|
HC SOM PCDES NMO/AQP4 FACS
|
Facility
|
IP
|
$118.12
|
|
|
Service Code
|
CPT 86053
|
| Hospital Charge Code |
900915493
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.38 |
| Max. Negotiated Rate |
$88.59 |
| Rate for Payer: Adventist Health Commercial |
$23.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.07
|
| Rate for Payer: Cash Price |
$118.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$79.97
|
| Rate for Payer: Heritage Provider Network Senior |
$79.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.53
|
| Rate for Payer: Multiplan Commercial |
$88.59
|
|
|
HC SOM PCDES PCA-TR
|
Facility
|
IP
|
$37.72
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915488
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.83 |
| Max. Negotiated Rate |
$28.29 |
| Rate for Payer: Adventist Health Commercial |
$7.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.29
|
| Rate for Payer: Cash Price |
$37.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.54
|
| Rate for Payer: Heritage Provider Network Senior |
$25.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.43
|
| Rate for Payer: Multiplan Commercial |
$28.29
|
|
|
HC SOM PCDES PCA-TR
|
Facility
|
OP
|
$37.72
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915488
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.83 |
| Max. Negotiated Rate |
$114.48 |
| Rate for Payer: Adventist Health Commercial |
$7.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.31
|
| 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 |
$37.72
|
| Rate for Payer: Cash Price |
$37.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.52
|
| 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 |
$24.52
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.35
|
| Rate for Payer: Heritage Provider Network Senior |
$23.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$17.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.15
|
| Rate for Payer: Multiplan Commercial |
$28.29
|
| 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 PENICILLIN G IGE
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
900912843
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$150.09 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$150.09
|
| Rate for Payer: Blue Shield of California Commercial |
$42.05
|
| Rate for Payer: Blue Shield of California EPN |
$33.73
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.74
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$5.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.94
|
| Rate for Payer: Heritage Provider Network Senior |
$2.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.99
|
| Rate for Payer: Multiplan Commercial |
$3.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.22
|
| Rate for Payer: TriValley Medical Group Senior |
$5.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.74
|
| Rate for Payer: Vantage Medical Group Senior |
$5.22
|
|
|
HC SOM PENICILLIN G IGE
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
900912843
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.06
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.22
|
| Rate for Payer: Heritage Provider Network Senior |
$3.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$3.56
|
|
|
HC SOM PENICILLIN V IGE
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
900912842
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.06
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.22
|
| Rate for Payer: Heritage Provider Network Senior |
$3.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$3.56
|
|
|
HC SOM PENICILLIN V IGE
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
900912842
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$150.09 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$150.09
|
| Rate for Payer: Blue Shield of California Commercial |
$42.05
|
| Rate for Payer: Blue Shield of California EPN |
$33.73
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.74
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$5.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.94
|
| Rate for Payer: Heritage Provider Network Senior |
$2.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.99
|
| Rate for Payer: Multiplan Commercial |
$3.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.22
|
| Rate for Payer: TriValley Medical Group Senior |
$5.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.74
|
| Rate for Payer: Vantage Medical Group Senior |
$5.22
|
|
|
HC SOM PERNIC ANEM CASC B12
|
Facility
|
IP
|
$79.28
|
|
|
Service Code
|
CPT 82607
|
| Hospital Charge Code |
900914690
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.35 |
| Max. Negotiated Rate |
$59.46 |
| Rate for Payer: Adventist Health Commercial |
$15.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.06
|
| Rate for Payer: Cash Price |
$79.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$53.67
|
| Rate for Payer: Heritage Provider Network Senior |
$53.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.82
|
| Rate for Payer: Multiplan Commercial |
$59.46
|
|
|
HC SOM PERNIC ANEM CASC B12
|
Facility
|
OP
|
$79.28
|
|
|
Service Code
|
CPT 82607
|
| Hospital Charge Code |
900914690
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.35 |
| Max. Negotiated Rate |
$143.12 |
| Rate for Payer: Adventist Health Commercial |
$15.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$143.12
|
| Rate for Payer: Blue Shield of California Commercial |
$121.31
|
| Rate for Payer: Blue Shield of California EPN |
$97.30
|
| Rate for Payer: Cash Price |
$79.28
|
