|
HC OTHER PT/OT GOAL STATUS
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT G8991
|
| Hospital Charge Code |
900018313
|
|
Hospital Revenue Code
|
440
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
HC OTHER PT/OT GOAL STATUS
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT G8991
|
| Hospital Charge Code |
900018313
|
|
Hospital Revenue Code
|
440
|
| Max. Negotiated Rate |
$478.00 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$478.00
|
| Rate for Payer: Blue Shield of California Commercial |
$291.00
|
| Rate for Payer: Blue Shield of California Commercial |
$439.00
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$417.00
|
| Rate for Payer: United Healthcare All Other HMO |
$295.00
|
| Rate for Payer: United Healthcare HMO Rider |
$224.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$206.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
HC OTHER ULTRASOUND PROCEDURE
|
Facility
|
IP
|
$1,950.00
|
|
|
Service Code
|
CPT 76999
|
| Hospital Charge Code |
906811769
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$390.00 |
| Max. Negotiated Rate |
$1,657.50 |
| Rate for Payer: Adventist Health Commercial |
$390.00
|
| Rate for Payer: Cash Price |
$877.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,365.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$780.00
|
| Rate for Payer: EPIC Health Plan Senior |
$780.00
|
| Rate for Payer: Galaxy Health WC |
$1,657.50
|
| Rate for Payer: Global Benefits Group Commercial |
$1,170.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,238.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,150.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$468.00
|
| Rate for Payer: Multiplan Commercial |
$1,560.00
|
| Rate for Payer: Networks By Design Commercial |
$1,267.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,657.50
|
|
|
HC OTHER ULTRASOUND PROCEDURE
|
Facility
|
OP
|
$1,950.00
|
|
|
Service Code
|
CPT 76999
|
| Hospital Charge Code |
906811769
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$111.93 |
| Max. Negotiated Rate |
$1,657.50 |
| Rate for Payer: Adventist Health Commercial |
$390.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,279.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$167.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$123.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$111.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,251.32
|
| Rate for Payer: Blue Shield of California Commercial |
$1,244.10
|
| Rate for Payer: Blue Shield of California Commercial |
$820.95
|
| Rate for Payer: Cash Price |
$877.50
|
| Rate for Payer: Cash Price |
$877.50
|
| Rate for Payer: Cigna of CA HMO |
$1,248.00
|
| Rate for Payer: Cigna of CA PPO |
$1,443.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$167.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$123.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$111.93
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,365.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$184.68
|
| Rate for Payer: EPIC Health Plan Senior |
$123.12
|
| Rate for Payer: Galaxy Health WC |
$1,657.50
|
| Rate for Payer: Global Benefits Group Commercial |
$1,170.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$183.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$111.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,238.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$156.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$468.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$141.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$149.99
|
| Rate for Payer: Multiplan Commercial |
$1,560.00
|
| Rate for Payer: Networks By Design Commercial |
$1,267.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,657.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,170.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,170.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$161.07
|
| Rate for Payer: United Healthcare All Other HMO |
$161.07
|
| Rate for Payer: United Healthcare HMO Rider |
$161.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$161.07
|
| Rate for Payer: Upland Medical Group Pediatric |
$111.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$167.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$123.12
|
| Rate for Payer: Vantage Medical Group Senior |
$111.93
|
|
|
HC OT INIT EVAL HIGH
|
Facility
|
OP
|
$1,156.00
|
|
|
Service Code
|
CPT 97167
|
| Hospital Charge Code |
905197167
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$206.00 |
| Max. Negotiated Rate |
$982.60 |
| Rate for Payer: Adventist Health Commercial |
$473.96
|
| Rate for Payer: Aetna of CA HMO/PPO |
$466.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$982.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$635.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$867.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$478.00
|
| Rate for Payer: Blue Shield of California Commercial |
$291.00
|
| Rate for Payer: Blue Shield of California Commercial |
$439.00
|
| Rate for Payer: Cash Price |
$520.20
|
| Rate for Payer: Cash Price |
$520.20
|
| Rate for Payer: Cash Price |
$520.20
|
| Rate for Payer: Cash Price |
$520.20
|
| Rate for Payer: Cigna of CA HMO |
$739.84
|
| Rate for Payer: Cigna of CA PPO |
