|
HC ADMIN VACCINE SINGLE
|
Facility
|
OP
|
$93.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
900501277
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$6.96 |
| Max. Negotiated Rate |
$167.24 |
| Rate for Payer: Adventist Health Commercial |
$18.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$63.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$132.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$96.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$88.02
|
| Rate for Payer: Blue Shield of California Commercial |
$57.75
|
| Rate for Payer: Blue Shield of California EPN |
$54.59
|
| Rate for Payer: Cash Price |
$41.85
|
| Rate for Payer: Cash Price |
$41.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$60.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$132.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.82
|
| Rate for Payer: Dignity Health Senior |
$88.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$88.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$57.57
|
| Rate for Payer: Heritage Provider Network Senior |
$57.57
|
| Rate for Payer: Humana Medicare |
$88.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$88.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$167.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$103.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$110.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$110.91
|
| Rate for Payer: Multiplan Commercial |
$69.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$96.82
|
| Rate for Payer: TriValley Medical Group Senior |
$88.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$132.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.82
|
| Rate for Payer: Vantage Medical Group Senior |
$88.02
|
|
|
HC ADM SARSCOV2 MOD BV BOOSTER 50MCG/0.5ML
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 0134A
|
| Hospital Charge Code |
949001350
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$95.20 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$59.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.00
|
| Rate for Payer: Blue Shield of California Commercial |
$69.55
|
| Rate for Payer: Blue Shield of California EPN |
$65.74
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.20
|
| Rate for Payer: Dignity Health Senior |
$95.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.33
|
| Rate for Payer: Heritage Provider Network Senior |
$69.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$53.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.20
|
| Rate for Payer: Vantage Medical Group Senior |
$95.20
|
|
|
HC ADM SARSCOV2 MOD BV BOOSTER 50MCG/0.5ML
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 0134A
|
| Hospital Charge Code |
949001350
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.94
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.82
|
| Rate for Payer: Heritage Provider Network Senior |
$75.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
|
|
HC ADM SARSCOV2 MOD BV PEDS (6-11YRS) BOOSTER 25MCG/0.25ML
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 0144A
|
| Hospital Charge Code |
949001352
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$95.20 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$59.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.00
|
| Rate for Payer: Blue Shield of California Commercial |
$69.55
|
| Rate for Payer: Blue Shield of California EPN |
$65.74
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.20
|
| Rate for Payer: Dignity Health Senior |
$95.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.33
|
| Rate for Payer: Heritage Provider Network Senior |
$69.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$53.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.20
|
| Rate for Payer: Vantage Medical Group Senior |
$95.20
|
|
|
HC ADM SARSCOV2 MOD BV PEDS (6-11YRS) BOOSTER 25MCG/0.25ML
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 0144A
|
| Hospital Charge Code |
949001352
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.94
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.82
|
| Rate for Payer: Heritage Provider Network Senior |
$75.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
|
|
HC ADM SARSCOV2 MOD BV PEDS (6MS-5YRS) BOOSTER 10MCG/0.2ML
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 0164A
|
| Hospital Charge Code |
949001353
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.94
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.82
|
| Rate for Payer: Heritage Provider Network Senior |
$75.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
|
|
HC ADM SARSCOV2 MOD BV PEDS (6MS-5YRS) BOOSTER 10MCG/0.2ML
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 0164A
|
| Hospital Charge Code |
949001353
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$95.20 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$59.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.00
|
| Rate for Payer: Blue Shield of California Commercial |
$69.55
|
| Rate for Payer: Blue Shield of California EPN |
$65.74
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.20
|
| Rate for Payer: Dignity Health Senior |
$95.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.33
|
| Rate for Payer: Heritage Provider Network Senior |
$69.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$53.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.20
|
| Rate for Payer: Vantage Medical Group Senior |
$95.20
|
|
|
HC ADM SARSCOV2 NV 2ND 5MCG/0.5ML IM
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 0042A
|
| Hospital Charge Code |
949001340
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$95.20 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$59.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.00
|
| Rate for Payer: Blue Shield of California Commercial |
$69.55
|
