|
HC ADDL PMP NW SUBC THER INF SITE
|
Facility
|
IP
|
$294.00
|
|
|
Service Code
|
CPT 96371
|
| Hospital Charge Code |
907296371
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$53.21 |
| Max. Negotiated Rate |
$220.50 |
| Rate for Payer: Adventist Health Commercial |
$58.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$201.98
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$199.04
|
| Rate for Payer: Heritage Provider Network Senior |
$199.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$53.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$73.50
|
| Rate for Payer: Multiplan Commercial |
$220.50
|
|
|
HC ADD VENOUS ABLATION SNGL EXTRE
|
Facility
|
OP
|
$10,950.00
|
|
|
Service Code
|
CPT 36476
|
| Hospital Charge Code |
909080042
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$119.04 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$2,190.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,522.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9,307.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6,022.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,212.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$7,562.15
|
| Rate for Payer: Blue Shield of California EPN |
$6,499.32
|
| Rate for Payer: Cash Price |
$4,927.50
|
| Rate for Payer: Cash Price |
$4,927.50
|
| Rate for Payer: Cash Price |
$4,927.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,117.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,307.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,307.50
|
| Rate for Payer: Dignity Health Senior |
$9,307.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,778.05
|
| Rate for Payer: Heritage Provider Network Senior |
$6,778.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$119.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,277.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,981.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,737.50
|
| Rate for Payer: Multiplan Commercial |
$8,212.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,040.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$874.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,307.50
|
| Rate for Payer: Vantage Medical Group Senior |
$9,307.50
|
|
|
HC ADD VENOUS ABLATION SNGL EXTRE
|
Facility
|
IP
|
$10,950.00
|
|
|
Service Code
|
CPT 36476
|
| Hospital Charge Code |
909080042
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,981.95 |
| Max. Negotiated Rate |
$8,212.50 |
| Rate for Payer: Adventist Health Commercial |
$2,190.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,522.65
|
| Rate for Payer: Cash Price |
$4,927.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,413.15
|
| Rate for Payer: Heritage Provider Network Senior |
$7,413.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,981.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,737.50
|
| Rate for Payer: Multiplan Commercial |
$8,212.50
|
|
|
HC ADJACNT TISS TRNSF LT 10 SQ CM
|
Facility
|
OP
|
$7,512.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
900501289
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$936.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,502.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,160.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Cash Price |
$3,380.40
|
| Rate for Payer: Cash Price |
$3,380.40
|
| Rate for Payer: Cash Price |
$3,380.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,882.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,085.62
|
| Rate for Payer: Heritage Provider Network Senior |
$5,085.62
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,620.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,359.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,878.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: Multiplan Commercial |
$5,634.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,727.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,509.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
HC ADJACNT TISS TRNSF LT 10 SQ CM
|
Facility
|
IP
|
$7,512.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
900501289
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,359.67 |
| Max. Negotiated Rate |
$5,634.00 |
| Rate for Payer: Adventist Health Commercial |
$1,502.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,160.74
|
| Rate for Payer: Cash Price |
$3,380.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,085.62
|
| Rate for Payer: Heritage Provider Network Senior |
$5,085.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,359.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,878.00
|
| Rate for Payer: Multiplan Commercial |
$5,634.00
|
|
|
HC ADJ GASTRIC BAND DIAM VIA PORT
|
Facility
|
OP
|
$2,096.00
|
|
|
Service Code
|
CPT 43999
|
| Hospital Charge Code |
906743999
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$379.38 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$419.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,439.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,132.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,756.00
|
| Rate for Payer: Cash Price |
$943.20
|
| Rate for Payer: Cash Price |
$943.20
|
| Rate for Payer: Cash Price |
$943.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,362.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,245.85
|
| Rate for Payer: Dignity Health Senior |
$1,132.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,132.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,418.99
|
| Rate for Payer: Heritage Provider Network Senior |
$1,418.99
|
