LA care Medi-Cal HMO: disclosed hospital rates

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Based on the published hospital price files, LA care Medi-Cal HMO appears in disclosed negotiated rates across 2 hospitals and 160 services. This is public hospital price transparency data, not a guaranteed estimate of your bill.

Actual patient responsibility may vary based on your insurance plan, deductible, coinsurance, network status, diagnosis, setting, bundled services, clinical circumstances, and hospital billing practices.

160 prices shown.

Service	Hospital	Code	List price	Cash price	Negotiated range	Allowed (median)
0.9% SODIUM CHLORIDE--CONTROL FOR ATG Outpatient	Ronald Reagan UCLA Medical Center	63323018610 NDC	$40.00	$22.00	$10.00 – $200	—
0.9% SODIUM CHLORIDE--CONTROL FOR ATG Outpatient	UCLA Santa Monica Medical Center	63323018610 NDC	$40.00	$22.00	$1.03 – $200	—
1 em core session Outpatient	Ronald Reagan UCLA Medical Center	G9873 HCPCS	—	—	$20.00 – $20.00	—
1 em core session Outpatient	UCLA Santa Monica Medical Center	G9873 HCPCS	—	—	$20.00 – $20.00	—
12-24hr sealed lead acid Outpatient	Ronald Reagan UCLA Medical Center	K0733 HCPCS	—	—	$6.09 – $28.90	—
12-24hr sealed lead acid Outpatient	UCLA Santa Monica Medical Center	K0733 HCPCS	—	—	$5.25 – $28.90	—
1ST HOSP IP/OBS HIGH 75 Outpatient	Ronald Reagan UCLA Medical Center	99223 HCPCS	—	—	$80.10 – $80.10	—
1ST HOSP IP/OBS HIGH 75 Outpatient	UCLA Santa Monica Medical Center	99223 HCPCS	—	—	$80.10 – $80.10	—
1ST HOSP IP/OBS MODERATE 55 Outpatient	Ronald Reagan UCLA Medical Center	99222 HCPCS	—	—	$73.20 – $73.20	—
1ST HOSP IP/OBS MODERATE 55 Outpatient	UCLA Santa Monica Medical Center	99222 HCPCS	—	—	$73.20 – $73.20	—
1ST HOSP IP/OBS SF/LOW 40 Outpatient	Ronald Reagan UCLA Medical Center	99221 HCPCS	—	—	$34.30 – $34.30	—
1ST HOSP IP/OBS SF/LOW 40 Outpatient	UCLA Santa Monica Medical Center	99221 HCPCS	—	—	$34.30 – $34.30	—
1ST NF CARE HIGH MDM 50 Outpatient	Ronald Reagan UCLA Medical Center	99306 HCPCS	—	—	$72.10 – $72.10	—
1ST NF CARE HIGH MDM 50 Outpatient	UCLA Santa Monica Medical Center	99306 HCPCS	—	—	$72.10 – $72.10	—
1ST NF CARE MODERATE MDM 35 Outpatient	Ronald Reagan UCLA Medical Center	99305 HCPCS	—	—	$46.90 – $46.90	—
1ST NF CARE MODERATE MDM 35 Outpatient	UCLA Santa Monica Medical Center	99305 HCPCS	—	—	$46.90 – $46.90	—
1ST NF CARE SF/LOW MDM 25 Outpatient	Ronald Reagan UCLA Medical Center	99304 HCPCS	—	—	$37.80 – $37.80	—
1ST NF CARE SF/LOW MDM 25 Outpatient	UCLA Santa Monica Medical Center	99304 HCPCS	—	—	$37.80 – $37.80	—
1ST PSYC COLLAB CARE MGMT Outpatient	Ronald Reagan UCLA Medical Center	99492 HCPCS	—	—	$111 – $375	—
1ST PSYC COLLAB CARE MGMT Outpatient	UCLA Santa Monica Medical Center	99492 HCPCS	—	—	$118 – $375	—
1ST/SBSQ PSYC COLLAB CARE Outpatient	Ronald Reagan UCLA Medical Center	99494 HCPCS	—	—	$57.88 – $57.88	—
1ST/SBSQ PSYC COLLAB CARE Outpatient	UCLA Santa Monica Medical Center	99494 HCPCS	—	—	$57.88 – $57.88	—
2 em core ms mo 10-12 no wl Outpatient	Ronald Reagan UCLA Medical Center	G9877 HCPCS	—	—	$12.00 – $12.00	—
2 em core ms mo 10-12 no wl Outpatient	UCLA Santa Monica Medical Center	G9877 HCPCS	—	—	$12.00 – $12.00	—
2 em core ms mo 10-12 wl Outpatient	Ronald Reagan UCLA Medical Center	G9879 HCPCS	—	—	$48.00 – $48.00	—