|
HC LIVNG FUNCT RESTRTN UE
|
Facility
|
OP
|
$11,750.00
|
|
|
Service Code
|
CPT L7499
|
| Hospital Charge Code |
915380024
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$2,820.00 |
| Max. Negotiated Rate |
$9,987.50 |
| Rate for Payer: Adventist Health Commercial |
$4,817.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9,987.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6,462.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,812.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,805.60
|
| Rate for Payer: Blue Shield of California Commercial |
$8,671.50
|
| Rate for Payer: Blue Shield of California EPN |
$5,710.50
|
| Rate for Payer: Cash Price |
$5,287.50
|
| Rate for Payer: Cigna of CA HMO |
$8,225.00
|
| Rate for Payer: Cigna of CA PPO |
$8,225.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,987.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,987.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9,987.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,700.00
|
| Rate for Payer: EPIC Health Plan Senior |
$4,700.00
|
| Rate for Payer: Galaxy Health WC |
$9,987.50
|
| Rate for Payer: Global Benefits Group Commercial |
$7,050.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7,837.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,476.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,273.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,820.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,225.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,225.00
|
| Rate for Payer: Multiplan Commercial |
$9,400.00
|
| Rate for Payer: Networks By Design Commercial |
$5,875.00
|
| Rate for Payer: Prime Health Services Commercial |
$9,987.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7,050.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7,050.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,409.77
|
| Rate for Payer: United Healthcare All Other HMO |
$4,292.27
|
| Rate for Payer: United Healthcare HMO Rider |
$4,199.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,848.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,987.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,987.50
|
| Rate for Payer: Vantage Medical Group Senior |
$9,987.50
|
|
|
HC LIVNG FUNCT RESTRTN UE
|
Facility
|
IP
|
$11,750.00
|
|
|
Service Code
|
CPT L7499
|
| Hospital Charge Code |
915380024
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$2,350.00 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$2,350.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$5,287.50
|
| Rate for Payer: Cash Price |
$5,287.50
|
| Rate for Payer: Cigna of CA HMO |
$8,225.00
|
| Rate for Payer: Cigna of CA PPO |
$8,225.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,700.00
|
| Rate for Payer: EPIC Health Plan Senior |
$4,700.00
|
| Rate for Payer: Galaxy Health WC |
$9,987.50
|
| Rate for Payer: Global Benefits Group Commercial |
$7,050.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7,837.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,476.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,273.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,820.00
|
| Rate for Payer: Multiplan Commercial |
$9,400.00
|
| Rate for Payer: Networks By Design Commercial |
$5,875.00
|
| Rate for Payer: Prime Health Services Commercial |
$9,987.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,409.77
|
| Rate for Payer: United Healthcare All Other HMO |
$4,292.27
|
| Rate for Payer: United Healthcare HMO Rider |
$4,199.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,848.12
|
|
|
HC LIVNG FUNCT RESTRTN UE
|
Facility
|
OP
|
$11,750.00
|
|
|
Service Code
|
CPT L7499
|
| Hospital Charge Code |
905380024
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$2,820.00 |
| Max. Negotiated Rate |
$9,987.50 |
| Rate for Payer: Adventist Health Commercial |
$4,817.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9,987.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6,462.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,812.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,805.60
|
| Rate for Payer: Blue Shield of California Commercial |
$8,671.50
|
| Rate for Payer: Blue Shield of California EPN |
$5,710.50
|
| Rate for Payer: Cash Price |
$5,287.50
|
| Rate for Payer: Cigna of CA HMO |
$8,225.00
|
| Rate for Payer: Cigna of CA PPO |
$8,225.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,987.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,987.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9,987.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,700.00
|
| Rate for Payer: EPIC Health Plan Senior |
$4,700.00
|
| Rate for Payer: Galaxy Health WC |
$9,987.50
|
| Rate for Payer: Global Benefits Group Commercial |
$7,050.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7,837.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,476.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,273.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,820.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,225.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,225.00
|