| Rate for Payer: Cash Price |
$79.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$51.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.59
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.78
|
| Rate for Payer: EPIC Health Plan Medicare |
$15.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$49.07
|
| Rate for Payer: Heritage Provider Network Senior |
$49.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$37.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$20.21
|
| Rate for Payer: Multiplan Commercial |
$59.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.08
|
| Rate for Payer: TriValley Medical Group Senior |
$15.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.59
|
| Rate for Payer: Vantage Medical Group Senior |
$15.08
|
|
|
HC SOM PHENCYCLIDINE CONFIRM, U
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
CPT 83992
|
| Hospital Charge Code |
900912920
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.04 |
| Max. Negotiated Rate |
$122.54 |
| Rate for Payer: Adventist Health Commercial |
$12.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$33.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$122.54
|
| Rate for Payer: Blue Shield of California Commercial |
$112.26
|
| Rate for Payer: Blue Shield of California EPN |
$90.04
|
| Rate for Payer: Cash Price |
$61.00
|
| Rate for Payer: Cash Price |
$61.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$39.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$51.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.76
|
| Rate for Payer: Heritage Provider Network Senior |
$37.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$29.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$42.70
|
| Rate for Payer: Multiplan Commercial |
$45.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$40.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$51.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.85
|
| Rate for Payer: Vantage Medical Group Senior |
$51.85
|
|
|
HC SOM PHENCYCLIDINE CONFIRM, U
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
CPT 83992
|
| Hospital Charge Code |
900912920
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.04 |
| Max. Negotiated Rate |
$45.75 |
| Rate for Payer: Adventist Health Commercial |
$12.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$39.28
|
| Rate for Payer: Cash Price |
$61.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.30
|
| Rate for Payer: Heritage Provider Network Senior |
$41.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.25
|
| Rate for Payer: Multiplan Commercial |
$45.75
|
|
|
HC SOM PHENOBARBITAL LEVEL
|
Facility
|
OP
|
$17.29
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
900912658
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.13 |
| Max. Negotiated Rate |
$108.54 |
| Rate for Payer: Adventist Health Commercial |
$3.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$108.54
|
| Rate for Payer: Blue Shield of California Commercial |
$92.22
|
| Rate for Payer: Blue Shield of California EPN |
$73.97
|
| Rate for Payer: Cash Price |
$17.29
|
| Rate for Payer: Cash Price |
$17.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$15.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.70
|
| Rate for Payer: Heritage Provider Network Senior |
$10.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$20.50
|
| Rate for Payer: Multiplan Commercial |
$12.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.30
|
| Rate for Payer: TriValley Medical Group Senior |
$15.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.83
|
| Rate for Payer: Vantage Medical Group Senior |
$15.30
|
|
|
HC SOM PHENOBARBITAL LEVEL
|
Facility
|
IP
|
$17.29
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
900912658
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.13 |
| Max. Negotiated Rate |
$12.97 |
| Rate for Payer: Adventist Health Commercial |
$3.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.13
|
| Rate for Payer: Cash Price |
$17.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.71
|
| Rate for Payer: Heritage Provider Network Senior |
$11.71
|
| 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 |
$12.97
|
|
|
HC SOM PHI 2PROPSA
|
Facility
|
OP
|
$34.36
|
|
|
Service Code
|
CPT 86316
|
| Hospital Charge Code |
900915520
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.22 |
| Max. Negotiated Rate |
$197.58 |
| Rate for Payer: Adventist Health Commercial |
$6.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$22.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$197.58
|
| Rate for Payer: Blue Shield of California Commercial |
$167.44
|
| Rate for Payer: Blue Shield of California EPN |
$134.30
|
| Rate for Payer: Cash Price |
$34.36
|
| Rate for Payer: Cash Price |
$34.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$20.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.33
|
| Rate for Payer: EPIC Health Plan Medicare |
$20.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.27
|
| Rate for Payer: Heritage Provider Network Senior |
$21.27
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20.81
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$16.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$23.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$27.89
|
| Rate for Payer: Multiplan Commercial |
$25.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$20.81
|
| Rate for Payer: TriValley Medical Group Senior |
$20.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.89
|
| Rate for Payer: Vantage Medical Group Senior |
$20.81
|
|
|
HC SOM PHI 2PROPSA
