|
HC SOM PIPERACILLIN LEVEL BA
|
Facility
|
OP
|
$106.40
|
|
|
Service Code
|
CPT 84999
|
| Hospital Charge Code |
900914693
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.26 |
| Max. Negotiated Rate |
$90.44 |
| Rate for Payer: Adventist Health Commercial |
$21.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$65.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$58.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$79.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$53.22
|
| Rate for Payer: Blue Shield of California Commercial |
$64.90
|
| Rate for Payer: Blue Shield of California EPN |
$51.92
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$90.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$90.44
|
| Rate for Payer: Dignity Health Medicare Advantage |
$90.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$62.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.86
|
| Rate for Payer: Heritage Provider Network Senior |
$65.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$50.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$74.48
|
| Rate for Payer: Multiplan Commercial |
$79.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$53.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$53.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$90.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$90.44
|
| Rate for Payer: Vantage Medical Group Senior |
$90.44
|
|
|
HC SOM PIPERACILLIN LEVEL BA
|
Facility
|
IP
|
$106.40
|
|
|
Service Code
|
CPT 84999
|
| Hospital Charge Code |
900914693
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.26 |
| Max. Negotiated Rate |
$79.80 |
| Rate for Payer: Adventist Health Commercial |
$21.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$68.52
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$72.03
|
| Rate for Payer: Heritage Provider Network Senior |
$72.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.60
|
| Rate for Payer: Multiplan Commercial |
$79.80
|
|
|
HC SOM PKHD1 GENE
|
Facility
|
OP
|
$1,525.00
|
|
|
Service Code
|
CPT 84999
|
| Hospital Charge Code |
900914705
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$276.02 |
| Max. Negotiated Rate |
$1,296.25 |
| Rate for Payer: Adventist Health Commercial |
$305.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$942.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,296.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$838.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,143.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$762.80
|
| Rate for Payer: Blue Shield of California Commercial |
$930.25
|
| Rate for Payer: Blue Shield of California EPN |
$744.20
|
| Rate for Payer: Cash Price |
$1,525.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$991.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,296.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,296.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,296.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$991.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$943.98
|
| Rate for Payer: Heritage Provider Network Senior |
$943.98
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$727.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$276.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$381.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,067.50
|
| Rate for Payer: Multiplan Commercial |
$1,143.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$762.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$762.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,296.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,296.25
|
| Rate for Payer: Vantage Medical Group Senior |
$1,296.25
|
|
|
HC SOM PKHD1 GENE
|
Facility
|
IP
|
$1,525.00
|
|
|
Service Code
|
CPT 84999
|
| Hospital Charge Code |
900914705
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$276.02 |
| Max. Negotiated Rate |
$1,143.75 |
| Rate for Payer: Adventist Health Commercial |
$305.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$982.10
|
| Rate for Payer: Cash Price |
$1,525.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,032.42
|
| Rate for Payer: Heritage Provider Network Senior |
$1,032.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$276.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$381.25
|
| Rate for Payer: Multiplan Commercial |
$1,143.75
|
|
|
HC SOM PLASMINOGEN ACTIVITY
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT 85420
|
| Hospital Charge Code |
900911325
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$6.53 |
| Max. Negotiated Rate |
$62.13 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$62.13
|
| Rate for Payer: Blue Shield of California Commercial |
$52.59
|
| Rate for Payer: Blue Shield of California EPN |
$42.18
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$6.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.95
|
| Rate for Payer: Heritage Provider Network Senior |
$30.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$23.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8.75
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.53
|
| Rate for Payer: TriValley Medical Group Senior |
$6.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.18
|
| Rate for Payer: Vantage Medical Group Senior |
$6.53
|
|
|
HC SOM PLASMINOGEN ACTIVITY
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT 85420
|
| Hospital Charge Code |
900911325
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$37.50 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.20
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.85
|
| Rate for Payer: Heritage Provider Network Senior |
$33.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.50