| Rate for Payer: Multiplan Commercial |
$9,400.00
|
| Rate for Payer: Networks By Design Commercial |
$5,875.00
|
| Rate for Payer: Prime Health Services Commercial |
$9,987.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7,050.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7,050.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,409.77
|
| Rate for Payer: United Healthcare All Other HMO |
$4,292.27
|
| Rate for Payer: United Healthcare HMO Rider |
$4,199.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,848.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,987.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,987.50
|
| Rate for Payer: Vantage Medical Group Senior |
$9,987.50
|
|
|
HC LMA AIRWARY
|
Facility
|
OP
|
$348.00
|
|
|
Service Code
|
CPT 94799
|
| Hospital Charge Code |
900800911
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$69.60 |
| Max. Negotiated Rate |
$764.00 |
| Rate for Payer: Adventist Health Commercial |
$69.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$228.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$298.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$218.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$198.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$213.71
|
| Rate for Payer: Blue Shield of California Commercial |
$212.98
|
| Rate for Payer: Blue Shield of California EPN |
$140.59
|
| Rate for Payer: Cash Price |
$156.60
|
| Rate for Payer: Cash Price |
$156.60
|
| Rate for Payer: Cash Price |
$156.60
|
| Rate for Payer: Cigna of CA HMO |
$222.72
|
| Rate for Payer: Cigna of CA PPO |
$257.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$298.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$218.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$198.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$268.38
|
| Rate for Payer: EPIC Health Plan Senior |
$198.80
|
| Rate for Payer: Galaxy Health WC |
$295.80
|
| Rate for Payer: Global Benefits Group Commercial |
$208.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$326.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$198.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$232.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$198.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$250.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$266.39
|
| Rate for Payer: Multiplan Commercial |
$278.40
|
| Rate for Payer: Networks By Design Commercial |
$226.20
|
| Rate for Payer: Prime Health Services Commercial |
$295.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$208.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$208.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$764.00
|
| Rate for Payer: United Healthcare All Other HMO |
$295.00
|
| Rate for Payer: United Healthcare HMO Rider |
$731.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$669.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$198.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$298.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$218.68
|
| Rate for Payer: Vantage Medical Group Senior |
$198.80
|
|
|
HC LMA AIRWARY
|
Facility
|
IP
|
$348.00
|
|
|
Service Code
|
CPT 94799
|
| Hospital Charge Code |
900800911
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$69.60 |
| Max. Negotiated Rate |
$295.80 |
| Rate for Payer: Adventist Health Commercial |
$69.60
|
| Rate for Payer: Cash Price |
$156.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$139.20
|
| Rate for Payer: EPIC Health Plan Senior |
$139.20
|
| Rate for Payer: Galaxy Health WC |
$295.80
|
| Rate for Payer: Global Benefits Group Commercial |
$208.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$232.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$132.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$215.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.52
|
| Rate for Payer: Multiplan Commercial |
$278.40
|
| Rate for Payer: Networks By Design Commercial |
$226.20
|
| Rate for Payer: Prime Health Services Commercial |
$295.80
|
|
|
HC LMA FASTRACH CHILD #3
|
Facility
|
OP
|
$336.00
|
|
| Hospital Charge Code |
901698641
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$67.20 |
| Max. Negotiated Rate |
$285.60 |
| Rate for Payer: Adventist Health Commercial |
$67.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$220.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$285.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$184.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$252.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$206.34
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cigna of CA HMO |
$215.04
|
| Rate for Payer: Cigna of CA PPO |
$248.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$285.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$285.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$285.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$134.40
|
| Rate for Payer: EPIC Health Plan Senior |
$134.40
|
| Rate for Payer: Galaxy Health WC |
$285.60
|
| Rate for Payer: Global Benefits Group Commercial |
