|
HC TC-99 BICISTAE/NUEROLITE LT 25MCI
|
Facility
|
OP
|
$1,693.00
|
|
|
Service Code
|
CPT A9557
|
| Hospital Charge Code |
909301541
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$338.60 |
| Max. Negotiated Rate |
$1,439.05 |
| Rate for Payer: Adventist Health Commercial |
$338.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$854.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$752.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$752.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,039.67
|
| Rate for Payer: Cash Price |
$931.15
|
| Rate for Payer: Cash Price |
$931.15
|
| Rate for Payer: Cigna of CA HMO |
$1,185.10
|
| Rate for Payer: Cigna of CA PPO |
$1,185.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$854.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$752.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$752.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$923.13
|
| Rate for Payer: EPIC Health Plan Senior |
$683.80
|
| Rate for Payer: Galaxy Health WC |
$1,439.05
|
| Rate for Payer: Global Benefits Group Commercial |
$1,015.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,121.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$570.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$683.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,129.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$644.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$683.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$406.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$861.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$916.29
|
| Rate for Payer: Multiplan Commercial |
$1,354.40
|
| Rate for Payer: Networks By Design Commercial |
$846.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,439.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,015.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,015.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$635.38
|
| Rate for Payer: United Healthcare All Other HMO |
$618.45
|
| Rate for Payer: United Healthcare HMO Rider |
$605.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$554.46
|
| Rate for Payer: Upland Medical Group Pediatric |
$683.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$854.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$752.18
|
| Rate for Payer: Vantage Medical Group Senior |
$752.18
|
|
|
HC TC-99 BICISTAE/NUEROLITE LT 25MCI
|
Facility
|
IP
|
$1,693.00
|
|
|
Service Code
|
CPT A9557
|
| Hospital Charge Code |
909301541
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$338.60 |
| Max. Negotiated Rate |
$1,439.05 |
| Rate for Payer: Adventist Health Commercial |
$338.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1,249.43
|
| Rate for Payer: Blue Shield of California EPN |
$822.80
|
| Rate for Payer: Cash Price |
$931.15
|
| Rate for Payer: Cigna of CA HMO |
$1,185.10
|
| Rate for Payer: Cigna of CA PPO |
$1,185.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$677.20
|
| Rate for Payer: EPIC Health Plan Senior |
$677.20
|
| Rate for Payer: Galaxy Health WC |
$1,439.05
|
| Rate for Payer: Global Benefits Group Commercial |
$1,015.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,129.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$645.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,047.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$406.32
|
| Rate for Payer: Multiplan Commercial |
$1,354.40
|
| Rate for Payer: Networks By Design Commercial |
$846.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,439.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$635.38
|
| Rate for Payer: United Healthcare All Other HMO |
$618.45
|
| Rate for Payer: United Healthcare HMO Rider |
$605.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$554.46
|
|
|
HC TC-99 CERETEC UP TO 25 MCI
|
Facility
|
OP
|
$3,130.00
|
|
|
Service Code
|
CPT A9521
|
| Hospital Charge Code |
909301535
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$626.00 |
| Max. Negotiated Rate |
$2,660.50 |
| Rate for Payer: Adventist Health Commercial |
$626.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,002.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$882.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$882.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,922.13
|
| Rate for Payer: Cash Price |
$1,721.50
|
| Rate for Payer: Cash Price |
$1,721.50
|
| Rate for Payer: Cigna of CA HMO |
$2,191.00
|
| Rate for Payer: Cigna of CA PPO |
$2,191.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,002.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$882.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$882.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,083.16
|
| Rate for Payer: EPIC Health Plan Senior |
$802.34
|
| Rate for Payer: Galaxy Health WC |
$2,660.50
|
| Rate for Payer: Global Benefits Group Commercial |
$1,878.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,315.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$762.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$802.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,087.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$862.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$802.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$751.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,010.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,075.14
|
| Rate for Payer: Multiplan Commercial |
$2,504.00
|
| Rate for Payer: Networks By Design Commercial |
