Loma Linda University Medical Center

All Charges

Charge

Type

Price

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure)

Facility OP

$3,237.00

Service Code	CPT 64491
Min. Negotiated Rate	$124.29
Max. Negotiated Rate	$3,237.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: IEHP Medi-Cal	$124.29

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level

Facility OP

$3,237.00

Service Code	CPT 64490
Min. Negotiated Rate	$250.89
Max. Negotiated Rate	$3,237.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$1,708.24
Rate for Payer: AlphaCare Medical Group Medi-Cal	$1,252.71
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$1,138.83
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$1,708.24
Rate for Payer: Dignity Health Medi-Cal	$1,252.71
Rate for Payer: Dignity Health Senior	$1,138.83
Rate for Payer: EPIC Health Plan Medicare	$1,138.83
Rate for Payer: Humana Medicare	$1,138.83
Rate for Payer: IEHP Medi-Cal	$250.89
Rate for Payer: IEHP Medicare Advantage	$1,138.83
Rate for Payer: Kaiser Permanente of CA Commercial	$2,163.78
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$1,343.82
Rate for Payer: Molina Healthcare of CA Medi-Cal	$1,434.93
Rate for Payer: Molina Healthcare of CA Medicare	$1,434.93
Rate for Payer: TriValley Medical Group Commercial	$1,252.71
Rate for Payer: TriValley Medical Group Senior	$1,138.83
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1,708.24
Rate for Payer: Vantage Medical Group Medi-Cal	$1,252.71
Rate for Payer: Vantage Medical Group Senior	$1,138.83

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)

Facility OP

$3,237.00

Service Code	CPT 64492
Min. Negotiated Rate	$126.03
Max. Negotiated Rate	$3,237.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: IEHP Medi-Cal	$126.03

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure)

Facility OP

$3,237.00

Service Code	CPT 64494
Min. Negotiated Rate	$113.83
Max. Negotiated Rate	$3,237.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: IEHP Medi-Cal	$113.83

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level

Facility OP

$3,237.00

Service Code	CPT 64493
Min. Negotiated Rate	$225.34
Max. Negotiated Rate	$3,237.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$1,708.24
Rate for Payer: AlphaCare Medical Group Medi-Cal	$1,252.71
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$1,138.83
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$1,708.24
Rate for Payer: Dignity Health Medi-Cal	$1,252.71
Rate for Payer: Dignity Health Senior	$1,138.83
Rate for Payer: EPIC Health Plan Medicare	$1,138.83
Rate for Payer: Humana Medicare	$1,138.83
Rate for Payer: IEHP Medi-Cal	$225.34
Rate for Payer: IEHP Medicare Advantage	$1,138.83
Rate for Payer: Kaiser Permanente of CA Commercial	$2,163.78
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$1,343.82
Rate for Payer: Molina Healthcare of CA Medi-Cal	$1,434.93
Rate for Payer: Molina Healthcare of CA Medicare	$1,434.93
Rate for Payer: TriValley Medical Group Commercial	$1,252.71
Rate for Payer: TriValley Medical Group Senior	$1,138.83
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1,708.24
Rate for Payer: Vantage Medical Group Medi-Cal	$1,252.71
Rate for Payer: Vantage Medical Group Senior	$1,138.83

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)

Facility OP

$3,237.00

Service Code	CPT 64495
Min. Negotiated Rate	$115.58
Max. Negotiated Rate	$3,237.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: IEHP Medi-Cal	$115.58

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)

Facility OP

$3,237.00

Service Code	CPT 62321
Min. Negotiated Rate	$348.47
Max. Negotiated Rate	$3,237.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$1,296.06
Rate for Payer: AlphaCare Medical Group Medi-Cal	$950.44
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$864.04
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$1,296.06
Rate for Payer: Dignity Health Medi-Cal	$950.44
Rate for Payer: Dignity Health Senior	$864.04
Rate for Payer: EPIC Health Plan Medicare	$864.04
Rate for Payer: Humana Medicare	$864.04
Rate for Payer: IEHP Medi-Cal	$348.47
Rate for Payer: IEHP Medicare Advantage	$864.04
Rate for Payer: Kaiser Permanente of CA Commercial	$1,641.68
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$1,019.57
Rate for Payer: Molina Healthcare of CA Medi-Cal	$1,088.69
Rate for Payer: Molina Healthcare of CA Medicare	$1,088.69
Rate for Payer: TriValley Medical Group Commercial	$950.44
Rate for Payer: TriValley Medical Group Senior	$864.04
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1,296.06
Rate for Payer: Vantage Medical Group Medi-Cal	$950.44
Rate for Payer: Vantage Medical Group Senior	$864.04

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)