|
Facility
|
IP
|
$34.36
|
|
|
Service Code
|
CPT 86316
|
| Hospital Charge Code |
900915520
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.22 |
| Max. Negotiated Rate |
$25.77 |
| Rate for Payer: Adventist Health Commercial |
$6.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.13
|
| Rate for Payer: Cash Price |
$34.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.26
|
| Rate for Payer: Heritage Provider Network Senior |
$23.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.59
|
| Rate for Payer: Multiplan Commercial |
$25.77
|
|
|
HC SOM PHI FREE PSA
|
Facility
|
IP
|
$30.36
|
|
|
Service Code
|
CPT 84154
|
| Hospital Charge Code |
900915519
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$22.77 |
| Rate for Payer: Adventist Health Commercial |
$6.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.55
|
| Rate for Payer: Cash Price |
$30.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.55
|
| Rate for Payer: Heritage Provider Network Senior |
$20.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.59
|
| Rate for Payer: Multiplan Commercial |
$22.77
|
|
|
HC SOM PHI FREE PSA
|
Facility
|
OP
|
$30.36
|
|
|
Service Code
|
CPT 84154
|
| Hospital Charge Code |
900915519
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$173.87 |
| Rate for Payer: Adventist Health Commercial |
$6.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$173.87
|
| Rate for Payer: Blue Shield of California Commercial |
$148.03
|
| Rate for Payer: Blue Shield of California EPN |
$118.73
|
| Rate for Payer: Cash Price |
$30.36
|
| Rate for Payer: Cash Price |
$30.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$18.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.73
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.79
|
| Rate for Payer: Heritage Provider Network Senior |
$18.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$14.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$24.64
|
| Rate for Payer: Multiplan Commercial |
$22.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.39
|
| Rate for Payer: TriValley Medical Group Senior |
$18.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.23
|
| Rate for Payer: Vantage Medical Group Senior |
$18.39
|
|
|
HC SOM PHOSPHATIDYL ETHANOL
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
CPT 80321
|
| Hospital Charge Code |
900915352
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.86 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Adventist Health Commercial |
$12.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.64
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.62
|
| Rate for Payer: Heritage Provider Network Senior |
$40.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.00
|
| Rate for Payer: Multiplan Commercial |
$45.00
|
|
|
HC SOM PHOSPHATIDYL ETHANOL
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
CPT 80321
|
| Hospital Charge Code |
900915352
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.67 |
| Max. Negotiated Rate |
$98.44 |
| Rate for Payer: Adventist Health Commercial |
$14.00
|
| Rate for Payer: Adventist Health Commercial |
$12.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$43.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$59.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$33.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$52.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$98.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$98.44
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$39.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$45.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$59.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$59.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$51.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$59.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$43.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.14
|
| Rate for Payer: Heritage Provider Network Senior |
$37.14
|
| Rate for Payer: Heritage Provider Network Senior |
$43.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$33.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$28.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$49.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$42.00
|
| Rate for Payer: Multiplan Commercial |
$45.00
|
| Rate for Payer: Multiplan Commercial |
$52.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$35.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$30.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$30.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$35.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$59.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$51.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$59.50
|
| Rate for Payer: Vantage Medical Group Senior |
$51.00
|
| Rate for Payer: Vantage Medical Group Senior |
$59.50
|
|
|
HC SOM PHOSPHOLIPID AB IGA
|
Facility
|
IP
|
$24.10
|
|
|
Service Code
|
CPT 86147
|
| Hospital Charge Code |
900914172
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$18.07 |
| Rate for Payer: Adventist Health Commercial |
$4.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.52
|
| Rate for Payer: Cash Price |
$24.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.32
|
| Rate for Payer: Heritage Provider Network Senior |
$16.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.03
|
| Rate for Payer: Multiplan Commercial |
$18.07
|
|
|
HC SOM PHOSPHOLIPID AB IGA
|
Facility
|
OP
|
$24.10
|
|
|
Service Code
|
CPT 86147
|
| Hospital Charge Code |
900914172