$1,565.00
|
| Rate for Payer: Prime Health Services Commercial |
$2,660.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,878.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,878.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,174.69
|
| Rate for Payer: United Healthcare All Other HMO |
$1,143.39
|
| Rate for Payer: United Healthcare HMO Rider |
$1,118.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,025.08
|
| Rate for Payer: Upland Medical Group Pediatric |
$802.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,002.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$882.57
|
| Rate for Payer: Vantage Medical Group Senior |
$882.57
|
|
|
HC TC-99 CERETEC UP TO 25 MCI
|
Facility
|
IP
|
$3,130.00
|
|
|
Service Code
|
CPT A9521
|
| Hospital Charge Code |
909301535
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$626.00 |
| Max. Negotiated Rate |
$2,660.50 |
| Rate for Payer: Adventist Health Commercial |
$626.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,309.94
|
| Rate for Payer: Blue Shield of California EPN |
$1,521.18
|
| Rate for Payer: Cash Price |
$1,721.50
|
| Rate for Payer: Cigna of CA HMO |
$2,191.00
|
| Rate for Payer: Cigna of CA PPO |
$2,191.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,252.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,252.00
|
| Rate for Payer: Galaxy Health WC |
$2,660.50
|
| Rate for Payer: Global Benefits Group Commercial |
$1,878.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,087.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,192.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,937.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$751.20
|
| Rate for Payer: Multiplan Commercial |
$2,504.00
|
| Rate for Payer: Networks By Design Commercial |
$1,565.00
|
| Rate for Payer: Prime Health Services Commercial |
$2,660.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,174.69
|
| Rate for Payer: United Healthcare All Other HMO |
$1,143.39
|
| Rate for Payer: United Healthcare HMO Rider |
$1,118.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,025.08
|
|
|
HC TC-99 GHT UP TO 25 MCI
|
Facility
|
IP
|
$256.00
|
|
|
Service Code
|
CPT A9550
|
| Hospital Charge Code |
909301509
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.20 |
| Max. Negotiated Rate |
$217.60 |
| Rate for Payer: Adventist Health Commercial |
$51.20
|
| Rate for Payer: Blue Shield of California Commercial |
$188.93
|
| Rate for Payer: Blue Shield of California EPN |
$124.42
|
| Rate for Payer: Cash Price |
$140.80
|
| Rate for Payer: Cigna of CA HMO |
$179.20
|
| Rate for Payer: Cigna of CA PPO |
$179.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$102.40
|
| Rate for Payer: EPIC Health Plan Senior |
$102.40
|
| Rate for Payer: Galaxy Health WC |
$217.60
|
| Rate for Payer: Global Benefits Group Commercial |
$153.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$170.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$158.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.44
|
| Rate for Payer: Multiplan Commercial |
$204.80
|
| Rate for Payer: Networks By Design Commercial |
$128.00
|
| Rate for Payer: Prime Health Services Commercial |
$217.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$96.08
|
| Rate for Payer: United Healthcare All Other HMO |
$93.52
|
| Rate for Payer: United Healthcare HMO Rider |
$91.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$83.84
|
|
|
HC TC-99 GHT UP TO 25 MCI
|
Facility
|
OP
|
$256.00
|
|
|
Service Code
|
CPT A9550
|
| Hospital Charge Code |
909301509
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.20 |
| Max. Negotiated Rate |
$217.60 |
| Rate for Payer: Adventist Health Commercial |
$51.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$217.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$140.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$192.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$157.21
|
| Rate for Payer: Cash Price |
$140.80
|
| Rate for Payer: Cigna of CA HMO |
$179.20
|
| Rate for Payer: Cigna of CA PPO |
$179.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$217.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$217.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$217.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$102.40
|
| Rate for Payer: EPIC Health Plan Senior |
$102.40
|
| Rate for Payer: Galaxy Health WC |
$217.60
|
| Rate for Payer: Global Benefits Group Commercial |
$153.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$170.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$158.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$179.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$179.20
|
| Rate for Payer: Multiplan Commercial |
$204.80
|
| Rate for Payer: Networks By Design Commercial |
$128.00
|
| Rate for Payer: Prime Health Services Commercial |
$217.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$153.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$153.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$96.08
|
| Rate for Payer: United Healthcare All Other HMO |
$93.52
|
| Rate for Payer: United Healthcare HMO Rider |
$91.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$83.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$217.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$217.60
|
| Rate for Payer: Vantage Medical Group Senior |
$217.60
|
|
|
HC TC-99 HEPATOLITE UP TO 15 MCI
|
Facility
|
OP
|
$449.00
|
|
|
Service Code
|
CPT A9510
|
| Hospital Charge Code |
909301505