| Rate for Payer: Blue Shield of California EPN |
$65.74
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.20
|
| Rate for Payer: Dignity Health Senior |
$95.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.33
|
| Rate for Payer: Heritage Provider Network Senior |
$69.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$53.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.20
|
| Rate for Payer: Vantage Medical Group Senior |
$95.20
|
|
|
HC ADM SARSCOV2 NV 2ND 5MCG/0.5ML IM
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 0042A
|
| Hospital Charge Code |
949001340
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.94
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.82
|
| Rate for Payer: Heritage Provider Network Senior |
$75.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
|
|
HC ADM SARSCOV2 PF BV BOOSTER 30MCG/0.3ML 12YRS OR OLDER
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 0124A
|
| Hospital Charge Code |
949001346
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.94
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.82
|
| Rate for Payer: Heritage Provider Network Senior |
$75.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
|
|
HC ADM SARSCOV2 PF BV BOOSTER 30MCG/0.3ML 12YRS OR OLDER
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 0124A
|
| Hospital Charge Code |
949001346
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$95.20 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$59.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.00
|
| Rate for Payer: Blue Shield of California Commercial |
$69.55
|
| Rate for Payer: Blue Shield of California EPN |
$65.74
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.20
|
| Rate for Payer: Dignity Health Senior |
$95.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.33
|
| Rate for Payer: Heritage Provider Network Senior |
$69.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$53.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.20
|
| Rate for Payer: Vantage Medical Group Senior |
$95.20
|
|
|
HC ADM SARSCOV2 PF BV PEDS (5-11YRS) BOOSTER 10MCG/0.2ML
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 0154A
|
| Hospital Charge Code |
949001348
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.94
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.82
|
| Rate for Payer: Heritage Provider Network Senior |
$75.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
|
|
HC ADM SARSCOV2 PF BV PEDS (5-11YRS) BOOSTER 10MCG/0.2ML
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 0154A
|
| Hospital Charge Code |
949001348
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$95.20 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$59.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.00
|
| Rate for Payer: Blue Shield of California Commercial |
$69.55
|
| Rate for Payer: Blue Shield of California EPN |
$65.74
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.20
|
| Rate for Payer: Dignity Health Senior |
$95.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.33
|
| Rate for Payer: Heritage Provider Network Senior |
$69.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$53.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.20
|
| Rate for Payer: Vantage Medical Group Senior |
$95.20
|
|
|
HC ADM SARSCOV2 PF PEDS (6MS-4YRS)BOOSTER 3MCG/0.2ML TRS-SUCR 3
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 0173A
|
| Hospital Charge Code |
949001356
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$95.20 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$59.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.00
|
| Rate for Payer: Blue Shield of California Commercial |
$69.55
|
| Rate for Payer: Blue Shield of California EPN |
$65.74
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.20
|
| Rate for Payer: Dignity Health Senior |
$95.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.33
|
| Rate for Payer: Heritage Provider Network Senior |
$69.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$53.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.20
|
| Rate for Payer: Vantage Medical Group Senior |
$95.20
|
|
|
HC ADM SARSCOV2 PF PEDS (6MS-4YRS)BOOSTER 3MCG/0.2ML TRS-SUCR 3
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 0173A
|
| Hospital Charge Code |
949001356
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.94
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.82
|
| Rate for Payer: Heritage Provider Network Senior |
$75.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
|
|
HC ADM SARSCOV2 VACCINE SINGLE DOSE IM
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
CPT 90480
|
| Hospital Charge Code |
949001358
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$23.35 |
| Max. Negotiated Rate |
$96.75 |
| Rate for Payer: Adventist Health Commercial |
$25.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$88.62
|
| Rate for Payer: Cash Price |
$58.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$87.33
|
| Rate for Payer: Heritage Provider Network Senior |
$87.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.25
|
| Rate for Payer: Multiplan Commercial |
$96.75
|
|
|
HC ADM SARSCOV2 VACCINE SINGLE DOSE IM
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
CPT 90480
|
| Hospital Charge Code |
949001358
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$23.35 |
| Max. Negotiated Rate |
$103.46 |
| Rate for Payer: Adventist Health Commercial |
$25.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$97.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$88.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$81.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$59.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$54.45
|
| Rate for Payer: Blue Shield of California Commercial |
$80.11
|
| Rate for Payer: Blue Shield of California EPN |
$75.72
|