$201.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$224.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$128.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$207.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$235.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$235.20
|
| Rate for Payer: Multiplan Commercial |
$268.80
|
| Rate for Payer: Networks By Design Commercial |
$218.40
|
| Rate for Payer: Prime Health Services Commercial |
$285.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$201.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$201.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$168.00
|
| Rate for Payer: United Healthcare All Other HMO |
$168.00
|
| Rate for Payer: United Healthcare HMO Rider |
$168.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$168.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$285.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$285.60
|
| Rate for Payer: Vantage Medical Group Senior |
$285.60
|
|
|
HC LMA FASTRACH CHILD #3
|
Facility
|
IP
|
$336.00
|
|
| Hospital Charge Code |
901698641
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$67.20 |
| Max. Negotiated Rate |
$285.60 |
| Rate for Payer: Adventist Health Commercial |
$67.20
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$134.40
|
| Rate for Payer: EPIC Health Plan Senior |
$134.40
|
| Rate for Payer: Galaxy Health WC |
$285.60
|
| Rate for Payer: Global Benefits Group Commercial |
$201.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$224.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$128.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$207.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.64
|
| Rate for Payer: Multiplan Commercial |
$268.80
|
| Rate for Payer: Networks By Design Commercial |
$218.40
|
| Rate for Payer: Prime Health Services Commercial |
$285.60
|
|
|
HC LMA FASTRACH CHILD #4
|
Facility
|
OP
|
$336.00
|
|
| Hospital Charge Code |
901698642
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$67.20 |
| Max. Negotiated Rate |
$285.60 |
| Rate for Payer: Adventist Health Commercial |
$67.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$220.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$285.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$184.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$252.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$206.34
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cigna of CA HMO |
$215.04
|
| Rate for Payer: Cigna of CA PPO |
$248.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$285.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$285.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$285.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$134.40
|
| Rate for Payer: EPIC Health Plan Senior |
$134.40
|
| Rate for Payer: Galaxy Health WC |
$285.60
|
| Rate for Payer: Global Benefits Group Commercial |
$201.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$224.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$128.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$207.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$235.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$235.20
|
| Rate for Payer: Multiplan Commercial |
$268.80
|
| Rate for Payer: Networks By Design Commercial |
$218.40
|
| Rate for Payer: Prime Health Services Commercial |
$285.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$201.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$201.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$168.00
|
| Rate for Payer: United Healthcare All Other HMO |
$168.00
|
| Rate for Payer: United Healthcare HMO Rider |
$168.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$168.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$285.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$285.60
|
| Rate for Payer: Vantage Medical Group Senior |
$285.60
|
|
|
HC LMA FASTRACH CHILD #4
|
Facility
|
IP
|
$336.00
|
|
| Hospital Charge Code |
901698642
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$67.20 |
| Max. Negotiated Rate |
$285.60 |
| Rate for Payer: Adventist Health Commercial |
$67.20
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$134.40
|
| Rate for Payer: EPIC Health Plan Senior |
$134.40
|
| Rate for Payer: Galaxy Health WC |
$285.60
|
| Rate for Payer: Global Benefits Group Commercial |
$201.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$224.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$128.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$207.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.64
|
| Rate for Payer: Multiplan Commercial |
$268.80
|
| Rate for Payer: Networks By Design Commercial |
$218.40
|
| Rate for Payer: Prime Health Services Commercial |
$285.60
|
|
|
HC LMA FASTRACH CHILD #5
|
Facility
|
OP
|
$329.00
|
|
| Hospital Charge Code |
901698643
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$65.80 |
| Max. Negotiated Rate |
$279.65 |
| Rate for Payer: Adventist Health Commercial |
$65.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$215.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$279.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$180.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$246.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$202.04