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.51 |
| Max. Negotiated Rate |
$381.65 |
| Rate for Payer: Adventist Health Commercial |
$89.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$381.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$246.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$336.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$275.73
|
| Rate for Payer: Cash Price |
$246.95
|
| Rate for Payer: Cash Price |
$246.95
|
| Rate for Payer: Cigna of CA HMO |
$314.30
|
| Rate for Payer: Cigna of CA PPO |
$314.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$381.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$381.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$381.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$179.60
|
| Rate for Payer: EPIC Health Plan Senior |
$179.60
|
| Rate for Payer: Galaxy Health WC |
$381.65
|
| Rate for Payer: Global Benefits Group Commercial |
$269.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$58.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$299.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.18
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$277.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$314.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$314.30
|
| Rate for Payer: Multiplan Commercial |
$359.20
|
| Rate for Payer: Networks By Design Commercial |
$224.50
|
| Rate for Payer: Prime Health Services Commercial |
$381.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$269.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$269.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$168.51
|
| Rate for Payer: United Healthcare All Other HMO |
$164.02
|
| Rate for Payer: United Healthcare HMO Rider |
$160.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$147.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$381.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$381.65
|
| Rate for Payer: Vantage Medical Group Senior |
$381.65
|
|
|
HC TC-99 HEPATOLITE UP TO 15 MCI
|
Facility
|
IP
|
$449.00
|
|
|
Service Code
|
CPT A9510
|
| Hospital Charge Code |
909301505
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.80 |
| Max. Negotiated Rate |
$381.65 |
| Rate for Payer: Adventist Health Commercial |
$89.80
|
| Rate for Payer: Blue Shield of California Commercial |
$331.36
|
| Rate for Payer: Blue Shield of California EPN |
$218.21
|
| Rate for Payer: Cash Price |
$246.95
|
| Rate for Payer: Cigna of CA HMO |
$314.30
|
| Rate for Payer: Cigna of CA PPO |
$314.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$179.60
|
| Rate for Payer: EPIC Health Plan Senior |
$179.60
|
| Rate for Payer: Galaxy Health WC |
$381.65
|
| Rate for Payer: Global Benefits Group Commercial |
$269.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$299.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$171.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$277.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.76
|
| Rate for Payer: Multiplan Commercial |
$359.20
|
| Rate for Payer: Networks By Design Commercial |
$224.50
|
| Rate for Payer: Prime Health Services Commercial |
$381.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$168.51
|
| Rate for Payer: United Healthcare All Other HMO |
$164.02
|
| Rate for Payer: United Healthcare HMO Rider |
$160.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$147.05
|
|
|
HC TC-99 MAA UP TO 10 MCI
|
Facility
|
IP
|
$294.00
|
|
|
Service Code
|
CPT A9540
|
| Hospital Charge Code |
909301506
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$249.90 |
| Rate for Payer: Adventist Health Commercial |
$58.80
|
| Rate for Payer: Blue Shield of California Commercial |
$216.97
|
| Rate for Payer: Blue Shield of California EPN |
$142.88
|
| Rate for Payer: Cash Price |
$161.70
|
| Rate for Payer: Cigna of CA HMO |
$205.80
|
| Rate for Payer: Cigna of CA PPO |
$205.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$117.60
|
| Rate for Payer: EPIC Health Plan Senior |
$117.60
|
| Rate for Payer: Galaxy Health WC |
$249.90
|
| Rate for Payer: Global Benefits Group Commercial |
$176.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$196.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$112.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$181.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.56
|
| Rate for Payer: Multiplan Commercial |
$235.20
|
| Rate for Payer: Networks By Design Commercial |
$147.00
|
| Rate for Payer: Prime Health Services Commercial |
$249.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$110.34
|
| Rate for Payer: United Healthcare All Other HMO |
$107.40
|
| Rate for Payer: United Healthcare HMO Rider |
$105.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$96.28
|
|
|
HC TC-99 MAA UP TO 10 MCI
|
Facility
|
OP
|
$294.00
|
|
|
Service Code
|
CPT A9540
|
| Hospital Charge Code |
909301506
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.40 |
| Max. Negotiated Rate |
$249.90 |
| Rate for Payer: Adventist Health Commercial |
$58.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$249.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$161.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$220.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$180.55
|
| Rate for Payer: Cash Price |
$161.70
|
| Rate for Payer: Cash Price |
$161.70
|
| Rate for Payer: Cigna of CA HMO |
$205.80
|
| Rate for Payer: Cigna of CA PPO |