| Rate for Payer: Humana Medicare |
$1,132.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,132.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,010.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$379.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,336.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$524.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,427.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,427.06
|
| Rate for Payer: Multiplan Commercial |
$1,572.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$761.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$700.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1,132.59
|
|
|
HC ADJ GASTRIC BAND DIAM VIA PORT
|
Facility
|
IP
|
$4,179.00
|
|
|
Service Code
|
CPT 43999
|
| Hospital Charge Code |
906743999
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$756.40 |
| Max. Negotiated Rate |
$3,134.25 |
| Rate for Payer: Adventist Health Commercial |
$835.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,870.97
|
| Rate for Payer: Cash Price |
$1,880.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,829.18
|
| Rate for Payer: Heritage Provider Network Senior |
$2,829.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$756.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,044.75
|
| Rate for Payer: Multiplan Commercial |
$3,134.25
|
|
|
HC ADJ GASTRIC BAND DIAM VIA PORT
|
Facility
|
IP
|
$4,179.00
|
|
|
Service Code
|
CPT 43999
|
| Hospital Charge Code |
906743999
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$756.40 |
| Max. Negotiated Rate |
$3,134.25 |
| Rate for Payer: Adventist Health Commercial |
$835.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,870.97
|
| Rate for Payer: Cash Price |
$1,880.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,829.18
|
| Rate for Payer: Heritage Provider Network Senior |
$2,829.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$756.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,044.75
|
| Rate for Payer: Multiplan Commercial |
$3,134.25
|
|
|
HC ADJ GASTRIC BAND DIAM VIA PORT
|
Facility
|
OP
|
$1,649.00
|
|
|
Service Code
|
CPT S2083
|
| Hospital Charge Code |
909020143
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$298.47 |
| Max. Negotiated Rate |
$8,689.75 |
| Rate for Payer: Adventist Health Commercial |
$329.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,132.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,401.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$906.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,236.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,689.75
|
| Rate for Payer: Blue Shield of California EPN |
$7,468.44
|
| Rate for Payer: Cash Price |
$742.05
|
| Rate for Payer: Cash Price |
$742.05
|
| Rate for Payer: Cash Price |
$742.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,071.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,401.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,401.65
|
| Rate for Payer: Dignity Health Senior |
$1,401.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$989.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,020.73
|
| Rate for Payer: Heritage Provider Network Senior |
$1,020.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$794.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$298.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$412.25
|
| Rate for Payer: Multiplan Commercial |
$1,236.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,401.65
|
| Rate for Payer: Vantage Medical Group Senior |
$1,401.65
|
|
|
HC ADJ GASTRIC BAND DIAM VIA PORT
|
Facility
|
IP
|
$1,649.00
|
|
|
Service Code
|
CPT S2083
|
| Hospital Charge Code |
909020143
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$298.47 |
| Max. Negotiated Rate |
$1,236.75 |
| Rate for Payer: Adventist Health Commercial |
$329.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,132.86
|
| Rate for Payer: Cash Price |
$742.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,116.37
|
| Rate for Payer: Heritage Provider Network Senior |
$1,116.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$298.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$412.25
|
| Rate for Payer: Multiplan Commercial |
$1,236.75
|
|
|
HC ADJ GASTRIC BAND DIAM VIA PORT
|
Facility
|
OP
|
$2,096.00
|
|
|
Service Code
|
CPT 43999
|
| Hospital Charge Code |
906743999
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$379.38 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$419.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,439.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,132.59
|
| Rate for Payer: Blue Shield of California Commercial |
$3,517.28
|
| Rate for Payer: Blue Shield of California EPN |
$3,022.94
|
| Rate for Payer: Cash Price |
$943.20
|
| Rate for Payer: Cash Price |
$943.20
|
| Rate for Payer: Cash Price |
$943.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,362.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,245.85
|
| Rate for Payer: Dignity Health Senior |
$1,132.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,132.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,297.42
|
| Rate for Payer: Heritage Provider Network Senior |
$1,393.09
|
| Rate for Payer: Humana Medicare |
$1,132.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,132.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,151.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$379.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,336.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$524.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,427.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,427.06