Facility OP

$3,237.00

Service Code	CPT 62323
Min. Negotiated Rate	$343.25
Max. Negotiated Rate	$3,237.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$1,296.06
Rate for Payer: AlphaCare Medical Group Medi-Cal	$950.44
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$864.04
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$1,296.06
Rate for Payer: Dignity Health Medi-Cal	$950.44
Rate for Payer: Dignity Health Senior	$864.04
Rate for Payer: EPIC Health Plan Medicare	$864.04
Rate for Payer: Humana Medicare	$864.04
Rate for Payer: IEHP Medi-Cal	$343.25
Rate for Payer: IEHP Medicare Advantage	$864.04
Rate for Payer: Kaiser Permanente of CA Commercial	$1,641.68
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$1,019.57
Rate for Payer: Molina Healthcare of CA Medi-Cal	$1,088.69
Rate for Payer: Molina Healthcare of CA Medicare	$1,088.69
Rate for Payer: TriValley Medical Group Commercial	$950.44
Rate for Payer: TriValley Medical Group Senior	$864.04
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1,296.06
Rate for Payer: Vantage Medical Group Medi-Cal	$950.44
Rate for Payer: Vantage Medical Group Senior	$864.04

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance

Facility OP

$3,237.00

Service Code	CPT 62322
Min. Negotiated Rate	$216.06
Max. Negotiated Rate	$3,237.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$1,708.24
Rate for Payer: AlphaCare Medical Group Medi-Cal	$1,252.71
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$1,138.83
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$1,708.24
Rate for Payer: Dignity Health Medi-Cal	$1,252.71
Rate for Payer: Dignity Health Senior	$1,138.83
Rate for Payer: EPIC Health Plan Medicare	$1,138.83
Rate for Payer: Humana Medicare	$1,138.83
Rate for Payer: IEHP Medi-Cal	$216.06
Rate for Payer: IEHP Medicare Advantage	$1,138.83
Rate for Payer: Kaiser Permanente of CA Commercial	$2,163.78
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$1,343.82
Rate for Payer: Molina Healthcare of CA Medi-Cal	$1,434.93
Rate for Payer: Molina Healthcare of CA Medicare	$1,434.93
Rate for Payer: TriValley Medical Group Commercial	$1,252.71
Rate for Payer: TriValley Medical Group Senior	$1,138.83
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1,708.24
Rate for Payer: Vantage Medical Group Medi-Cal	$1,252.71
Rate for Payer: Vantage Medical Group Senior	$1,138.83

Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed

Facility OP

$3,237.00

Service Code	CPT 0232T
Min. Negotiated Rate	$497.82
Max. Negotiated Rate	$3,237.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$746.73
Rate for Payer: AlphaCare Medical Group Medi-Cal	$547.60
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$497.82
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$746.73
Rate for Payer: Dignity Health Medi-Cal	$547.60
Rate for Payer: Dignity Health Senior	$497.82
Rate for Payer: EPIC Health Plan Medicare	$497.82
Rate for Payer: Humana Medicare	$497.82
Rate for Payer: IEHP Medicare Advantage	$497.82
Rate for Payer: Kaiser Permanente of CA Commercial	$945.86
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$587.43
Rate for Payer: Molina Healthcare of CA Medi-Cal	$627.25
Rate for Payer: Molina Healthcare of CA Medicare	$627.25
Rate for Payer: TriValley Medical Group Commercial	$547.60
Rate for Payer: TriValley Medical Group Senior	$497.82
Rate for Payer: Vantage Medical Group Commercial/Exchange	$746.73
Rate for Payer: Vantage Medical Group Medi-Cal	$547.60
Rate for Payer: Vantage Medical Group Senior	$497.82

Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)

Facility OP

$9,616.00

Service Code	CPT 20552
Min. Negotiated Rate	$81.88
Max. Negotiated Rate	$9,616.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$555.09
Rate for Payer: AlphaCare Medical Group Medi-Cal	$407.07
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$370.06
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$555.09
Rate for Payer: Dignity Health Medi-Cal	$407.07
Rate for Payer: Dignity Health Senior	$370.06
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$370.06
Rate for Payer: Humana Medicare	$370.06
Rate for Payer: IEHP Medi-Cal	$81.88
Rate for Payer: IEHP Medicare Advantage	$370.06
Rate for Payer: Kaiser Permanente of CA Commercial	$703.11
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$436.67
Rate for Payer: Molina Healthcare of CA Medi-Cal	$466.28
Rate for Payer: Molina Healthcare of CA Medicare	$466.28
Rate for Payer: TriValley Medical Group Commercial	$407.07
Rate for Payer: TriValley Medical Group Senior	$370.06
Rate for Payer: Vantage Medical Group Commercial/Exchange	$555.09
Rate for Payer: Vantage Medical Group Medi-Cal	$407.07
Rate for Payer: Vantage Medical Group Senior	$370.06