$205.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$249.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$249.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$249.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$117.60
|
| Rate for Payer: EPIC Health Plan Senior |
$117.60
|
| Rate for Payer: Galaxy Health WC |
$249.90
|
| Rate for Payer: Global Benefits Group Commercial |
$176.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$50.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$196.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$57.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$181.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$205.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$205.80
|
| Rate for Payer: Multiplan Commercial |
$235.20
|
| Rate for Payer: Networks By Design Commercial |
$147.00
|
| Rate for Payer: Prime Health Services Commercial |
$249.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$176.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$176.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$110.34
|
| Rate for Payer: United Healthcare All Other HMO |
$107.40
|
| Rate for Payer: United Healthcare HMO Rider |
$105.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$96.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$249.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$249.90
|
| Rate for Payer: Vantage Medical Group Senior |
$249.90
|
|
|
HC TC-99M APCITIDE/ACCUTEC LT 20MCI
|
Facility
|
OP
|
$1,933.00
|
|
|
Service Code
|
CPT A9504
|
| Hospital Charge Code |
909301540
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$386.60 |
| Max. Negotiated Rate |
$1,643.05 |
| Rate for Payer: Adventist Health Commercial |
$386.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,643.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,063.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,449.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,187.06
|
| Rate for Payer: Cash Price |
$1,063.15
|
| Rate for Payer: Cash Price |
$1,063.15
|
| Rate for Payer: Cigna of CA HMO |
$1,353.10
|
| Rate for Payer: Cigna of CA PPO |
$1,353.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,643.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,643.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,643.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$773.20
|
| Rate for Payer: EPIC Health Plan Senior |
$773.20
|
| Rate for Payer: Galaxy Health WC |
$1,643.05
|
| Rate for Payer: Global Benefits Group Commercial |
$1,159.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$638.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,289.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$722.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,196.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$463.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,353.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,353.10
|
| Rate for Payer: Multiplan Commercial |
$1,546.40
|
| Rate for Payer: Networks By Design Commercial |
$966.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,643.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,159.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,159.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$725.45
|
| Rate for Payer: United Healthcare All Other HMO |
$706.12
|
| Rate for Payer: United Healthcare HMO Rider |
$690.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$633.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,643.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,643.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1,643.05
|
|
|
HC TC-99M APCITIDE/ACCUTEC LT 20MCI
|
Facility
|
IP
|
$1,933.00
|
|
|
Service Code
|
CPT A9504
|
| Hospital Charge Code |
909301540
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$386.60 |
| Max. Negotiated Rate |
$1,643.05 |
| Rate for Payer: Adventist Health Commercial |
$386.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1,426.55
|
| Rate for Payer: Blue Shield of California EPN |
$939.44
|
| Rate for Payer: Cash Price |
$1,063.15
|
| Rate for Payer: Cigna of CA HMO |
$1,353.10
|
| Rate for Payer: Cigna of CA PPO |
$1,353.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$773.20
|
| Rate for Payer: EPIC Health Plan Senior |
$773.20
|
| Rate for Payer: Galaxy Health WC |
$1,643.05
|
| Rate for Payer: Global Benefits Group Commercial |
$1,159.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,289.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$736.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,196.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$463.92
|
| Rate for Payer: Multiplan Commercial |
$1,546.40
|
| Rate for Payer: Networks By Design Commercial |
$966.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,643.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$725.45
|
| Rate for Payer: United Healthcare All Other HMO |
$706.12
|
| Rate for Payer: United Healthcare HMO Rider |
$690.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$633.06
|
|
|
HC TC-99M DEPREOTID NEOTEC LT 35MCI
|
Facility
|
OP
|
$2,398.00
|
|
|
Service Code
|
CPT A9536
|
| Hospital Charge Code |
909301542
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$479.60 |
| Max. Negotiated Rate |
$2,038.30 |
| Rate for Payer: Adventist Health Commercial |
$479.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,038.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,318.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,798.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,472.61
|
