|
HC SOM PCA3 U
|
Facility
|
IP
|
$500.00
|
|
|
Service Code
|
CPT 81479
|
| Hospital Charge Code |
900913905
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$90.50 |
| Max. Negotiated Rate |
$375.00 |
| Rate for Payer: Adventist Health Commercial |
$100.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$322.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$338.50
|
| Rate for Payer: Heritage Provider Network Senior |
$338.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$90.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.00
|
| Rate for Payer: Multiplan Commercial |
$375.00
|
|
|
HC SOM PCDEC AMPA-R AB CBA
|
Facility
|
OP
|
$45.06
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915486
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$114.48 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$114.48
|
| Rate for Payer: Blue Shield of California Commercial |
$97.00
|
| Rate for Payer: Blue Shield of California EPN |
$77.80
|
| Rate for Payer: Cash Price |
$45.06
|
| Rate for Payer: Cash Price |
$45.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.29
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.89
|
| Rate for Payer: Heritage Provider Network Senior |
$27.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$21.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.15
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| 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 |
$18.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$12.05
|
|
|
HC SOM PCDEC AMPA-R AB CBA
|
Facility
|
IP
|
$45.06
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915486
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.02
|
| Rate for Payer: Cash Price |
$45.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.51
|
| Rate for Payer: Heritage Provider Network Senior |
$30.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
|
|
HC SOM PCDEC ANNA1
|
Facility
|
IP
|
$45.06
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915442
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.02
|
| Rate for Payer: Cash Price |
$45.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.51
|
| Rate for Payer: Heritage Provider Network Senior |
$30.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
|
|
HC SOM PCDEC ANNA1
|
Facility
|
OP
|
$45.06
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915442
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$114.48 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$114.48
|
| Rate for Payer: Blue Shield of California Commercial |
$97.00
|
| Rate for Payer: Blue Shield of California EPN |
$77.80
|
| Rate for Payer: Cash Price |
$45.06
|
| Rate for Payer: Cash Price |
$45.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.29
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.89
|
| Rate for Payer: Heritage Provider Network Senior |
$27.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$21.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.15
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| 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 |
$18.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$12.05
|
|
|
HC SOM PCDEC CASPR2-IGG
|
Facility
|
IP
|
$45.07
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915449
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.03
|
| Rate for Payer: Cash Price |
$45.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.51
|
| Rate for Payer: Heritage Provider Network Senior |
$30.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
|
|
HC SOM PCDEC CASPR2-IGG
|
Facility
|
OP
|
$45.07
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915449
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$114.48 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$114.48
|
| Rate for Payer: Blue Shield of California Commercial |
$97.00
|
| Rate for Payer: Blue Shield of California EPN |
$77.80
|
| Rate for Payer: Cash Price |
$45.07
|
| Rate for Payer: Cash Price |
$45.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.30
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.90
|
| Rate for Payer: Heritage Provider Network Senior |
$27.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$21.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.15
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| 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 |
$18.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$12.05
|
|
|
HC SOM PCDEC DPPX AB IFA
|
Facility
|
OP
|
$45.07
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915451
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$114.48 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$114.48
|
| Rate for Payer: Blue Shield of California Commercial |
$97.00
|
| Rate for Payer: Blue Shield of California EPN |
$77.80
|
| Rate for Payer: Cash Price |
$45.07
|
| Rate for Payer: Cash Price |
$45.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.30
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.90
|
| Rate for Payer: Heritage Provider Network Senior |
$27.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$21.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.15
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| 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 |
$18.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$12.05
|
|
|
HC SOM PCDEC DPPX AB IFA
|
Facility
|
IP
|
$45.07
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915451
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.03
|
| Rate for Payer: Cash Price |
$45.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.51
|
| Rate for Payer: Heritage Provider Network Senior |
$30.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
|
|
HC SOM PCDEC GABA-B-R AB CBA
|
Facility
|
OP
|
$45.07
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915446
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$114.48 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$114.48
|
| Rate for Payer: Blue Shield of California Commercial |
$97.00
|
| Rate for Payer: Blue Shield of California EPN |
$77.80
|
| Rate for Payer: Cash Price |
$45.07
|
| Rate for Payer: Cash Price |
$45.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.30
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.90
|
| Rate for Payer: Heritage Provider Network Senior |
$27.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$21.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.15
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| 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 |
$18.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$12.05
|
|
|
HC SOM PCDEC GABA-B-R AB CBA
|
Facility
|
IP
|
$45.07
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915446
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.03
|
| Rate for Payer: Cash Price |
$45.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.51
|
| Rate for Payer: Heritage Provider Network Senior |
$30.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
|
|
HC SOM PCDEC GAD65 AB
|
Facility
|
OP
|
$88.16
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
900915444
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.96 |
| Max. Negotiated Rate |
$146.00 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$54.48
|
| Rate for Payer: Adventist Health Commercial |
$17.63
|
| 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 |
$88.16
|
| Rate for Payer: Cash Price |
$88.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.30
|
| 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 |
$57.30
|
| Rate for Payer: EPIC Health Plan Medicare |
$23.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.57
|
| Rate for Payer: Heritage Provider Network Senior |
$54.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$23.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$42.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$31.58
|
| Rate for Payer: Multiplan Commercial |
$66.12
|
| 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 PCDEC GAD65 AB
|
Facility
|
IP
|
$88.16
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
900915444
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.96 |
| Max. Negotiated Rate |
$66.12 |
| Rate for Payer: Adventist Health Commercial |
$17.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.78
|
| Rate for Payer: Cash Price |
$88.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$59.68
|