Injection(s); single or multiple trigger point(s), 3 or more muscles

Facility OP

$9,616.00

Service Code	CPT 20553
Min. Negotiated Rate	$87.70
Max. Negotiated Rate	$9,616.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$555.09
Rate for Payer: AlphaCare Medical Group Medi-Cal	$407.07
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$370.06
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$555.09
Rate for Payer: Dignity Health Medi-Cal	$407.07
Rate for Payer: Dignity Health Senior	$370.06
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$370.06
Rate for Payer: Humana Medicare	$370.06
Rate for Payer: IEHP Medi-Cal	$87.70
Rate for Payer: IEHP Medicare Advantage	$370.06
Rate for Payer: Kaiser Permanente of CA Commercial	$703.11
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$436.67
Rate for Payer: Molina Healthcare of CA Medi-Cal	$466.28
Rate for Payer: Molina Healthcare of CA Medicare	$466.28
Rate for Payer: TriValley Medical Group Commercial	$407.07
Rate for Payer: TriValley Medical Group Senior	$370.06
Rate for Payer: Vantage Medical Group Commercial/Exchange	$555.09
Rate for Payer: Vantage Medical Group Medi-Cal	$407.07
Rate for Payer: Vantage Medical Group Senior	$370.06

Injection(s); single tendon origin/insertion

Facility OP

$9,616.00

Service Code	CPT 20551
Min. Negotiated Rate	$82.02
Max. Negotiated Rate	$9,616.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$555.09
Rate for Payer: AlphaCare Medical Group Medi-Cal	$407.07
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$370.06
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$555.09
Rate for Payer: Dignity Health Medi-Cal	$407.07
Rate for Payer: Dignity Health Senior	$370.06
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$370.06
Rate for Payer: Humana Medicare	$370.06
Rate for Payer: IEHP Medi-Cal	$82.02
Rate for Payer: IEHP Medicare Advantage	$370.06
Rate for Payer: Kaiser Permanente of CA Commercial	$703.11
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$436.67
Rate for Payer: Molina Healthcare of CA Medi-Cal	$466.28
Rate for Payer: Molina Healthcare of CA Medicare	$466.28
Rate for Payer: TriValley Medical Group Commercial	$407.07
Rate for Payer: TriValley Medical Group Senior	$370.06
Rate for Payer: Vantage Medical Group Commercial/Exchange	$555.09
Rate for Payer: Vantage Medical Group Medi-Cal	$407.07
Rate for Payer: Vantage Medical Group Senior	$370.06

Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel

Facility OP

$9,616.00

Service Code	CPT 20526
Min. Negotiated Rate	$81.88
Max. Negotiated Rate	$9,616.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$555.09
Rate for Payer: AlphaCare Medical Group Medi-Cal	$407.07
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$370.06
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$555.09
Rate for Payer: Dignity Health Medi-Cal	$407.07
Rate for Payer: Dignity Health Senior	$370.06
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$370.06
Rate for Payer: Humana Medicare	$370.06
Rate for Payer: IEHP Medi-Cal	$81.88
Rate for Payer: IEHP Medicare Advantage	$370.06
Rate for Payer: Kaiser Permanente of CA Commercial	$703.11
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$436.67
Rate for Payer: Molina Healthcare of CA Medi-Cal	$466.28
Rate for Payer: Molina Healthcare of CA Medicare	$466.28
Rate for Payer: TriValley Medical Group Commercial	$407.07
Rate for Payer: TriValley Medical Group Senior	$370.06
Rate for Payer: Vantage Medical Group Commercial/Exchange	$555.09
Rate for Payer: Vantage Medical Group Medi-Cal	$407.07
Rate for Payer: Vantage Medical Group Senior	$370.06

INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN [219527]