|
| Rate for Payer: Cash Price |
$148.05
|
| Rate for Payer: Cigna of CA HMO |
$210.56
|
| Rate for Payer: Cigna of CA PPO |
$243.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$279.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$279.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$279.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$131.60
|
| Rate for Payer: EPIC Health Plan Senior |
$131.60
|
| Rate for Payer: Galaxy Health WC |
$279.65
|
| Rate for Payer: Global Benefits Group Commercial |
$197.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$219.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$125.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$203.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$230.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$230.30
|
| Rate for Payer: Multiplan Commercial |
$263.20
|
| Rate for Payer: Networks By Design Commercial |
$213.85
|
| Rate for Payer: Prime Health Services Commercial |
$279.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$197.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$197.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$164.50
|
| Rate for Payer: United Healthcare All Other HMO |
$164.50
|
| Rate for Payer: United Healthcare HMO Rider |
$164.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$164.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$279.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$279.65
|
| Rate for Payer: Vantage Medical Group Senior |
$279.65
|
|
|
HC LMA FASTRACH CHILD #5
|
Facility
|
IP
|
$329.00
|
|
| Hospital Charge Code |
901698643
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$65.80 |
| Max. Negotiated Rate |
$279.65 |
| Rate for Payer: Adventist Health Commercial |
$65.80
|
| Rate for Payer: Cash Price |
$148.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$131.60
|
| Rate for Payer: EPIC Health Plan Senior |
$131.60
|
| Rate for Payer: Galaxy Health WC |
$279.65
|
| Rate for Payer: Global Benefits Group Commercial |
$197.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$219.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$125.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$203.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.96
|
| Rate for Payer: Multiplan Commercial |
$263.20
|
| Rate for Payer: Networks By Design Commercial |
$213.85
|
| Rate for Payer: Prime Health Services Commercial |
$279.65
|
|
|
HC LOCALIZATION OF TUMOR PLANAR
|
Facility
|
IP
|
$1,001.00
|
|
|
Service Code
|
CPT 78801
|
| Hospital Charge Code |
909301253
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$200.20 |
| Max. Negotiated Rate |
$850.85 |
| Rate for Payer: Adventist Health Commercial |
$200.20
|
| Rate for Payer: Cash Price |
$450.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$400.40
|
| Rate for Payer: EPIC Health Plan Senior |
$400.40
|
| Rate for Payer: Galaxy Health WC |
$850.85
|
| Rate for Payer: Global Benefits Group Commercial |
$600.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$667.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$381.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$619.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$240.24
|
| Rate for Payer: Multiplan Commercial |
$800.80
|
| Rate for Payer: Networks By Design Commercial |
$650.65
|
| Rate for Payer: Prime Health Services Commercial |
$850.85
|
|
|
HC LOCALIZATION OF TUMOR PLANAR
|
Facility
|
OP
|
$1,001.00
|
|
|
Service Code
|
CPT 78801
|
| Hospital Charge Code |
909301253
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$200.20 |
| Max. Negotiated Rate |
$1,260.70 |
| Rate for Payer: Adventist Health Commercial |
$200.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$656.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$765.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$561.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$510.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$614.71
|
| Rate for Payer: Blue Shield of California Commercial |
$612.61
|
| Rate for Payer: Blue Shield of California EPN |
$404.40
|
| Rate for Payer: Cash Price |
$450.45
|
| Rate for Payer: Cash Price |
$450.45
|
| Rate for Payer: Cigna of CA HMO |
$640.64
|
| Rate for Payer: Cigna of CA PPO |
$740.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$765.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$561.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$510.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$689.27
|
| Rate for Payer: EPIC Health Plan Senior |
$510.57
|
| Rate for Payer: Galaxy Health WC |
$850.85
|
| Rate for Payer: Global Benefits Group Commercial |
$600.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$837.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$222.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$510.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$667.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$251.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$510.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$240.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$643.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$684.16