$855.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$982.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$982.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$982.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$809.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$462.40
|
| Rate for Payer: EPIC Health Plan Senior |
$462.40
|
| Rate for Payer: Galaxy Health WC |
$982.60
|
| Rate for Payer: Global Benefits Group Commercial |
$693.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$211.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$734.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$238.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$682.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$277.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$809.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$809.20
|
| Rate for Payer: Multiplan Commercial |
$924.80
|
| Rate for Payer: Networks By Design Commercial |
$751.40
|
| Rate for Payer: Prime Health Services Commercial |
$982.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$693.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$693.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$417.00
|
| Rate for Payer: United Healthcare All Other HMO |
$295.00
|
| Rate for Payer: United Healthcare HMO Rider |
$224.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$206.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$982.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$982.60
|
| Rate for Payer: Vantage Medical Group Senior |
$982.60
|
|
|
HC OT INIT EVAL HIGH
|
Facility
|
IP
|
$1,156.00
|
|
|
Service Code
|
CPT 97167
|
| Hospital Charge Code |
905197167
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$231.20 |
| Max. Negotiated Rate |
$982.60 |
| Rate for Payer: Adventist Health Commercial |
$231.20
|
| Rate for Payer: Cash Price |
$520.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$809.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$462.40
|
| Rate for Payer: EPIC Health Plan Senior |
$462.40
|
| Rate for Payer: Galaxy Health WC |
$982.60
|
| Rate for Payer: Global Benefits Group Commercial |
$693.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$734.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$682.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$277.44
|
| Rate for Payer: Multiplan Commercial |
$924.80
|
| Rate for Payer: Networks By Design Commercial |
$751.40
|
| Rate for Payer: Prime Health Services Commercial |
$982.60
|
|
|
HC OT INIT EVAL HIGH
|
Facility
|
OP
|
$1,156.00
|
|
|
Service Code
|
CPT 97167
|
| Hospital Charge Code |
908697167
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$206.00 |
| Max. Negotiated Rate |
$982.60 |
| Rate for Payer: EPIC Health Plan Senior |
$462.40
|
| Rate for Payer: Adventist Health Commercial |
$473.96
|
| Rate for Payer: Aetna of CA HMO/PPO |
$466.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$982.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$635.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$867.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$478.00
|
| Rate for Payer: Blue Shield of California Commercial |
$291.00
|
| Rate for Payer: Blue Shield of California Commercial |
$439.00
|
| Rate for Payer: Cash Price |
$520.20
|
| Rate for Payer: Cash Price |
$520.20
|
| Rate for Payer: Cash Price |
$520.20
|
| Rate for Payer: Cash Price |
$520.20
|
| Rate for Payer: Cigna of CA HMO |
$739.84
|
| Rate for Payer: Cigna of CA PPO |
$855.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$982.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$982.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$982.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$809.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$462.40
|
| Rate for Payer: Galaxy Health WC |
$982.60
|
| Rate for Payer: Global Benefits Group Commercial |
$693.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$211.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$734.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$238.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$682.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$277.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$809.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$809.20
|
| Rate for Payer: Multiplan Commercial |
$924.80
|
| Rate for Payer: Networks By Design Commercial |
$751.40
|
| Rate for Payer: Prime Health Services Commercial |
$982.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$693.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$693.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$417.00
|
| Rate for Payer: United Healthcare All Other HMO |
$295.00
|
| Rate for Payer: United Healthcare HMO Rider |
$224.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$206.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$982.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$982.60
|
| Rate for Payer: Vantage Medical Group Senior |
$982.60
|
|
|
HC OT INIT EVAL HIGH
|
Facility
|
IP
|
$1,156.00
|
|
|
Service Code
|
CPT 97167
|
| Hospital Charge Code |
908697167
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$231.20 |
| Max. Negotiated Rate |
$982.60 |
| Rate for Payer: Adventist Health Commercial |
$231.20
|
| Rate for Payer: Cash Price |
$520.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$809.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$462.40
|
| Rate for Payer: EPIC Health Plan Senior |
$462.40
|
| Rate for Payer: Galaxy Health WC |