|
| Rate for Payer: Multiplan Commercial |
$1,572.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$425.00
|
| Rate for Payer: TriValley Medical Group Senior |
$425.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,374.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,841.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1,132.59
|
|
|
HC ADJ TISS TRNSFR 10 SQ CM OR LT
|
Facility
|
OP
|
$5,545.00
|
|
|
Service Code
|
CPT 14060
|
| Hospital Charge Code |
900501331
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$936.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,109.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,809.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Cash Price |
$2,495.25
|
| Rate for Payer: Cash Price |
$2,495.25
|
| Rate for Payer: Cash Price |
$2,495.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,604.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,753.96
|
| Rate for Payer: Heritage Provider Network Senior |
$3,753.96
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,672.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,003.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,386.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: Multiplan Commercial |
$4,158.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,013.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,852.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
HC ADJ TISS TRNSFR 10 SQ CM OR LT
|
Facility
|
IP
|
$5,545.00
|
|
|
Service Code
|
CPT 14060
|
| Hospital Charge Code |
900501331
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,003.64 |
| Max. Negotiated Rate |
$4,158.75 |
| Rate for Payer: Adventist Health Commercial |
$1,109.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,809.42
|
| Rate for Payer: Cash Price |
$2,495.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,753.96
|
| Rate for Payer: Heritage Provider Network Senior |
$3,753.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,003.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,386.25
|
| Rate for Payer: Multiplan Commercial |
$4,158.75
|
|
|
HC ADM FR D LOW A/D SAME DT-HR
|
Facility
|
IP
|
$236.00
|
|
|
Service Code
|
CPT 99234
|
| Hospital Charge Code |
902100007
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$42.72 |
| Max. Negotiated Rate |
$177.00 |
| Rate for Payer: Adventist Health Commercial |
$47.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$162.13
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$159.77
|
| Rate for Payer: Heritage Provider Network Senior |
$159.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.00
|
| Rate for Payer: Multiplan Commercial |
$177.00
|
|
|
HC ADM FR D LOW A/D SAME DT-HR
|
Facility
|
OP
|
$236.00
|
|
|
Service Code
|
CPT 99234
|
| Hospital Charge Code |
902100007
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$42.72 |
| Max. Negotiated Rate |
$5,287.00 |
| Rate for Payer: Adventist Health Commercial |
$47.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,276.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$162.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$200.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$129.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$177.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,890.00
|
| Rate for Payer: Blue Shield of California Commercial |
$146.56
|
| Rate for Payer: Blue Shield of California EPN |
$138.53
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$153.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$200.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$200.60
|
| Rate for Payer: Dignity Health Senior |
$200.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,860.00
|
| Rate for Payer: Heritage Provider Network Senior |
$2,602.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$116.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,287.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.00
|
| Rate for Payer: Multiplan Commercial |
$177.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$118.00
|
| Rate for Payer: TriValley Medical Group Senior |
$118.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,882.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,267.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$200.60
|
| Rate for Payer: Vantage Medical Group Senior |
$200.60
|
|
|
HC ADM FR H-COMP A/D SAME/ HR
|
Facility
|
IP
|
$259.00
|
|
|
Service Code
|
CPT G0378
|
| Hospital Charge Code |
902100009
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$46.88 |
| Max. Negotiated Rate |
$194.25 |
| Rate for Payer: Adventist Health Commercial |
$51.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$177.93
|
| Rate for Payer: Cash Price |
$116.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$175.34
|
| Rate for Payer: Heritage Provider Network Senior |
$175.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.75
|
| Rate for Payer: Multiplan Commercial |
$194.25
|
|
|
HC ADM FR H-COMP A/D SAME/ HR
|
Facility
|
OP
|
$259.00
|
|
|
Service Code
|
CPT G0378
|
| Hospital Charge Code |
902100009
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$46.88 |
| Max. Negotiated Rate |
$5,287.00 |
| Rate for Payer: Adventist Health Commercial |
$51.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,276.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$177.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$220.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$142.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$194.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,890.00