| Rate for Payer: Cash Price |
$1,318.90
|
| Rate for Payer: Cash Price |
$1,318.90
|
| Rate for Payer: Cigna of CA HMO |
$1,678.60
|
| Rate for Payer: Cigna of CA PPO |
$1,678.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,038.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,038.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,038.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$959.20
|
| Rate for Payer: EPIC Health Plan Senior |
$959.20
|
| Rate for Payer: Galaxy Health WC |
$2,038.30
|
| Rate for Payer: Global Benefits Group Commercial |
$1,438.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,021.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,599.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,155.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,484.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$575.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,678.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,678.60
|
| Rate for Payer: Multiplan Commercial |
$1,918.40
|
| Rate for Payer: Networks By Design Commercial |
$1,199.00
|
| Rate for Payer: Prime Health Services Commercial |
$2,038.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,438.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,438.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$899.97
|
| Rate for Payer: United Healthcare All Other HMO |
$875.99
|
| Rate for Payer: United Healthcare HMO Rider |
$857.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$785.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,038.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,038.30
|
| Rate for Payer: Vantage Medical Group Senior |
$2,038.30
|
|
|
HC TC-99M DEPREOTID NEOTEC LT 35MCI
|
Facility
|
IP
|
$2,398.00
|
|
|
Service Code
|
CPT A9536
|
| Hospital Charge Code |
909301542
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$479.60 |
| Max. Negotiated Rate |
$2,038.30 |
| Rate for Payer: Adventist Health Commercial |
$479.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1,769.72
|
| Rate for Payer: Blue Shield of California EPN |
$1,165.43
|
| Rate for Payer: Cash Price |
$1,318.90
|
| Rate for Payer: Cigna of CA HMO |
$1,678.60
|
| Rate for Payer: Cigna of CA PPO |
$1,678.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$959.20
|
| Rate for Payer: EPIC Health Plan Senior |
$959.20
|
| Rate for Payer: Galaxy Health WC |
$2,038.30
|
| Rate for Payer: Global Benefits Group Commercial |
$1,438.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,599.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$913.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,484.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$575.52
|
| Rate for Payer: Multiplan Commercial |
$1,918.40
|
| Rate for Payer: Networks By Design Commercial |
$1,199.00
|
| Rate for Payer: Prime Health Services Commercial |
$2,038.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$899.97
|
| Rate for Payer: United Healthcare All Other HMO |
$875.99
|
| Rate for Payer: United Healthcare HMO Rider |
$857.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$785.35
|
|
|
HC TC-99 MEBROFEN/CHOLETEC LT 15MCI
|
Facility
|
OP
|
$1,086.00
|
|
|
Service Code
|
CPT A9537
|
| Hospital Charge Code |
909301537
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.20 |
| Max. Negotiated Rate |
$923.10 |
| Rate for Payer: Adventist Health Commercial |
$217.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$923.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$597.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$814.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$666.91
|
| Rate for Payer: Cash Price |
$597.30
|
| Rate for Payer: Cash Price |
$597.30
|
| Rate for Payer: Cigna of CA HMO |
$760.20
|
| Rate for Payer: Cigna of CA PPO |
$760.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$923.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$923.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$923.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$434.40
|
| Rate for Payer: EPIC Health Plan Senior |
$434.40
|
| Rate for Payer: Galaxy Health WC |
$923.10
|
| Rate for Payer: Global Benefits Group Commercial |
$651.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$76.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$724.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.18
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$672.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$260.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$760.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$760.20
|
| Rate for Payer: Multiplan Commercial |
$868.80
|
| Rate for Payer: Networks By Design Commercial |
$543.00
|
| Rate for Payer: Prime Health Services Commercial |
$923.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$651.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$651.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$407.58
|
| Rate for Payer: United Healthcare All Other HMO |
$396.72
|
| Rate for Payer: United Healthcare HMO Rider |
$388.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$355.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$923.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$923.10
|
| Rate for Payer: Vantage Medical Group Senior |
$923.10
|
|
|
HC TC-99 MEBROFEN/CHOLETEC LT 15MCI
|
Facility
|
IP
|
$1,086.00
|
|
|
Service Code
|
CPT A9537
|
| Hospital Charge Code |
909301537
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$217.20 |
| Max. Negotiated Rate |