$982.60
|
| Rate for Payer: Global Benefits Group Commercial |
$693.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$734.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$682.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$277.44
|
| Rate for Payer: Multiplan Commercial |
$924.80
|
| Rate for Payer: Networks By Design Commercial |
$751.40
|
| Rate for Payer: Prime Health Services Commercial |
$982.60
|
|
|
HC OT INIT EVAL LOW
|
Facility
|
IP
|
$772.00
|
|
|
Service Code
|
CPT 97165
|
| Hospital Charge Code |
908697165
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$154.40 |
| Max. Negotiated Rate |
$656.20 |
| Rate for Payer: Adventist Health Commercial |
$154.40
|
| Rate for Payer: Cash Price |
$347.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$540.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$308.80
|
| Rate for Payer: EPIC Health Plan Senior |
$308.80
|
| Rate for Payer: Galaxy Health WC |
$656.20
|
| Rate for Payer: Global Benefits Group Commercial |
$463.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$490.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$455.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$185.28
|
| Rate for Payer: Multiplan Commercial |
$617.60
|
| Rate for Payer: Networks By Design Commercial |
$501.80
|
| Rate for Payer: Prime Health Services Commercial |
$656.20
|
|
|
HC OT INIT EVAL LOW
|
Facility
|
OP
|
$772.00
|
|
|
Service Code
|
CPT 97165
|
| Hospital Charge Code |
908697165
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$185.28 |
| Max. Negotiated Rate |
$656.20 |
| Rate for Payer: Adventist Health Commercial |
$316.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$466.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$656.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$424.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$579.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$478.00
|
| Rate for Payer: Blue Shield of California Commercial |
$439.00
|
| Rate for Payer: Blue Shield of California Commercial |
$291.00
|
| Rate for Payer: Cash Price |
$347.40
|
| Rate for Payer: Cash Price |
$347.40
|
| Rate for Payer: Cash Price |
$347.40
|
| Rate for Payer: Cash Price |
$347.40
|
| Rate for Payer: Cigna of CA HMO |
$494.08
|
| Rate for Payer: Cigna of CA PPO |
$571.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$656.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$656.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$656.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$540.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$308.80
|
| Rate for Payer: EPIC Health Plan Senior |
$308.80
|
| Rate for Payer: Galaxy Health WC |
$656.20
|
| Rate for Payer: Global Benefits Group Commercial |
$463.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$490.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$280.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$455.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$185.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$540.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$540.40
|
| Rate for Payer: Multiplan Commercial |
$617.60
|
| Rate for Payer: Networks By Design Commercial |
$501.80
|
| Rate for Payer: Prime Health Services Commercial |
$656.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$463.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$463.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$417.00
|
| Rate for Payer: United Healthcare All Other HMO |
$295.00
|
| Rate for Payer: United Healthcare HMO Rider |
$224.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$206.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$656.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$656.20
|
| Rate for Payer: Vantage Medical Group Senior |
$656.20
|
|
|
HC OT INIT EVAL LOW
|
Facility
|
OP
|
$771.00
|
|
|
Service Code
|
CPT 97165
|
| Hospital Charge Code |
905197165
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$185.04 |
| Max. Negotiated Rate |
$655.35 |
| Rate for Payer: Adventist Health Commercial |
$316.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$466.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$655.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$424.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$578.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$478.00
|
| Rate for Payer: Blue Shield of California Commercial |
$439.00
|
| Rate for Payer: Blue Shield of California Commercial |
$291.00
|
| Rate for Payer: Cash Price |
$346.95
|
| Rate for Payer: Cash Price |
$346.95
|
| Rate for Payer: Cash Price |
$346.95
|
| Rate for Payer: Cash Price |
$346.95
|
| Rate for Payer: Cigna of CA HMO |
$493.44
|
| Rate for Payer: Cigna of CA PPO |
$570.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$655.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$655.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$655.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$539.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$308.40
|
| Rate for Payer: EPIC Health Plan Senior |
$308.40
|
| Rate for Payer: Galaxy Health WC |
$655.35
|
| Rate for Payer: Global Benefits Group Commercial |
$462.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$489.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$279.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$454.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$185.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$539.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$539.70