| Rate for Payer: Cash Price |
$58.05
|
| Rate for Payer: Cash Price |
$58.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$83.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$59.90
|
| Rate for Payer: Dignity Health Senior |
$54.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$83.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$54.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$79.85
|
| Rate for Payer: Heritage Provider Network Senior |
$79.85
|
| Rate for Payer: Humana Medicare |
$54.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$62.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$54.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$103.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$64.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$68.61
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$68.61
|
| Rate for Payer: Multiplan Commercial |
$96.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$59.90
|
| Rate for Payer: TriValley Medical Group Senior |
$54.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$81.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$59.90
|
| Rate for Payer: Vantage Medical Group Senior |
$54.45
|
|
|
HC ADRENAL SCAN
|
Facility
|
IP
|
$2,744.00
|
|
|
Service Code
|
CPT 78075
|
| Hospital Charge Code |
909301425
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$496.66 |
| Max. Negotiated Rate |
$2,058.00 |
| Rate for Payer: Adventist Health Commercial |
$548.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,885.13
|
| Rate for Payer: Cash Price |
$1,234.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,857.69
|
| Rate for Payer: Heritage Provider Network Senior |
$1,857.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$496.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$686.00
|
| Rate for Payer: Multiplan Commercial |
$2,058.00
|
|
|
HC ADRENAL SCAN
|
Facility
|
OP
|
$2,744.00
|
|
|
Service Code
|
CPT 78075
|
| Hospital Charge Code |
909301425
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$339.80 |
| Max. Negotiated Rate |
$3,370.88 |
| Rate for Payer: Adventist Health Commercial |
$548.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$867.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,885.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,661.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,951.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,774.15
|
| Rate for Payer: Blue Shield of California Commercial |
$1,109.45
|
| Rate for Payer: Blue Shield of California EPN |
$630.91
|
| Rate for Payer: Cash Price |
$1,234.80
|
| Rate for Payer: Cash Price |
$1,234.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,783.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,661.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,951.56
|
| Rate for Payer: Dignity Health Senior |
$1,774.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,783.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,774.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,698.54
|
| Rate for Payer: Heritage Provider Network Senior |
$1,698.54
|
| Rate for Payer: Humana Medicare |
$1,774.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$339.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,774.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,370.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$496.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,093.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$686.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,235.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,235.43
|
| Rate for Payer: Multiplan Commercial |
$2,058.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,951.56
|
| Rate for Payer: TriValley Medical Group Senior |
$1,774.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,661.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,951.56
|
| Rate for Payer: Vantage Medical Group Senior |
$1,774.15
|
|
|
HC AERO INHAL MDI/DPI INITIAL
|
Facility
|
OP
|
$466.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
900800330
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$18.25 |
| Max. Negotiated Rate |
$506.33 |
| Rate for Payer: Adventist Health Commercial |
$93.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$38.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$320.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$399.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$293.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$266.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$306.00
|
| Rate for Payer: Blue Shield of California Commercial |
$343.00
|
| Rate for Payer: Blue Shield of California EPN |
$295.00
|
| Rate for Payer: Cash Price |
$209.70
|
| Rate for Payer: Cash Price |
$209.70
|
| Rate for Payer: Cash Price |
$209.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$302.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$399.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$293.14
|
| Rate for Payer: Dignity Health Senior |
$266.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$302.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$266.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$288.45
|
| Rate for Payer: Heritage Provider Network Senior |
$288.45
|
| Rate for Payer: Humana Medicare |
$266.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$266.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$506.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$314.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$335.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$335.78
|
| Rate for Payer: Multiplan Commercial |
$349.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$358.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$304.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$399.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$293.14