|
| Rate for Payer: Multiplan Commercial |
$800.80
|
| Rate for Payer: Networks By Design Commercial |
$650.65
|
| Rate for Payer: Prime Health Services Commercial |
$850.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$600.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$600.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,260.70
|
| Rate for Payer: United Healthcare All Other HMO |
$1,260.70
|
| Rate for Payer: United Healthcare HMO Rider |
$1,260.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,260.70
|
| Rate for Payer: Upland Medical Group Pediatric |
$510.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$765.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$561.63
|
| Rate for Payer: Vantage Medical Group Senior |
$510.57
|
|
|
HC LOCK ELBOW FOREARM COUNTER BAL
|
Facility
|
OP
|
$5,998.00
|
|
|
Service Code
|
CPT L6693
|
| Hospital Charge Code |
915356693
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,439.52 |
| Max. Negotiated Rate |
$5,098.30 |
| Rate for Payer: Adventist Health Commercial |
$2,459.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,098.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,298.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,498.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,474.04
|
| Rate for Payer: Blue Shield of California Commercial |
$4,426.52
|
| Rate for Payer: Blue Shield of California EPN |
$2,915.03
|
| Rate for Payer: Cash Price |
$2,699.10
|
| Rate for Payer: Cash Price |
$2,699.10
|
| Rate for Payer: Cigna of CA HMO |
$4,198.60
|
| Rate for Payer: Cigna of CA PPO |
$4,198.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,098.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,098.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5,098.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,399.20
|
| Rate for Payer: EPIC Health Plan Senior |
$2,399.20
|
| Rate for Payer: Galaxy Health WC |
$5,098.30
|
| Rate for Payer: Global Benefits Group Commercial |
$3,598.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2,180.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,000.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,465.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,712.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,439.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,198.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,198.60
|
| Rate for Payer: Multiplan Commercial |
$4,798.40
|
| Rate for Payer: Networks By Design Commercial |
$2,999.00
|
| Rate for Payer: Prime Health Services Commercial |
$5,098.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,598.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,598.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,251.05
|
| Rate for Payer: United Healthcare All Other HMO |
$2,191.07
|
| Rate for Payer: United Healthcare HMO Rider |
$2,143.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,964.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,098.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,098.30
|
| Rate for Payer: Vantage Medical Group Senior |
$5,098.30
|
|
|
HC LOCK ELBOW FOREARM COUNTER BAL
|
Facility
|
OP
|
$5,998.00
|
|
|
Service Code
|
CPT L6693
|
| Hospital Charge Code |
905356693
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,439.52 |
| Max. Negotiated Rate |
$5,098.30 |
| Rate for Payer: Adventist Health Commercial |
$2,459.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,098.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,298.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,498.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,474.04
|
| Rate for Payer: Blue Shield of California Commercial |
$4,426.52
|
| Rate for Payer: Blue Shield of California EPN |
$2,915.03
|
| Rate for Payer: Cash Price |
$2,699.10
|
| Rate for Payer: Cash Price |
$2,699.10
|
| Rate for Payer: Cigna of CA HMO |
$4,198.60
|
| Rate for Payer: Cigna of CA PPO |
$4,198.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,098.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,098.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5,098.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,399.20
|
| Rate for Payer: EPIC Health Plan Senior |
$2,399.20
|
| Rate for Payer: Galaxy Health WC |
$5,098.30
|
| Rate for Payer: Global Benefits Group Commercial |
$3,598.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2,180.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,000.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,465.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,712.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,439.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,198.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,198.60
|
| Rate for Payer: Multiplan Commercial |
$4,798.40
|
| Rate for Payer: Networks By Design Commercial |
$2,999.00
|
| Rate for Payer: Prime Health Services Commercial |