|
| Rate for Payer: Blue Shield of California Commercial |
$160.84
|
| Rate for Payer: Blue Shield of California EPN |
$152.03
|
| Rate for Payer: Cash Price |
$116.55
|
| Rate for Payer: Cash Price |
$116.55
|
| Rate for Payer: Cash Price |
$116.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$168.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$220.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$220.15
|
| Rate for Payer: Dignity Health Senior |
$220.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,860.00
|
| Rate for Payer: Heritage Provider Network Senior |
$2,602.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,287.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.75
|
| Rate for Payer: Multiplan Commercial |
$194.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$129.50
|
| Rate for Payer: TriValley Medical Group Senior |
$129.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,882.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,267.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$220.15
|
| Rate for Payer: Vantage Medical Group Senior |
$220.15
|
|
|
HC ADM FR HIGH A/D 2DATES/ HR
|
Facility
|
OP
|
$259.00
|
|
|
Service Code
|
CPT G0378
|
| Hospital Charge Code |
902100006
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$46.88 |
| Max. Negotiated Rate |
$5,287.00 |
| Rate for Payer: Adventist Health Commercial |
$51.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,276.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$177.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$220.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$142.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$194.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,890.00
|
| Rate for Payer: Blue Shield of California Commercial |
$160.84
|
| Rate for Payer: Blue Shield of California EPN |
$152.03
|
| Rate for Payer: Cash Price |
$116.55
|
| Rate for Payer: Cash Price |
$116.55
|
| Rate for Payer: Cash Price |
$116.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$168.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$220.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$220.15
|
| Rate for Payer: Dignity Health Senior |
$220.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,860.00
|
| Rate for Payer: Heritage Provider Network Senior |
$2,602.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,287.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.75
|
| Rate for Payer: Multiplan Commercial |
$194.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$129.50
|
| Rate for Payer: TriValley Medical Group Senior |
$129.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,882.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,267.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$220.15
|
| Rate for Payer: Vantage Medical Group Senior |
$220.15
|
|
|
HC ADM FR HIGH A/D 2DATES/ HR
|
Facility
|
IP
|
$259.00
|
|
|
Service Code
|
CPT G0378
|
| Hospital Charge Code |
902100006
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$46.88 |
| Max. Negotiated Rate |
$194.25 |
| Rate for Payer: Adventist Health Commercial |
$51.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$177.93
|
| Rate for Payer: Cash Price |
$116.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$175.34
|
| Rate for Payer: Heritage Provider Network Senior |
$175.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.75
|
| Rate for Payer: Multiplan Commercial |
$194.25
|
|
|
HC ADM FR MOD A/D SAME DT/HR
|
Facility
|
IP
|
$236.00
|
|
|
Service Code
|
CPT 99235
|
| Hospital Charge Code |
902100008
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$42.72 |
| Max. Negotiated Rate |
$177.00 |
| Rate for Payer: Adventist Health Commercial |
$47.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$162.13
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$159.77
|
| Rate for Payer: Heritage Provider Network Senior |
$159.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.00
|
| Rate for Payer: Multiplan Commercial |
$177.00
|
|
|
HC ADM FR MOD A/D SAME DT/HR
|
Facility
|
OP
|
$236.00
|
|
|
Service Code
|
CPT 99235
|
| Hospital Charge Code |
902100008
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$42.72 |
| Max. Negotiated Rate |
$5,287.00 |
| Rate for Payer: Adventist Health Commercial |
$47.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,276.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$162.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$200.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$129.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$177.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,890.00
|
| Rate for Payer: Blue Shield of California Commercial |
$146.56
|
| Rate for Payer: Blue Shield of California EPN |
$138.53
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$153.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$200.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$200.60
|
| Rate for Payer: Dignity Health Senior |
$200.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,860.00
|
| Rate for Payer: Heritage Provider Network Senior |
$2,602.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$161.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,287.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.00
|
| Rate for Payer: Multiplan Commercial |
$177.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$118.00
|
| Rate for Payer: TriValley Medical Group Senior |