|
| Rate for Payer: Vantage Medical Group Senior |
$266.49
|
|
|
HC AERO INHAL MDI/DPI INITIAL
|
Facility
|
IP
|
$466.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
900800330
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$84.35 |
| Max. Negotiated Rate |
$349.50 |
| Rate for Payer: Adventist Health Commercial |
$93.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$320.14
|
| Rate for Payer: Cash Price |
$209.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$315.48
|
| Rate for Payer: Heritage Provider Network Senior |
$315.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.50
|
| Rate for Payer: Multiplan Commercial |
$349.50
|
|
|
HC AERO INHAL MDI/DPI SUB
|
Facility
|
OP
|
$466.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
900800331
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$18.25 |
| Max. Negotiated Rate |
$506.33 |
| Rate for Payer: Adventist Health Commercial |
$93.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$38.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$320.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$399.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$293.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$266.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$306.00
|
| Rate for Payer: Blue Shield of California Commercial |
$343.00
|
| Rate for Payer: Blue Shield of California EPN |
$295.00
|
| Rate for Payer: Cash Price |
$209.70
|
| Rate for Payer: Cash Price |
$209.70
|
| Rate for Payer: Cash Price |
$209.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$302.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$399.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$293.14
|
| Rate for Payer: Dignity Health Senior |
$266.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$302.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$266.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$288.45
|
| Rate for Payer: Heritage Provider Network Senior |
$288.45
|
| Rate for Payer: Humana Medicare |
$266.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$266.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$506.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$314.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$335.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$335.78
|
| Rate for Payer: Multiplan Commercial |
$349.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$358.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$304.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$399.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$293.14
|
| Rate for Payer: Vantage Medical Group Senior |
$266.49
|
|
|
HC AERO INHAL MDI/DPI SUB
|
Facility
|
IP
|
$466.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
900800331
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$84.35 |
| Max. Negotiated Rate |
$349.50 |
| Rate for Payer: Adventist Health Commercial |
$93.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$320.14
|
| Rate for Payer: Cash Price |
$209.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$315.48
|
| Rate for Payer: Heritage Provider Network Senior |
$315.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.50
|
| Rate for Payer: Multiplan Commercial |
$349.50
|
|
|
HC AERO INHAL PENTAMIDINE TX
|
Facility
|
OP
|
$334.00
|
|
|
Service Code
|
CPT 94642
|
| Hospital Charge Code |
900800300
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$60.45 |
| Max. Negotiated Rate |
$506.33 |
| Rate for Payer: Adventist Health Commercial |
$66.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$98.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$229.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$399.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$293.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$266.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$306.00
|
| Rate for Payer: Blue Shield of California Commercial |
$343.00
|
| Rate for Payer: Blue Shield of California EPN |
$295.00
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$217.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$399.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$293.14
|
| Rate for Payer: Dignity Health Senior |
$266.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$217.10
|
| Rate for Payer: EPIC Health Plan Medicare |
$266.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$206.75
|
| Rate for Payer: Heritage Provider Network Senior |
$206.75
|
| Rate for Payer: Humana Medicare |
$266.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$134.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$266.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$506.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$314.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$335.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$335.78
|
| Rate for Payer: Multiplan Commercial |
$250.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$358.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$304.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$399.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$293.14
|
| Rate for Payer: Vantage Medical Group Senior |
$266.49
|
|
|
HC AERO INHAL PENTAMIDINE TX
|
Facility
|
IP
|
$334.00
|
|
|
Service Code
|
CPT 94642
|
| Hospital Charge Code |
900800300
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$60.45 |
| Max. Negotiated Rate |
$250.50 |
| Rate for Payer: Adventist Health Commercial |
$66.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$229.46
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$226.12
|
| Rate for Payer: Heritage Provider Network Senior |
$226.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.50
|
| Rate for Payer: Multiplan Commercial |
$250.50
|
|