|
| Rate for Payer: Multiplan Commercial |
$616.80
|
| Rate for Payer: Networks By Design Commercial |
$501.15
|
| Rate for Payer: Prime Health Services Commercial |
$655.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$462.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$462.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$417.00
|
| Rate for Payer: United Healthcare All Other HMO |
$295.00
|
| Rate for Payer: United Healthcare HMO Rider |
$224.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$206.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$655.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$655.35
|
| Rate for Payer: Vantage Medical Group Senior |
$655.35
|
|
|
HC OT INIT EVAL LOW
|
Facility
|
IP
|
$771.00
|
|
|
Service Code
|
CPT 97165
|
| Hospital Charge Code |
905197165
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$154.20 |
| Max. Negotiated Rate |
$655.35 |
| Rate for Payer: Adventist Health Commercial |
$154.20
|
| Rate for Payer: Cash Price |
$346.95
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$539.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$308.40
|
| Rate for Payer: EPIC Health Plan Senior |
$308.40
|
| Rate for Payer: Galaxy Health WC |
$655.35
|
| Rate for Payer: Global Benefits Group Commercial |
$462.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$489.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$454.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$185.04
|
| Rate for Payer: Multiplan Commercial |
$616.80
|
| Rate for Payer: Networks By Design Commercial |
$501.15
|
| Rate for Payer: Prime Health Services Commercial |
$655.35
|
|
|
HC OT INIT EVAL MODERATE
|
Facility
|
IP
|
$964.00
|
|
|
Service Code
|
CPT 97166
|
| Hospital Charge Code |
908697166
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$192.80 |
| Max. Negotiated Rate |
$819.40 |
| Rate for Payer: Adventist Health Commercial |
$192.80
|
| Rate for Payer: Cash Price |
$433.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$674.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$385.60
|
| Rate for Payer: EPIC Health Plan Senior |
$385.60
|
| Rate for Payer: Galaxy Health WC |
$819.40
|
| Rate for Payer: Global Benefits Group Commercial |
$578.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$612.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$568.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$231.36
|
| Rate for Payer: Multiplan Commercial |
$771.20
|
| Rate for Payer: Networks By Design Commercial |
$626.60
|
| Rate for Payer: Prime Health Services Commercial |
$819.40
|
|
|
HC OT INIT EVAL MODERATE
|
Facility
|
OP
|
$963.00
|
|
|
Service Code
|
CPT 97166
|
| Hospital Charge Code |
905197166
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$206.00 |
| Max. Negotiated Rate |
$818.55 |
| Rate for Payer: Adventist Health Commercial |
$394.83
|
| Rate for Payer: Aetna of CA HMO/PPO |
$466.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$818.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$529.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$722.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$478.00
|
| Rate for Payer: Blue Shield of California Commercial |
$439.00
|
| Rate for Payer: Blue Shield of California Commercial |
$291.00
|
| Rate for Payer: Cash Price |
$433.35
|
| Rate for Payer: Cash Price |
$433.35
|
| Rate for Payer: Cash Price |
$433.35
|
| Rate for Payer: Cash Price |
$433.35
|
| Rate for Payer: Cigna of CA HMO |
$616.32
|
| Rate for Payer: Cigna of CA PPO |
$712.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$818.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$818.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$818.55
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$674.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$385.20
|
| Rate for Payer: EPIC Health Plan Senior |
$385.20
|
| Rate for Payer: Galaxy Health WC |
$818.55
|
| Rate for Payer: Global Benefits Group Commercial |
$577.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$611.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$349.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$568.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$231.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$674.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$674.10
|
| Rate for Payer: Multiplan Commercial |
$770.40
|
| Rate for Payer: Networks By Design Commercial |
$625.95
|
| Rate for Payer: Prime Health Services Commercial |
$818.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$577.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$577.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$417.00
|
| Rate for Payer: United Healthcare All Other HMO |
$295.00
|
| Rate for Payer: United Healthcare HMO Rider |
$224.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$206.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$818.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$818.55
|
| Rate for Payer: Vantage Medical Group Senior |
$818.55
|
|
|
HC OT INIT EVAL MODERATE
|
Facility
|
IP
|
$963.00
|
|
|
Service Code
|
CPT 97166
|
| Hospital Charge Code |
905197166
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$192.60 |
| Max. Negotiated Rate |