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
|
|
HC SOM PML/RARA QUANT, PCR
|
Facility
|
OP
|
$255.94
|
|
|
Service Code
|
CPT 81315
|
| Hospital Charge Code |
900913891
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$46.33 |
| Max. Negotiated Rate |
$506.97 |
| Rate for Payer: Adventist Health Commercial |
$51.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$158.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$310.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$228.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$207.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$506.97
|
| Rate for Payer: Blue Shield of California Commercial |
$156.12
|
| Rate for Payer: Blue Shield of California EPN |
$124.90
|
| Rate for Payer: Cash Price |
$255.94
|
| Rate for Payer: Cash Price |
$255.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$166.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$310.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$207.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$166.36
|
| Rate for Payer: EPIC Health Plan Medicare |
$207.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$158.43
|
| Rate for Payer: Heritage Provider Network Senior |
$158.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$207.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$122.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$46.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$238.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$277.80
|
| Rate for Payer: Multiplan Commercial |
$191.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$207.31
|
| Rate for Payer: TriValley Medical Group Senior |
$207.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$223.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$223.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$310.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.04
|
| Rate for Payer: Vantage Medical Group Senior |
$207.31
|
|
|
HC SOM PML/RARA QUANT, PCR
|
Facility
|
IP
|
$255.94
|
|
|
Service Code
|
CPT 81315
|
| Hospital Charge Code |
900913891
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$46.33 |
| Max. Negotiated Rate |
$191.96 |
| Rate for Payer: Adventist Health Commercial |
$51.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.83
|
| Rate for Payer: Cash Price |
$255.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$173.27
|
| Rate for Payer: Heritage Provider Network Senior |
$173.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$46.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.98
|
| Rate for Payer: Multiplan Commercial |
$191.96
|
|
|
HC SOM PNEUMOCYSTIS PCR
|
Facility
|
IP
|
$94.33
|
|
|
Service Code
|
CPT 87594
|
| Hospital Charge Code |
900915467
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.07 |
| Max. Negotiated Rate |
$70.75 |
| Rate for Payer: Adventist Health Commercial |
$18.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$60.75
|
| Rate for Payer: Cash Price |
$94.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$63.86
|
| Rate for Payer: Heritage Provider Network Senior |
$63.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.58
|
| Rate for Payer: Multiplan Commercial |
$70.75
|
|
|
HC SOM PNEUMOCYSTIS PCR
|
Facility
|
OP
|
$94.33
|
|
|
Service Code
|
CPT 87594
|
| Hospital Charge Code |
900915467
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.07 |
| Max. Negotiated Rate |
$202.12 |
| Rate for Payer: Cigna of CA HMO/PPO |
$61.31
|
| Rate for Payer: Adventist Health Commercial |
$18.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$58.30
|
| 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 |
$56.25
|
| Rate for Payer: Blue Shield of California Commercial |
$202.12
|
| Rate for Payer: Blue Shield of California EPN |
$162.12
|
| Rate for Payer: Cash Price |
$94.33
|
| Rate for Payer: Cash Price |
$94.33
|
| 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 |
$61.31
|
| Rate for Payer: EPIC Health Plan Medicare |
$35.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.39
|
| Rate for Payer: Heritage Provider Network Senior |
$58.39
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$45.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$40.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$47.02
|
| Rate for Payer: Multiplan Commercial |
$70.75
|
| 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 |
$47.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$47.16
|
| 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 PORPHOBILINOGEN QUANT.
|
Facility
|
OP
|
$31.22
|
|
|
Service Code
|
CPT 84110
|
| Hospital Charge Code |
900912570
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$80.22 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.29
|
| Rate for Payer: Adventist Health Commercial |
$6.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$80.22
|
| Rate for Payer: Blue Shield of California Commercial |
$67.97
|
| Rate for Payer: Blue Shield of California EPN |
$54.52
|
| Rate for Payer: Cash Price |
$31.22
|
| Rate for Payer: Cash Price |
$31.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.42
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.33
|
| Rate for Payer: Heritage Provider Network Senior |
$19.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$14.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11.31
|
| Rate for Payer: Multiplan Commercial |
$23.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.44
|
| Rate for Payer: TriValley Medical Group Senior |
$8.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.28
|
| Rate for Payer: Vantage Medical Group Senior |
$8.44
|
|
|
HC SOM PORPHOBILINOGEN QUANT.