$5,098.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,598.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,598.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,251.05
|
| Rate for Payer: United Healthcare All Other HMO |
$2,191.07
|
| Rate for Payer: United Healthcare HMO Rider |
$2,143.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,964.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,098.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,098.30
|
| Rate for Payer: Vantage Medical Group Senior |
$5,098.30
|
|
|
HC LOCK ELBOW FOREARM COUNTER BAL
|
Facility
|
IP
|
$5,998.00
|
|
|
Service Code
|
CPT L6693
|
| Hospital Charge Code |
905356693
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,199.60 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$1,199.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$2,699.10
|
| Rate for Payer: Cash Price |
$2,699.10
|
| Rate for Payer: Cigna of CA HMO |
$4,198.60
|
| Rate for Payer: Cigna of CA PPO |
$4,198.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,399.20
|
| Rate for Payer: EPIC Health Plan Senior |
$2,399.20
|
| Rate for Payer: Galaxy Health WC |
$5,098.30
|
| Rate for Payer: Global Benefits Group Commercial |
$3,598.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,000.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,285.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,712.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,439.52
|
| Rate for Payer: Multiplan Commercial |
$4,798.40
|
| Rate for Payer: Networks By Design Commercial |
$2,999.00
|
| Rate for Payer: Prime Health Services Commercial |
$5,098.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,251.05
|
| Rate for Payer: United Healthcare All Other HMO |
$2,191.07
|
| Rate for Payer: United Healthcare HMO Rider |
$2,143.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,964.35
|
|
|
HC LOCK ELBOW FOREARM COUNTER BAL
|
Facility
|
IP
|
$5,998.00
|
|
|
Service Code
|
CPT L6693
|
| Hospital Charge Code |
915356693
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,199.60 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$1,199.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$2,699.10
|
| Rate for Payer: Cash Price |
$2,699.10
|
| Rate for Payer: Cigna of CA HMO |
$4,198.60
|
| Rate for Payer: Cigna of CA PPO |
$4,198.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,399.20
|
| Rate for Payer: EPIC Health Plan Senior |
$2,399.20
|
| Rate for Payer: Galaxy Health WC |
$5,098.30
|
| Rate for Payer: Global Benefits Group Commercial |
$3,598.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,000.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,285.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,712.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,439.52
|
| Rate for Payer: Multiplan Commercial |
$4,798.40
|
| Rate for Payer: Networks By Design Commercial |
$2,999.00
|
| Rate for Payer: Prime Health Services Commercial |
$5,098.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,251.05
|
| Rate for Payer: United Healthcare All Other HMO |
$2,191.07
|
| Rate for Payer: United Healthcare HMO Rider |
$2,143.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,964.35
|
|
|
HC LOCM (HEXABRIX) PER ML
|
Facility
|
OP
|
$4.30
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081002
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.64
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cigna of CA HMO |
$2.75
|
| Rate for Payer: Cigna of CA PPO |
$3.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.72
|
| Rate for Payer: EPIC Health Plan Senior |
$1.72
|
| Rate for Payer: Galaxy Health WC |
$3.65
|
| Rate for Payer: Global Benefits Group Commercial |
$2.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.01
|
| Rate for Payer: Multiplan Commercial |
$3.44
|
| Rate for Payer: Networks By Design Commercial |
$2.79
|
| Rate for Payer: Prime Health Services Commercial |
$3.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.15
|
| Rate for Payer: United Healthcare All Other HMO |
$2.15
|
| Rate for Payer: United Healthcare HMO Rider |
$2.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.65
|
| Rate for Payer: Vantage Medical Group Senior |
$3.65
|
|
|
HC LOCM (HEXABRIX) PER ML
|
Facility
|
IP
|
$4.30
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081002
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$3.17
|
| Rate for Payer: Blue Shield of California EPN |
$2.09
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.72
|
| Rate for Payer: EPIC Health Plan Senior |
$1.72
|
| Rate for Payer: Galaxy Health WC |
$3.65
|
| Rate for Payer: Global Benefits Group Commercial |
$2.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$3.44
|
| Rate for Payer: Networks By Design Commercial |
$2.79
|
| Rate for Payer: Prime Health Services Commercial |
$3.65
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 180
|
Facility
|
IP
|
$9.40
|
|
|
Service Code
|
CPT Q9965
|
| Hospital Charge Code |
909081004
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$7.99 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Blue Shield of California Commercial |
$6.94
|
| Rate for Payer: Blue Shield of California EPN |