$818.55 |
| Rate for Payer: Adventist Health Commercial |
$192.60
|
| Rate for Payer: Cash Price |
$433.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$674.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$385.20
|
| Rate for Payer: EPIC Health Plan Senior |
$385.20
|
| Rate for Payer: Galaxy Health WC |
$818.55
|
| Rate for Payer: Global Benefits Group Commercial |
$577.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$611.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$568.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$231.12
|
| Rate for Payer: Multiplan Commercial |
$770.40
|
| Rate for Payer: Networks By Design Commercial |
$625.95
|
| Rate for Payer: Prime Health Services Commercial |
$818.55
|
|
|
HC OT INIT EVAL MODERATE
|
Facility
|
OP
|
$964.00
|
|
|
Service Code
|
CPT 97166
|
| Hospital Charge Code |
908697166
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$206.00 |
| Max. Negotiated Rate |
$819.40 |
| Rate for Payer: Adventist Health Commercial |
$395.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$466.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$819.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$530.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$723.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$478.00
|
| Rate for Payer: Blue Shield of California Commercial |
$439.00
|
| Rate for Payer: Blue Shield of California Commercial |
$291.00
|
| Rate for Payer: Cash Price |
$433.80
|
| Rate for Payer: Cash Price |
$433.80
|
| Rate for Payer: Cash Price |
$433.80
|
| Rate for Payer: Cash Price |
$433.80
|
| Rate for Payer: Cigna of CA HMO |
$616.96
|
| Rate for Payer: Cigna of CA PPO |
$713.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$819.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$819.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$819.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$674.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$385.60
|
| Rate for Payer: EPIC Health Plan Senior |
$385.60
|
| Rate for Payer: Galaxy Health WC |
$819.40
|
| Rate for Payer: Global Benefits Group Commercial |
$578.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$612.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$349.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$568.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$231.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$674.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$674.80
|
| Rate for Payer: Multiplan Commercial |
$771.20
|
| Rate for Payer: Networks By Design Commercial |
$626.60
|
| Rate for Payer: Prime Health Services Commercial |
$819.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$578.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$578.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$417.00
|
| Rate for Payer: United Healthcare All Other HMO |
$295.00
|
| Rate for Payer: United Healthcare HMO Rider |
$224.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$206.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$819.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$819.40
|
| Rate for Payer: Vantage Medical Group Senior |
$819.40
|
|
|
HC OTOLARYNGOLOGIC EXAM GEN ANEST
|
Facility
|
IP
|
$717.00
|
|
|
Service Code
|
CPT 92502
|
| Hospital Charge Code |
900501620
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$143.40 |
| Max. Negotiated Rate |
$609.45 |
| Rate for Payer: Adventist Health Commercial |
$143.40
|
| Rate for Payer: Cash Price |
$322.65
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$501.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$286.80
|
| Rate for Payer: EPIC Health Plan Senior |
$286.80
|
| Rate for Payer: Galaxy Health WC |
$609.45
|
| Rate for Payer: Global Benefits Group Commercial |
$430.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$455.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$423.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$172.08
|
| Rate for Payer: Multiplan Commercial |
$573.60
|
| Rate for Payer: Networks By Design Commercial |
$466.05
|
| Rate for Payer: Prime Health Services Commercial |
$609.45
|
|
|
HC OTOLARYNGOLOGIC EXAM GEN ANEST
|
Facility
|
OP
|
$717.00
|
|
|
Service Code
|
CPT 92502
|
| Hospital Charge Code |
900501620
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$117.34 |
| Max. Negotiated Rate |
$5,641.00 |
| Rate for Payer: Dignity Health Medi-Cal |
$763.04
|
| Rate for Payer: Adventist Health Commercial |
$143.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3,171.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,040.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$763.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$693.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,641.00
|
| Rate for Payer: Cash Price |
$322.65
|
| Rate for Payer: Cash Price |
$322.65
|
| Rate for Payer: Cash Price |
$322.65
|
| Rate for Payer: Cigna of CA HMO |
$458.88
|
| Rate for Payer: Cigna of CA PPO |
$530.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,040.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$693.67
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$501.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,144.56
|
| Rate for Payer: EPIC Health Plan Senior |
$763.04
|
| Rate for Payer: Galaxy Health WC |
$609.45
|
| Rate for Payer: Global Benefits Group Commercial |
$430.20