|
Facility
|
IP
|
$31.22
|
|
|
Service Code
|
CPT 84110
|
| Hospital Charge Code |
900912570
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$23.41 |
| Rate for Payer: Adventist Health Commercial |
$6.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.11
|
| Rate for Payer: Cash Price |
$31.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.14
|
| Rate for Payer: Heritage Provider Network Senior |
$21.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.80
|
| Rate for Payer: Multiplan Commercial |
$23.41
|
|
|
HC SOM PORPHYRINS FRAC RND U
|
Facility
|
OP
|
$21.08
|
|
|
Service Code
|
CPT 84120
|
| Hospital Charge Code |
900914687
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$139.67 |
| Rate for Payer: Adventist Health Commercial |
$4.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$139.67
|
| Rate for Payer: Blue Shield of California Commercial |
$118.37
|
| Rate for Payer: Blue Shield of California EPN |
$94.94
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.44
|
| Rate for Payer: EPIC Health Plan Medicare |
$14.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.05
|
| Rate for Payer: Heritage Provider Network Senior |
$13.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$10.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$19.71
|
| Rate for Payer: Multiplan Commercial |
$15.81
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.71
|
| Rate for Payer: TriValley Medical Group Senior |
$14.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.18
|
| Rate for Payer: Vantage Medical Group Senior |
$14.71
|
|
|
HC SOM PORPHYRINS FRAC RND U
|
Facility
|
IP
|
$21.08
|
|
|
Service Code
|
CPT 84120
|
| Hospital Charge Code |
900914687
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$15.81 |
| Rate for Payer: Adventist Health Commercial |
$4.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.58
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.27
|
| Rate for Payer: Heritage Provider Network Senior |
$14.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.27
|
| Rate for Payer: Multiplan Commercial |
$15.81
|
|
|
HC SOM PORPHYRINS QN RND U
|
Facility
|
IP
|
$12.09
|
|
|
Service Code
|
CPT 84110
|
| Hospital Charge Code |
900914686
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$9.07 |
| Rate for Payer: Adventist Health Commercial |
$2.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.79
|
| Rate for Payer: Cash Price |
$12.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.18
|
| Rate for Payer: Heritage Provider Network Senior |
$8.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.02
|
| Rate for Payer: Multiplan Commercial |
$9.07
|
|
|
HC SOM PORPHYRINS QN RND U
|
Facility
|
OP
|
$12.09
|
|
|
Service Code
|
CPT 84110
|
| Hospital Charge Code |
900914686
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$80.22 |
| Rate for Payer: Adventist Health Commercial |
$2.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$80.22
|
| Rate for Payer: Blue Shield of California Commercial |
$67.97
|
| Rate for Payer: Blue Shield of California EPN |
$54.52
|
| Rate for Payer: Cash Price |
$12.09
|
| Rate for Payer: Cash Price |
$12.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.48
|
| Rate for Payer: Heritage Provider Network Senior |
$7.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11.31
|
| Rate for Payer: Multiplan Commercial |
$9.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.44
|
| Rate for Payer: TriValley Medical Group Senior |
$8.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.28
|
| Rate for Payer: Vantage Medical Group Senior |
$8.44
|
|
|
HC SOM PORPHYRINS TOTAL PLAS
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
CPT 84311
|
| Hospital Charge Code |
900914689
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.96 |
| Max. Negotiated Rate |
$41.25 |
| Rate for Payer: Adventist Health Commercial |
$11.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.42
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.23
|
| Rate for Payer: Heritage Provider Network Senior |
$37.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.75
|
| Rate for Payer: Multiplan Commercial |
$41.25
|
|
|
HC SOM PORPHYRINS TOTAL PLAS
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
CPT 84311
|
| Hospital Charge Code |
900914689
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$66.41 |
| Rate for Payer: Adventist Health Commercial |
$11.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$66.41
|
| Rate for Payer: Blue Shield of California Commercial |
$56.28
|
| Rate for Payer: Blue Shield of California EPN |
$45.14
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$35.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.05
|
| Rate for Payer: Heritage Provider Network Senior |
$34.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$26.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.85
|
| Rate for Payer: Multiplan Commercial |
$41.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.10
|
| Rate for Payer: TriValley Medical Group Senior |
$8.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.91
|
| Rate for Payer: Vantage Medical Group Senior |
$8.10
|
|
|
HC SOM PORPHYRINS URINE FRACTIONATED
|
Facility
|
IP
|
$14.22
|
|
|
Service Code
|
CPT 84120
|
| Hospital Charge Code |
900911511
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.57 |
| Max. Negotiated Rate |
$10.66 |
| Rate for Payer: Adventist Health Commercial |
$2.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.16
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.63
|
| Rate for Payer: Heritage Provider Network Senior |
$9.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.56
|
| Rate for Payer: Multiplan Commercial |
$10.66
|
|
|
HC SOM PORPHYRINS URINE FRACTIONATED
|
Facility
|
OP
|
$14.22
|
|
|
Service Code
|
CPT 84120
|
| Hospital Charge Code |
900911511
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.57 |
| Max. Negotiated Rate |
$139.67 |
| Rate for Payer: Adventist Health Commercial |
$2.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$139.67
|
| Rate for Payer: Blue Shield of California Commercial |
$118.37
|
| Rate for Payer: Blue Shield of California EPN |
$94.94