$4.57
|
| Rate for Payer: Cash Price |
$4.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.76
|
| Rate for Payer: EPIC Health Plan Senior |
$3.76
|
| Rate for Payer: Galaxy Health WC |
$7.99
|
| Rate for Payer: Global Benefits Group Commercial |
$5.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.26
|
| Rate for Payer: Multiplan Commercial |
$7.52
|
| Rate for Payer: Networks By Design Commercial |
$6.11
|
| Rate for Payer: Prime Health Services Commercial |
$7.99
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 180
|
Facility
|
OP
|
$9.40
|
|
|
Service Code
|
CPT Q9965
|
| Hospital Charge Code |
909081004
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$7.99 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.77
|
| Rate for Payer: Cash Price |
$4.23
|
| Rate for Payer: Cash Price |
$4.23
|
| Rate for Payer: Cigna of CA HMO |
$6.02
|
| Rate for Payer: Cigna of CA PPO |
$6.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.99
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.76
|
| Rate for Payer: EPIC Health Plan Senior |
$3.76
|
| Rate for Payer: Galaxy Health WC |
$7.99
|
| Rate for Payer: Global Benefits Group Commercial |
$5.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.58
|
| Rate for Payer: Multiplan Commercial |
$7.52
|
| Rate for Payer: Networks By Design Commercial |
$6.11
|
| Rate for Payer: Prime Health Services Commercial |
$7.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.70
|
| Rate for Payer: United Healthcare All Other HMO |
$4.70
|
| Rate for Payer: United Healthcare HMO Rider |
$4.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.99
|
| Rate for Payer: Vantage Medical Group Senior |
$7.99
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 240
|
Facility
|
IP
|
$2.95
|
|
|
Service Code
|
CPT Q9966
|
| Hospital Charge Code |
909081005
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.51 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$2.18
|
| Rate for Payer: Blue Shield of California EPN |
$1.43
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: EPIC Health Plan Senior |
$1.18
|
| Rate for Payer: Galaxy Health WC |
$2.51
|
| Rate for Payer: Global Benefits Group Commercial |
$1.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
| Rate for Payer: Networks By Design Commercial |
$1.92
|
| Rate for Payer: Prime Health Services Commercial |
$2.51
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 240
|
Facility
|
OP
|
$2.95
|
|
|
Service Code
|
CPT Q9966
|
| Hospital Charge Code |
909081005
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$2.51 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.81
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: Cigna of CA HMO |
$1.89
|
| Rate for Payer: Cigna of CA PPO |
$2.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: EPIC Health Plan Senior |
$1.18
|
| Rate for Payer: Galaxy Health WC |
$2.51
|
| Rate for Payer: Global Benefits Group Commercial |
$1.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.06
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
| Rate for Payer: Networks By Design Commercial |
$1.92
|
| Rate for Payer: Prime Health Services Commercial |
$2.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.77
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.48
|
| Rate for Payer: United Healthcare All Other HMO |
$1.48
|
| Rate for Payer: United Healthcare HMO Rider |
$1.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.51
|
| Rate for Payer: Vantage Medical Group Senior |
$2.51
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 300
|
Facility
|
OP
|
$3.38
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081006
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.08
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Cigna of CA HMO |
$2.16
|
| Rate for Payer: Cigna of CA PPO |
$2.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.35
|
| Rate for Payer: EPIC Health Plan Senior |
$1.35
|
| Rate for Payer: Galaxy Health WC |
$2.87
|
| Rate for Payer: Global Benefits Group Commercial |
$2.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.37
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Networks By Design Commercial |
$2.20
|
| Rate for Payer: Prime Health Services Commercial |
$2.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.69
|
| Rate for Payer: United Healthcare All Other HMO |
$1.69
|
| Rate for Payer: United Healthcare HMO Rider |
$1.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.87
|
| Rate for Payer: Vantage Medical Group Senior |
$2.87
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 300
|
Facility
|
IP
|
$3.38
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081006
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$2.49
|
| Rate for Payer: Blue Shield of California EPN |
$1.64
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.35
|
| Rate for Payer: EPIC Health Plan Senior |
$1.35
|
| Rate for Payer: Galaxy Health WC |
$2.87
|
| Rate for Payer: Global Benefits Group Commercial |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Networks By Design Commercial |
$2.20
|
| Rate for Payer: Prime Health Services Commercial |
$2.87
|
|