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$147.97 |
| Rate for Payer: Adventist Health Commercial |
$4.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$28.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$137.11
|
| Rate for Payer: Blue Shield of California Commercial |
$147.97
|
| Rate for Payer: Blue Shield of California EPN |
$118.69
|
| Rate for Payer: Cash Price |
$24.10
|
| Rate for Payer: Cash Price |
$24.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$25.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.22
|
| Rate for Payer: EPIC Health Plan Medicare |
$25.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.92
|
| Rate for Payer: Heritage Provider Network Senior |
$14.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$25.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$29.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$34.10
|
| Rate for Payer: Multiplan Commercial |
$18.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$25.45
|
| Rate for Payer: TriValley Medical Group Senior |
$25.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.00
|
| Rate for Payer: Vantage Medical Group Senior |
$25.45
|
|
|
HC SOM PI-LINKD AG FLOW EA ADD'L
|
Facility
|
IP
|
$79.46
|
|
|
Service Code
|
CPT 88185
|
| Hospital Charge Code |
900914176
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$14.38 |
| Max. Negotiated Rate |
$59.59 |
| Rate for Payer: Adventist Health Commercial |
$15.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.17
|
| Rate for Payer: Cash Price |
$79.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$53.79
|
| Rate for Payer: Heritage Provider Network Senior |
$53.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.86
|
| Rate for Payer: Multiplan Commercial |
$59.59
|
|
|
HC SOM PI-LINKD AG FLOW EA ADD'L
|
Facility
|
OP
|
$79.46
|
|
|
Service Code
|
CPT 88185
|
| Hospital Charge Code |
900914176
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$14.38 |
| Max. Negotiated Rate |
$181.99 |
| Rate for Payer: Adventist Health Commercial |
$15.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$67.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$43.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$59.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$181.99
|
| Rate for Payer: Blue Shield of California Commercial |
$132.14
|
| Rate for Payer: Blue Shield of California EPN |
$106.27
|
| Rate for Payer: Cash Price |
$79.46
|
| Rate for Payer: Cash Price |
$79.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$51.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$67.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$67.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$67.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$49.19
|
| Rate for Payer: Heritage Provider Network Senior |
$49.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$37.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$55.62
|
| Rate for Payer: Multiplan Commercial |
$59.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$67.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$67.54
|
| Rate for Payer: Vantage Medical Group Senior |
$67.54
|
|
|
HC SOM PI-LINKD AG FLOW TC 1 MRKR
|
Facility
|
OP
|
$70.54
|
|
|
Service Code
|
CPT 88184
|
| Hospital Charge Code |
900914173
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$691.53 |
| Rate for Payer: Adventist Health Commercial |
$14.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$43.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$691.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$507.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$461.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$370.36
|
| Rate for Payer: Blue Shield of California Commercial |
$269.52
|
| Rate for Payer: Blue Shield of California EPN |
$216.74
|
| Rate for Payer: Cash Price |
$70.54
|
| Rate for Payer: Cash Price |
$70.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$45.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$691.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$507.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$461.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$461.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$43.66
|
| Rate for Payer: Heritage Provider Network Senior |
$43.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$461.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$33.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$530.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$617.77
|
| Rate for Payer: Multiplan Commercial |
$52.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$461.02
|
| Rate for Payer: TriValley Medical Group Senior |
$461.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$321.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$321.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$691.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$507.12
|
| Rate for Payer: Vantage Medical Group Senior |
$461.02
|
|
|
HC SOM PI-LINKD AG FLOW TC 1 MRKR
|
Facility
|
IP
|
$70.54
|
|
|
Service Code
|
CPT 88184
|
| Hospital Charge Code |
900914173
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$52.91 |
| Rate for Payer: Adventist Health Commercial |
$14.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$45.43
|
| Rate for Payer: Cash Price |
$70.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$47.76
|
| Rate for Payer: Heritage Provider Network Senior |
$47.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.64
|
| Rate for Payer: Multiplan Commercial |
$52.91
|
|