$923.10 |
| Rate for Payer: Adventist Health Commercial |
$217.20
|
| Rate for Payer: Blue Shield of California Commercial |
$801.47
|
| Rate for Payer: Blue Shield of California EPN |
$527.80
|
| Rate for Payer: Cash Price |
$597.30
|
| Rate for Payer: Cigna of CA HMO |
$760.20
|
| Rate for Payer: Cigna of CA PPO |
$760.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$434.40
|
| Rate for Payer: EPIC Health Plan Senior |
$434.40
|
| Rate for Payer: Galaxy Health WC |
$923.10
|
| Rate for Payer: Global Benefits Group Commercial |
$651.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$724.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$413.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$672.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$260.64
|
| Rate for Payer: Multiplan Commercial |
$868.80
|
| Rate for Payer: Networks By Design Commercial |
$543.00
|
| Rate for Payer: Prime Health Services Commercial |
$923.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$407.58
|
| Rate for Payer: United Healthcare All Other HMO |
$396.72
|
| Rate for Payer: United Healthcare HMO Rider |
$388.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$355.67
|
|
|
HC TC-99 MEDRONATE/MDP LT 30MCI
|
Facility
|
IP
|
$294.00
|
|
|
Service Code
|
CPT A9503
|
| Hospital Charge Code |
909301508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$249.90 |
| Rate for Payer: Adventist Health Commercial |
$58.80
|
| Rate for Payer: Blue Shield of California Commercial |
$216.97
|
| Rate for Payer: Blue Shield of California EPN |
$142.88
|
| Rate for Payer: Cash Price |
$161.70
|
| Rate for Payer: Cigna of CA HMO |
$205.80
|
| Rate for Payer: Cigna of CA PPO |
$205.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$117.60
|
| Rate for Payer: EPIC Health Plan Senior |
$117.60
|
| Rate for Payer: Galaxy Health WC |
$249.90
|
| Rate for Payer: Global Benefits Group Commercial |
$176.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$196.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$112.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$181.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.56
|
| Rate for Payer: Multiplan Commercial |
$235.20
|
| Rate for Payer: Networks By Design Commercial |
$147.00
|
| Rate for Payer: Prime Health Services Commercial |
$249.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$110.34
|
| Rate for Payer: United Healthcare All Other HMO |
$107.40
|
| Rate for Payer: United Healthcare HMO Rider |
$105.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$96.28
|
|
|
HC TC-99 MEDRONATE/MDP LT 30MCI
|
Facility
|
OP
|
$294.00
|
|
|
Service Code
|
CPT A9503
|
| Hospital Charge Code |
909301508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.70 |
| Max. Negotiated Rate |
$249.90 |
| Rate for Payer: Adventist Health Commercial |
$58.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$249.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$161.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$220.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$180.55
|
| Rate for Payer: Cash Price |
$161.70
|
| Rate for Payer: Cash Price |
$161.70
|
| Rate for Payer: Cigna of CA HMO |
$205.80
|
| Rate for Payer: Cigna of CA PPO |
$205.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$249.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$249.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$249.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$117.60
|
| Rate for Payer: EPIC Health Plan Senior |
$117.60
|
| Rate for Payer: Galaxy Health WC |
$249.90
|
| Rate for Payer: Global Benefits Group Commercial |
$176.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$31.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$196.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$181.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$205.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$205.80
|
| Rate for Payer: Multiplan Commercial |
$235.20
|
| Rate for Payer: Networks By Design Commercial |
$147.00
|
| Rate for Payer: Prime Health Services Commercial |
$249.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$176.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$176.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$110.34
|
| Rate for Payer: United Healthcare All Other HMO |
$107.40
|
| Rate for Payer: United Healthcare HMO Rider |
$105.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$96.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$249.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$249.90
|
| Rate for Payer: Vantage Medical Group Senior |
$249.90
|
|
|
HC TC-99 MERTIATIDE/MAG3 LT 15MCI
|
Facility
|
OP
|
$1,997.00
|
|
|
Service Code
|
CPT A9562
|
| Hospital Charge Code |
909301531
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$399.40 |
| Max. Negotiated Rate |
$1,697.45 |
| Rate for Payer: Adventist Health Commercial |
$399.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,697.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,098.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,497.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,226.36
|
| Rate for Payer: Cash Price |
$1,098.35
|
| Rate for Payer: Cash Price |
$1,098.35
|
| Rate for Payer: Cigna of CA HMO |
$1,397.90
|
| Rate for Payer: Cigna of CA PPO |
$1,397.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,697.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,697.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,697.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$798.80