$118.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,882.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,267.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$200.60
|
| Rate for Payer: Vantage Medical Group Senior |
$200.60
|
|
|
HC ADMINISTRATION OF XOFIGO
|
Facility
|
IP
|
$732.00
|
|
|
Service Code
|
CPT 79101
|
| Hospital Charge Code |
909301549
|
|
Hospital Revenue Code
|
342
|
| Min. Negotiated Rate |
$132.49 |
| Max. Negotiated Rate |
$549.00 |
| Rate for Payer: Adventist Health Commercial |
$146.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$502.88
|
| Rate for Payer: Cash Price |
$329.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$495.56
|
| Rate for Payer: Heritage Provider Network Senior |
$495.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$132.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$183.00
|
| Rate for Payer: Multiplan Commercial |
$549.00
|
|
|
HC ADMINISTRATION OF XOFIGO
|
Facility
|
OP
|
$732.00
|
|
|
Service Code
|
CPT 79101
|
| Hospital Charge Code |
909301549
|
|
Hospital Revenue Code
|
342
|
| Min. Negotiated Rate |
$132.15 |
| Max. Negotiated Rate |
$590.60 |
| Rate for Payer: Adventist Health Commercial |
$146.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$132.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$502.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$466.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$341.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$310.84
|
| Rate for Payer: Blue Shield of California Commercial |
$533.43
|
| Rate for Payer: Blue Shield of California EPN |
$303.35
|
| Rate for Payer: Cash Price |
$329.40
|
| Rate for Payer: Cash Price |
$329.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$475.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$466.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$341.92
|
| Rate for Payer: Dignity Health Senior |
$310.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$475.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$310.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$453.11
|
| Rate for Payer: Heritage Provider Network Senior |
$453.11
|
| Rate for Payer: Humana Medicare |
$310.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$196.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$310.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$590.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$132.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$366.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$183.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$391.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$391.66
|
| Rate for Payer: Multiplan Commercial |
$549.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$341.92
|
| Rate for Payer: TriValley Medical Group Senior |
$310.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$466.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$341.92
|
| Rate for Payer: Vantage Medical Group Senior |
$310.84
|
|
|
HC ADMIN SOTROVIMAB INFUSION MA
|
Facility
|
OP
|
$900.00
|
|
|
Service Code
|
CPT M0247
|
| Hospital Charge Code |
949001325
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$162.90 |
| Max. Negotiated Rate |
$1,122.44 |
| Rate for Payer: Adventist Health Commercial |
$180.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,094.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$618.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$886.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$649.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$590.76
|
| Rate for Payer: Blue Shield of California Commercial |
$558.90
|
| Rate for Payer: Blue Shield of California EPN |
$528.30
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$585.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$886.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$649.84
|
| Rate for Payer: Dignity Health Senior |
$590.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$585.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$590.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$557.10
|
| Rate for Payer: Heritage Provider Network Senior |
$557.10
|
| Rate for Payer: Humana Medicare |
$590.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$590.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,122.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$162.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$697.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$225.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$744.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$744.36
|
| Rate for Payer: Multiplan Commercial |
$675.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$649.84
|
| Rate for Payer: TriValley Medical Group Senior |
$590.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$886.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$649.84
|
| Rate for Payer: Vantage Medical Group Senior |
$590.76
|
|
|
HC ADMIN SOTROVIMAB INFUSION MA
|
Facility
|
IP
|
$900.00
|
|
|
Service Code
|
CPT M0247
|
| Hospital Charge Code |
949001325
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$162.90 |
| Max. Negotiated Rate |
$675.00 |
| Rate for Payer: Adventist Health Commercial |
$180.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$618.30
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$609.30
|
| Rate for Payer: Heritage Provider Network Senior |
$609.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$162.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$225.00
|
| Rate for Payer: Multiplan Commercial |
$675.00
|
|