Facility OP

$26,288.27

Service Code	NDC 0008-0100-01
Hospital Charge Code	ERX219527
Hospital Revenue Code	636
Min. Negotiated Rate	$4,758.18
Max. Negotiated Rate	$22,345.03
Rate for Payer: Adventist Health Commercial	$5,257.65
Rate for Payer: Aetna of CA Gatekeeper	$14,051.08
Rate for Payer: Aetna of CA Non-Gatekeeper	$18,060.04
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$22,345.03
Rate for Payer: AlphaCare Medical Group Medi-Cal	$14,458.55
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$19,716.20
Rate for Payer: Blue Shield of California Commercial	$16,325.02
Rate for Payer: Blue Shield of California EPN	$15,431.21
Rate for Payer: Cash Price	$11,829.72
Rate for Payer: Cigna of CA HMO/PPO	$12,092.60
Rate for Payer: Dignity Health Commercial/Exchange	$22,345.03
Rate for Payer: Dignity Health Medi-Cal	$22,345.03
Rate for Payer: Dignity Health Senior	$22,345.03
Rate for Payer: EPIC Health Plan Commercial	$16,824.49
Rate for Payer: Heritage Provider Network Commercial	$12,171.47
Rate for Payer: Heritage Provider Network Senior	$12,171.47
Rate for Payer: Kaiser Permanente of CA Commercial	$12,670.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$4,758.18
Rate for Payer: LLUH Dept of Risk Management WC	$6,572.07
Rate for Payer: Multiplan Commercial	$19,716.20
Rate for Payer: United Healthcare All Other HMO/non HMO	$9,584.70
Rate for Payer: United Healthcare Navigate/Select/Select+	$8,782.91
Rate for Payer: Vantage Medical Group Medi-Cal	$22,345.03
Rate for Payer: Vantage Medical Group Senior	$22,345.03

INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN [219527]

Facility IP

$26,288.27

Service Code	NDC 0008-0100-01
Hospital Charge Code	ERX219527
Hospital Revenue Code	636
Min. Negotiated Rate	$4,758.18
Max. Negotiated Rate	$19,716.20
Rate for Payer: Adventist Health Commercial	$5,257.65
Rate for Payer: Aetna of CA Non-Gatekeeper	$18,060.04
Rate for Payer: Cash Price	$11,829.72
Rate for Payer: Cigna of CA HMO/PPO	$12,092.60
Rate for Payer: EPIC Health Plan Commercial	$14,195.67
Rate for Payer: Heritage Provider Network Commercial	$17,797.16
Rate for Payer: Heritage Provider Network Senior	$17,797.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$4,758.18
Rate for Payer: LLUH Dept of Risk Management WC	$6,572.07
Rate for Payer: Multiplan Commercial	$19,716.20
Rate for Payer: United Healthcare All Other HMO/non HMO	$9,584.70
Rate for Payer: United Healthcare Navigate/Select/Select+	$8,782.91

Inpatient Brachytherapy

Facility IP

$23,184.00

Service Code	ICD 0WHD41Z
Min. Negotiated Rate	$8,040.00
Max. Negotiated Rate	$23,184.00
Rate for Payer: Aetna of CA Gatekeeper	$23,184.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,040.00

Inpatient Brachytherapy

Facility IP

$23,184.00

Service Code	ICD 0XHF01Z
Min. Negotiated Rate	$8,040.00
Max. Negotiated Rate	$23,184.00
Rate for Payer: Aetna of CA Gatekeeper	$23,184.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,040.00

Inpatient Brachytherapy

Facility IP

$23,184.00

Service Code	ICD 0UHGX1Z
Min. Negotiated Rate	$8,040.00
Max. Negotiated Rate	$23,184.00
Rate for Payer: Aetna of CA Gatekeeper	$23,184.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,040.00

Inpatient Brachytherapy

Facility IP

$23,184.00

Service Code	ICD 0UHG81Z
Min. Negotiated Rate	$8,040.00
Max. Negotiated Rate	$23,184.00
Rate for Payer: Aetna of CA Gatekeeper	$23,184.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,040.00

Inpatient Brachytherapy

Facility IP

$23,184.00

Service Code	ICD 0YHF41Z
Min. Negotiated Rate	$8,040.00
Max. Negotiated Rate	$23,184.00
Rate for Payer: Aetna of CA Gatekeeper	$23,184.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,040.00

Inpatient Brachytherapy

Facility IP

$23,184.00

Service Code	ICD 0YHF01Z
Min. Negotiated Rate	$8,040.00
Max. Negotiated Rate	$23,184.00
Rate for Payer: Aetna of CA Gatekeeper	$23,184.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,040.00

Inpatient Brachytherapy

Facility IP

$23,184.00

Service Code	ICD 0YHD41Z
Min. Negotiated Rate	$8,040.00
Max. Negotiated Rate	$23,184.00
Rate for Payer: Aetna of CA Gatekeeper	$23,184.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,040.00

Inpatient Brachytherapy

Facility IP

$23,184.00

Service Code	ICD 0YHD31Z
Min. Negotiated Rate	$8,040.00
Max. Negotiated Rate	$23,184.00
Rate for Payer: Aetna of CA Gatekeeper	$23,184.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,040.00

Inpatient Brachytherapy

Facility IP

$23,184.00

Service Code	ICD 0WHM41Z
Min. Negotiated Rate	$8,040.00
Max. Negotiated Rate	$23,184.00
Rate for Payer: Aetna of CA Gatekeeper	$23,184.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,040.00

Price Transparency.

All Charges