|
| Rate for Payer: EPIC Health Plan Senior |
$798.80
|
| Rate for Payer: Galaxy Health WC |
$1,697.45
|
| Rate for Payer: Global Benefits Group Commercial |
$1,198.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$515.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,332.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$583.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,236.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$479.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,397.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,397.90
|
| Rate for Payer: Multiplan Commercial |
$1,597.60
|
| Rate for Payer: Networks By Design Commercial |
$998.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,697.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,198.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,198.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$749.47
|
| Rate for Payer: United Healthcare All Other HMO |
$729.50
|
| Rate for Payer: United Healthcare HMO Rider |
$713.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$654.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,697.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,697.45
|
| Rate for Payer: Vantage Medical Group Senior |
$1,697.45
|
|
|
HC TC-99 MERTIATIDE/MAG3 LT 15MCI
|
Facility
|
IP
|
$1,997.00
|
|
|
Service Code
|
CPT A9562
|
| Hospital Charge Code |
909301531
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$399.40 |
| Max. Negotiated Rate |
$1,697.45 |
| Rate for Payer: Adventist Health Commercial |
$399.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1,473.79
|
| Rate for Payer: Blue Shield of California EPN |
$970.54
|
| Rate for Payer: Cash Price |
$1,098.35
|
| Rate for Payer: Cigna of CA HMO |
$1,397.90
|
| Rate for Payer: Cigna of CA PPO |
$1,397.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$798.80
|
| Rate for Payer: EPIC Health Plan Senior |
$798.80
|
| Rate for Payer: Galaxy Health WC |
$1,697.45
|
| Rate for Payer: Global Benefits Group Commercial |
$1,198.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,332.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$760.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,236.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$479.28
|
| Rate for Payer: Multiplan Commercial |
$1,597.60
|
| Rate for Payer: Networks By Design Commercial |
$998.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,697.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$749.47
|
| Rate for Payer: United Healthcare All Other HMO |
$729.50
|
| Rate for Payer: United Healthcare HMO Rider |
$713.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$654.02
|
|
|
HC TC-99M PERTECHNETATE PER MCI
|
Facility
|
IP
|
$287.00
|
|
|
Service Code
|
CPT A9512
|
| Hospital Charge Code |
909301501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.40 |
| Max. Negotiated Rate |
$243.95 |
| Rate for Payer: Adventist Health Commercial |
$57.40
|
| Rate for Payer: Blue Shield of California Commercial |
$211.81
|
| Rate for Payer: Blue Shield of California EPN |
$139.48
|
| Rate for Payer: Cash Price |
$157.85
|
| Rate for Payer: Cigna of CA HMO |
$200.90
|
| Rate for Payer: Cigna of CA PPO |
$200.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$114.80
|
| Rate for Payer: EPIC Health Plan Senior |
$114.80
|
| Rate for Payer: Galaxy Health WC |
$243.95
|
| Rate for Payer: Global Benefits Group Commercial |
$172.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$191.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$109.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$177.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.88
|
| Rate for Payer: Multiplan Commercial |
$229.60
|
| Rate for Payer: Networks By Design Commercial |
$143.50
|
| Rate for Payer: Prime Health Services Commercial |
$243.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$107.71
|
| Rate for Payer: United Healthcare All Other HMO |
$104.84
|
| Rate for Payer: United Healthcare HMO Rider |
$102.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$93.99
|
|
|
HC TC-99M PERTECHNETATE PER MCI
|
Facility
|
OP
|
$287.00
|
|
|
Service Code
|
CPT A9512
|
| Hospital Charge Code |
909301501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.40 |
| Max. Negotiated Rate |
$243.95 |
| Rate for Payer: Adventist Health Commercial |
$57.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$243.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$157.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$215.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$176.25
|
| Rate for Payer: Cash Price |
$157.85
|
| Rate for Payer: Cigna of CA HMO |
$200.90
|
| Rate for Payer: Cigna of CA PPO |
$200.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$243.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$243.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$243.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$114.80
|
| Rate for Payer: EPIC Health Plan Senior |
$114.80
|
| Rate for Payer: Galaxy Health WC |
$243.95
|
| Rate for Payer: Global Benefits Group Commercial |
$172.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$191.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$177.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$200.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$200.90
|
| Rate for Payer: Multiplan Commercial |
$229.60
|
| Rate for Payer: Networks By Design Commercial |
$143.50
|