| Rate for Payer: Heritage Provider Network Senior |
$59.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.04
|
| Rate for Payer: Multiplan Commercial |
$66.12
|
|
|
HC SOM PCDEC GFAP IFA
|
Facility
|
IP
|
$45.07
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915452
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.03
|
| Rate for Payer: Cash Price |
$45.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.51
|
| Rate for Payer: Heritage Provider Network Senior |
$30.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
|
|
HC SOM PCDEC GFAP IFA
|
Facility
|
OP
|
$45.07
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915452
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$114.48 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$114.48
|
| Rate for Payer: Blue Shield of California Commercial |
$97.00
|
| Rate for Payer: Blue Shield of California EPN |
$77.80
|
| Rate for Payer: Cash Price |
$45.07
|
| Rate for Payer: Cash Price |
$45.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.30
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.90
|
| Rate for Payer: Heritage Provider Network Senior |
$27.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$21.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.15
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| 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 |
$18.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$12.05
|
|
|
HC SOM PCDEC LGI1-IGG CBA
|
Facility
|
IP
|
$45.07
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915448
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.03
|
| Rate for Payer: Cash Price |
$45.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.51
|
| Rate for Payer: Heritage Provider Network Senior |
$30.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
|
|
HC SOM PCDEC LGI1-IGG CBA
|
Facility
|
OP
|
$45.07
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915448
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$114.48 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$114.48
|
| Rate for Payer: Blue Shield of California Commercial |
$97.00
|
| Rate for Payer: Blue Shield of California EPN |
$77.80
|
| Rate for Payer: Cash Price |
$45.07
|
| Rate for Payer: Cash Price |
$45.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.30
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.90
|
| Rate for Payer: Heritage Provider Network Senior |
$27.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$21.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.15
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| 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 |
$18.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$12.05
|
|
|
HC SOM PCDEC MGLUR1 AB IFA
|
Facility
|
IP
|
$45.07
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915450
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.03
|
| Rate for Payer: Cash Price |
$45.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.51
|
| Rate for Payer: Heritage Provider Network Senior |
$30.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
|
|
HC SOM PCDEC MGLUR1 AB IFA
|
Facility
|
OP
|
$45.07
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915450
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$114.48 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$114.48
|
| Rate for Payer: Blue Shield of California Commercial |
$97.00
|
| Rate for Payer: Blue Shield of California EPN |
$77.80
|
| Rate for Payer: Cash Price |
$45.07
|
| Rate for Payer: Cash Price |
$45.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.30
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.90
|
| Rate for Payer: Heritage Provider Network Senior |
$27.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$21.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.15
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| 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 |
$18.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$12.05
|
|
|
HC SOM PCDEC NMDA-R AB CBA
|
Facility
|
OP
|
$45.06
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915445
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$114.48 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$114.48
|
| Rate for Payer: Blue Shield of California Commercial |
$97.00
|
| Rate for Payer: Blue Shield of California EPN |
$77.80
|
| Rate for Payer: Cash Price |
$45.06
|
| Rate for Payer: Cash Price |
$45.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.29
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.89
|
| Rate for Payer: Heritage Provider Network Senior |
$27.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$21.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.15
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| 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 |
$18.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$12.05
|
|
|
HC SOM PCDEC NMDA-R AB CBA
|
Facility
|
IP
|
$45.06
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915445
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.02
|
| Rate for Payer: Cash Price |
$45.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.51
|
| Rate for Payer: Heritage Provider Network Senior |
$30.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
|
|
HC SOM PCDEC NMO/AQP4 FACS
|
Facility
|
OP
|
$141.11
|
|
|
Service Code
|
CPT 86053
|
| Hospital Charge Code |
900915447
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.02 |
| Max. Negotiated Rate |
$105.83 |
| Rate for Payer: Adventist Health Commercial |
$28.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$87.21
|
| 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 |
$141.11
|
| Rate for Payer: Cash Price |
$141.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$91.72
|
| 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 |
$91.72
|
| Rate for Payer: EPIC Health Plan Medicare |
$37.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$87.35
|
| Rate for Payer: Heritage Provider Network Senior |
$87.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$37.73
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$67.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$25.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$43.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$50.56
|
| Rate for Payer: Multiplan Commercial |
$105.83
|
| 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 PCDEC NMO/AQP4 FACS
|
Facility
|
IP
|
$141.11
|
|
|
Service Code
|
CPT 86053
|
| Hospital Charge Code |
900915447
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.54 |
| Max. Negotiated Rate |
$105.83 |
| Rate for Payer: Adventist Health Commercial |
$28.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$90.87
|
| Rate for Payer: Cash Price |
$141.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$95.53
|
| Rate for Payer: Heritage Provider Network Senior |
$95.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$25.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.28
|
| Rate for Payer: Multiplan Commercial |
$105.83
|
|
|
HC SOM PCDEC PCA-TR
|
Facility
|
IP
|
$45.06
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915443
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.02
|
| Rate for Payer: Cash Price |
$45.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.51
|
| Rate for Payer: Heritage Provider Network Senior |
$30.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
|
|
HC SOM PCDEC PCA-TR
|
Facility
|
OP
|
$45.06
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915443
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$114.48 |
| Rate for Payer: Adventist Health Commercial |
$9.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$114.48
|
| Rate for Payer: Blue Shield of California Commercial |
$97.00
|
| Rate for Payer: Blue Shield of California EPN |
$77.80
|
| Rate for Payer: Cash Price |
$45.06
|
| Rate for Payer: Cash Price |
$45.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.29
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.89
|
| Rate for Payer: Heritage Provider Network Senior |
$27.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$21.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.15
|
| Rate for Payer: Multiplan Commercial |
$33.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| 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 |
$18.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$12.05
|
|