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$1,137.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$973.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$693.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$455.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$117.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$745.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$172.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$874.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$929.52
|
| Rate for Payer: Multiplan Commercial |
$573.60
|
| Rate for Payer: Multiplan WC |
$1,030.97
|
| Rate for Payer: Networks By Design Commercial |
$466.05
|
| Rate for Payer: Prime Health Services Commercial |
$609.45
|
| Rate for Payer: Prime Health Services WC |
$1,020.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$430.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$358.50
|
| Rate for Payer: United Healthcare All Other HMO |
$358.50
|
| Rate for Payer: United Healthcare HMO Rider |
$358.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$358.50
|
| Rate for Payer: Upland Medical Group Pediatric |
$693.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,040.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$763.04
|
| Rate for Payer: Vantage Medical Group Senior |
$693.67
|
|
|
HC OT RE-EVALUATION
|
Facility
|
OP
|
$665.00
|
|
|
Service Code
|
CPT 97168
|
| Hospital Charge Code |
908603273
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$146.70 |
| Max. Negotiated Rate |
$565.25 |
| Rate for Payer: Adventist Health Commercial |
$272.65
|
| Rate for Payer: Aetna of CA HMO/PPO |
$311.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$565.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$365.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$498.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$478.00
|
| Rate for Payer: Blue Shield of California Commercial |
$291.00
|
| Rate for Payer: Blue Shield of California Commercial |
$439.00
|
| Rate for Payer: Cash Price |
$299.25
|
| Rate for Payer: Cash Price |
$299.25
|
| Rate for Payer: Cash Price |
$299.25
|
| Rate for Payer: Cash Price |
$299.25
|
| Rate for Payer: Cigna of CA HMO |
$425.60
|
| Rate for Payer: Cigna of CA PPO |
$492.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$565.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$565.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$565.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$465.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$266.00
|
| Rate for Payer: EPIC Health Plan Senior |
$266.00
|
| Rate for Payer: Galaxy Health WC |
$565.25
|
| Rate for Payer: Global Benefits Group Commercial |
$399.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$146.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$422.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$165.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$392.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$159.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$465.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$465.50
|
| Rate for Payer: Multiplan Commercial |
$532.00
|
| Rate for Payer: Networks By Design Commercial |
$432.25
|
| Rate for Payer: Prime Health Services Commercial |
$565.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$399.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$399.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$417.00
|
| Rate for Payer: United Healthcare All Other HMO |
$295.00
|
| Rate for Payer: United Healthcare HMO Rider |
$224.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$206.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$565.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$565.25
|
| Rate for Payer: Vantage Medical Group Senior |
$565.25
|
|
|
HC OT RE-EVALUATION
|
Facility
|
IP
|
$665.00
|
|
|
Service Code
|
CPT 97168
|
| Hospital Charge Code |
908603273
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$133.00 |
| Max. Negotiated Rate |
$565.25 |
| Rate for Payer: Adventist Health Commercial |
$133.00
|
| Rate for Payer: Cash Price |
$299.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$465.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$266.00
|
| Rate for Payer: EPIC Health Plan Senior |
$266.00
|
| Rate for Payer: Galaxy Health WC |
$565.25
|
| Rate for Payer: Global Benefits Group Commercial |
$399.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$422.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$392.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$159.60
|
| Rate for Payer: Multiplan Commercial |
$532.00
|
| Rate for Payer: Networks By Design Commercial |
$432.25
|
| Rate for Payer: Prime Health Services Commercial |
$565.25
|
|
|
HC OT RE-EVALUATION
|
Facility
|
IP
|
$665.00
|
|
|
Service Code
|
CPT 97168
|
| Hospital Charge Code |
912197004
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$133.00 |
| Max. Negotiated Rate |
$565.25 |
| Rate for Payer: Adventist Health Commercial |
$133.00
|
| Rate for Payer: Cash Price |
$299.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$465.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$266.00
|
| Rate for Payer: EPIC Health Plan Senior |
$266.00
|
| Rate for Payer: Galaxy Health WC |
$565.25
|
| Rate for Payer: Global Benefits Group Commercial |