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.39
|
| Rate for Payer: EPIC Health Plan Medicare |
$14.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.80
|
| Rate for Payer: Heritage Provider Network Senior |
$8.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$19.71
|
| Rate for Payer: Multiplan Commercial |
$10.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.71
|
| Rate for Payer: TriValley Medical Group Senior |
$14.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.18
|
| Rate for Payer: Vantage Medical Group Senior |
$14.71
|
|
|
HC SOM PORPHYR UR FRAC PORPHOBIL
|
Facility
|
IP
|
$24.78
|
|
|
Service Code
|
CPT 84110
|
| Hospital Charge Code |
900912814
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.49 |
| Max. Negotiated Rate |
$18.59 |
| Rate for Payer: Adventist Health Commercial |
$4.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.96
|
| Rate for Payer: Cash Price |
$24.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.78
|
| Rate for Payer: Heritage Provider Network Senior |
$16.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.20
|
| Rate for Payer: Multiplan Commercial |
$18.59
|
|
|
HC SOM PORPHYR UR FRAC PORPHOBIL
|
Facility
|
OP
|
$24.78
|
|
|
Service Code
|
CPT 84110
|
| Hospital Charge Code |
900912814
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.49 |
| Max. Negotiated Rate |
$80.22 |
| Rate for Payer: Adventist Health Commercial |
$4.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$80.22
|
| Rate for Payer: Blue Shield of California Commercial |
$67.97
|
| Rate for Payer: Blue Shield of California EPN |
$54.52
|
| Rate for Payer: Cash Price |
$24.78
|
| Rate for Payer: Cash Price |
$24.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.62
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.34
|
| Rate for Payer: Heritage Provider Network Senior |
$15.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11.31
|
| Rate for Payer: Multiplan Commercial |
$18.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.44
|
| Rate for Payer: TriValley Medical Group Senior |
$8.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.28
|
| Rate for Payer: Vantage Medical Group Senior |
$8.44
|
|
|
HC SOM POSACONAZOLE LEVEL
|
Facility
|
IP
|
$27.11
|
|
|
Service Code
|
CPT 80187
|
| Hospital Charge Code |
900912708
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$20.33 |
| Rate for Payer: Adventist Health Commercial |
$5.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.46
|
| Rate for Payer: Cash Price |
$27.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.35
|
| Rate for Payer: Heritage Provider Network Senior |
$18.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.78
|
| Rate for Payer: Multiplan Commercial |
$20.33
|
|
|
HC SOM POSACONAZOLE LEVEL
|
Facility
|
OP
|
$27.11
|
|
|
Service Code
|
CPT 80187
|
| Hospital Charge Code |
900912708
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$156.15 |
| Rate for Payer: Adventist Health Commercial |
$5.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$29.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$91.22
|
| Rate for Payer: Blue Shield of California Commercial |
$156.15
|
| Rate for Payer: Blue Shield of California EPN |
$125.25
|
| Rate for Payer: Cash Price |
$27.11
|
| Rate for Payer: Cash Price |
$27.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$27.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.99
|
| Rate for Payer: EPIC Health Plan Medicare |
$27.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.78
|
| Rate for Payer: Heritage Provider Network Senior |
$16.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$27.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$12.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$31.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$36.33
|
| Rate for Payer: Multiplan Commercial |
$20.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$27.11
|
| Rate for Payer: TriValley Medical Group Senior |
$27.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$29.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$29.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.82
|
| Rate for Payer: Vantage Medical Group Senior |
$27.11
|
|
|
HC SOM PRADER WILLI SYNDROME ANALYSIS
|
Facility
|
OP
|
$358.60
|
|
|
Service Code
|
CPT 81331
|
| Hospital Charge Code |
900910668
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$51.07 |
| Max. Negotiated Rate |
$382.57 |
| Rate for Payer: Adventist Health Commercial |
$71.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$221.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$76.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$56.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$51.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$382.57
|
| Rate for Payer: Blue Shield of California Commercial |
$218.75
|
| Rate for Payer: Blue Shield of California EPN |
$175.00
|
| Rate for Payer: Cash Price |
$358.60
|
| Rate for Payer: Cash Price |
$358.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$233.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$76.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$56.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$51.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$211.57
|
| Rate for Payer: EPIC Health Plan Medicare |
$51.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$221.97
|
| Rate for Payer: Heritage Provider Network Senior |
$221.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$51.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$171.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$64.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$58.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$68.43
|
| Rate for Payer: Multiplan Commercial |
$268.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$51.07
|
| Rate for Payer: TriValley Medical Group Senior |
$51.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$55.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$55.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$76.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$56.18
|
| Rate for Payer: Vantage Medical Group Senior |
$51.07
|
|
