payer: Adventist Health Commercial |
$3.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.38
|
| Rate for Payer: Cash Price |
$19.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.02
|
| Rate for Payer: Heritage Provider Network Senior |
$13.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.81
|
| Rate for Payer: Multiplan Commercial |
$14.42
|
|
|
HC SOM N-TELOPEPTIDE URINE
|
Facility
|
OP
|
$19.23
|
|
|
Service Code
|
CPT 82523
|
| Hospital Charge Code |
900911412
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$261.63 |
| Rate for Payer: Adventist Health Commercial |
$3.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$261.63
|
| Rate for Payer: Blue Shield of California Commercial |
$149.24
|
| Rate for Payer: Blue Shield of California EPN |
$119.70
|
| Rate for Payer: Cash Price |
$19.23
|
| Rate for Payer: Cash Price |
$19.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$18.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.90
|
| Rate for Payer: Heritage Provider Network Senior |
$11.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$9.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.03
|
| Rate for Payer: Multiplan Commercial |
$14.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.68
|
| Rate for Payer: TriValley Medical Group Senior |
$18.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.55
|
| Rate for Payer: Vantage Medical Group Senior |
$18.68
|
|
|
HC SOM NUCLEOPHOSMIN MUTAT ANAL
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
CPT 81310
|
| Hospital Charge Code |
900914001
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$63.35 |
| Max. Negotiated Rate |
$369.78 |
| Rate for Payer: Adventist Health Commercial |
$70.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$216.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$369.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$271.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$246.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$356.81
|
| Rate for Payer: Blue Shield of California Commercial |
$213.50
|
| Rate for Payer: Blue Shield of California EPN |
$170.80
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$227.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$369.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$271.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$246.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$227.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$246.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$216.65
|
| Rate for Payer: Heritage Provider Network Senior |
$216.65
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$246.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$166.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$63.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$283.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$87.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$330.34
|
| Rate for Payer: Multiplan Commercial |
$262.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$246.52
|
| Rate for Payer: TriValley Medical Group Senior |
$246.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$266.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$266.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$369.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$271.17
|
| Rate for Payer: Vantage Medical Group Senior |
$246.52
|
|
|
HC SOM NUCLEOPHOSMIN MUTAT ANAL
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
CPT 81310
|
| Hospital Charge Code |
900914001
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$63.35 |
| Max. Negotiated Rate |
$262.50 |
| Rate for Payer: Adventist Health Commercial |
$70.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$225.40
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$236.95
|
| Rate for Payer: Heritage Provider Network Senior |
$236.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$63.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$87.50
|
| Rate for Payer: Multiplan Commercial |
$262.50
|
|