| Rate for Payer: Prime Health Services Commercial |
$243.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$172.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$172.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$107.71
|
| Rate for Payer: United Healthcare All Other HMO |
$104.84
|
| Rate for Payer: United Healthcare HMO Rider |
$102.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$93.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$243.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$243.95
|
| Rate for Payer: Vantage Medical Group Senior |
$243.95
|
|
|
HC TC-99 OXIDRONATE/HDP LT 30MCI
|
Facility
|
OP
|
$411.00
|
|
|
Service Code
|
CPT A9561
|
| Hospital Charge Code |
909301536
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.68 |
| Max. Negotiated Rate |
$349.35 |
| Rate for Payer: Adventist Health Commercial |
$82.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$349.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$226.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$308.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$252.40
|
| Rate for Payer: Cash Price |
$226.05
|
| Rate for Payer: Cash Price |
$226.05
|
| Rate for Payer: Cigna of CA HMO |
$287.70
|
| Rate for Payer: Cigna of CA PPO |
$287.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$349.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$349.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$349.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$164.40
|
| Rate for Payer: EPIC Health Plan Senior |
$164.40
|
| Rate for Payer: Galaxy Health WC |
$349.35
|
| Rate for Payer: Global Benefits Group Commercial |
$246.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$37.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$274.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$254.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$98.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$287.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$287.70
|
| Rate for Payer: Multiplan Commercial |
$328.80
|
| Rate for Payer: Networks By Design Commercial |
$205.50
|
| Rate for Payer: Prime Health Services Commercial |
$349.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$246.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$246.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$154.25
|
| Rate for Payer: United Healthcare All Other HMO |
$150.14
|
| Rate for Payer: United Healthcare HMO Rider |
$146.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$134.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$349.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$349.35
|
| Rate for Payer: Vantage Medical Group Senior |
$349.35
|
|
|
HC TC-99 OXIDRONATE/HDP LT 30MCI
|
Facility
|
IP
|
$411.00
|
|
|
Service Code
|
CPT A9561
|
| Hospital Charge Code |
909301536
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.20 |
| Max. Negotiated Rate |
$349.35 |
| Rate for Payer: Adventist Health Commercial |
$82.20
|
| Rate for Payer: Blue Shield of California Commercial |
$303.32
|
| Rate for Payer: Blue Shield of California EPN |
$199.75
|
| Rate for Payer: Cash Price |
$226.05
|
| Rate for Payer: Cigna of CA HMO |
$287.70
|
| Rate for Payer: Cigna of CA PPO |
$287.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$164.40
|
| Rate for Payer: EPIC Health Plan Senior |
$164.40
|
| Rate for Payer: Galaxy Health WC |
$349.35
|
| Rate for Payer: Global Benefits Group Commercial |
$246.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$274.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$156.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$254.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$98.64
|
| Rate for Payer: Multiplan Commercial |
$328.80
|
| Rate for Payer: Networks By Design Commercial |
$205.50
|
| Rate for Payer: Prime Health Services Commercial |
$349.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$154.25
|
| Rate for Payer: United Healthcare All Other HMO |
$150.14
|
| Rate for Payer: United Healthcare HMO Rider |
$146.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$134.60
|
|
|
HC TC-99 PENTETATE/DTPA LT 25MCI
|
Facility
|
IP
|
$1,036.00
|
|
|
Service Code
|
CPT A9539
|
| Hospital Charge Code |
909301510
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$207.20 |
| Max. Negotiated Rate |
$880.60 |
| Rate for Payer: Adventist Health Commercial |
$207.20
|
| Rate for Payer: Blue Shield of California Commercial |
$764.57
|
| Rate for Payer: Blue Shield of California EPN |
$503.50
|
| Rate for Payer: Cash Price |
$569.80
|
| Rate for Payer: Cigna of CA HMO |
$725.20
|
| Rate for Payer: Cigna of CA PPO |
$725.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$414.40
|
| Rate for Payer: EPIC Health Plan Senior |
$414.40
|
| Rate for Payer: Galaxy Health WC |
$880.60
|
| Rate for Payer: Global Benefits Group Commercial |
$621.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$691.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$394.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$641.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$248.64
|
| Rate for Payer: Multiplan Commercial |
$828.80
|
| Rate for Payer: Networks By Design Commercial |
$518.00
|
| Rate for Payer: Prime Health Services Commercial |
$880.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$388.81
|
| Rate for Payer: United Healthcare All Other HMO |
$378.45
|
| Rate for Payer: United Healthcare HMO Rider |
$370.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$339.29
|
|