$399.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$422.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$392.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$159.60
|
| Rate for Payer: Multiplan Commercial |
$532.00
|
| Rate for Payer: Networks By Design Commercial |
$432.25
|
| Rate for Payer: Prime Health Services Commercial |
$565.25
|
|
|
HC OT RE-EVALUATION
|
Facility
|
OP
|
$665.00
|
|
|
Service Code
|
CPT 97168
|
| Hospital Charge Code |
912197004
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$146.70 |
| Max. Negotiated Rate |
$565.25 |
| Rate for Payer: Adventist Health Commercial |
$272.65
|
| Rate for Payer: Aetna of CA HMO/PPO |
$311.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$565.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$365.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$498.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$478.00
|
| Rate for Payer: Blue Shield of California Commercial |
$291.00
|
| Rate for Payer: Blue Shield of California Commercial |
$439.00
|
| Rate for Payer: Cash Price |
$299.25
|
| Rate for Payer: Cash Price |
$299.25
|
| Rate for Payer: Cash Price |
$299.25
|
| Rate for Payer: Cash Price |
$299.25
|
| Rate for Payer: Cigna of CA HMO |
$425.60
|
| Rate for Payer: Cigna of CA PPO |
$492.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$565.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$565.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$565.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$465.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$266.00
|
| Rate for Payer: EPIC Health Plan Senior |
$266.00
|
| Rate for Payer: Galaxy Health WC |
$565.25
|
| Rate for Payer: Global Benefits Group Commercial |
$399.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$146.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$422.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$165.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$392.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$159.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$465.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$465.50
|
| Rate for Payer: Multiplan Commercial |
$532.00
|
| Rate for Payer: Networks By Design Commercial |
$432.25
|
| Rate for Payer: Prime Health Services Commercial |
$565.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$399.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$399.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$417.00
|
| Rate for Payer: United Healthcare All Other HMO |
$295.00
|
| Rate for Payer: United Healthcare HMO Rider |
$224.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$206.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$565.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$565.25
|
| Rate for Payer: Vantage Medical Group Senior |
$565.25
|
|
|
HC OTSM POUCH DRAIN BR 1.5"-38MM
|
Facility
|
IP
|
$11.40
|
|
|
Service Code
|
CPT A5057
|
| Hospital Charge Code |
901698480
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$9.69 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$7.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.56
|
| Rate for Payer: EPIC Health Plan Senior |
$4.56
|
| Rate for Payer: Galaxy Health WC |
$9.69
|
| Rate for Payer: Global Benefits Group Commercial |
$6.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.74
|
| Rate for Payer: Multiplan Commercial |
$9.12
|
| Rate for Payer: Networks By Design Commercial |
$7.41
|
| Rate for Payer: Prime Health Services Commercial |
$9.69
|
|
|
HC OTSM POUCH DRAIN BR 1.5"-38MM
|
Facility
|
OP
|
$11.40
|
|
|
Service Code
|
CPT A5057
|
| Hospital Charge Code |
901698480
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$28.02 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA HMO/PPO |
$28.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.32
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Cigna of CA HMO |
$7.30
|
| Rate for Payer: Cigna of CA PPO |
$8.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.69
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$7.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.56
|
| Rate for Payer: EPIC Health Plan Senior |
$4.56
|
| Rate for Payer: Galaxy Health WC |
$9.69
|
| Rate for Payer: Global Benefits Group Commercial |
$6.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.98
|
| Rate for Payer: Multiplan Commercial |
$9.12
|
| Rate for Payer: Networks By Design Commercial |
$7.41
|
| Rate for Payer: Prime Health Services Commercial |
$9.69
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.70
|
| Rate for Payer: United Healthcare All Other HMO |
$5.70
|
| Rate for Payer: United Healthcare HMO Rider |
$5.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.69
|
| Rate for Payer: Vantage Medical Group Senior |
$9.69
|
|
|
HC OTSM POUCH DRN BR 2.125"-55MM
|
Facility
|
IP
|
$11.40
|
|
|
Service Code
|
CPT A5057
|
| Hospital Charge Code |
901698479
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$9.69 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$7.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.56
|
| Rate for Payer: EPIC Health Plan Senior |
$4.56
|
| Rate for Payer: Galaxy Health WC |
$9.69
|
| Rate for Payer: Global Benefits Group Commercial |
$6.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.74
|
| Rate for Payer: Multiplan Commercial |
$9.12
|
| Rate for Payer: Networks By Design Commercial |
$7.41
|
| Rate for Payer: Prime Health Services Commercial |
$9.69
|
|
