|
HC ADJ TISS TRNSFR 10 SQ CM OR LT
|
Facility
|
IP
|
$7,334.00
|
|
|
Service Code
|
CPT 14060
|
| Hospital Charge Code |
900501331
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,327.45 |
| Max. Negotiated Rate |
$5,500.50 |
| Rate for Payer: Adventist Health Commercial |
$1,466.80
|
| Rate for Payer: Cash Price |
$4,033.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,965.12
|
| Rate for Payer: Heritage Provider Network Senior |
$4,965.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,327.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,833.50
|
| Rate for Payer: Multiplan Commercial |
$5,500.50
|
|
|
HC ADM FR D LOW A/D SAME DT-HR
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
CPT 99234
|
| Hospital Charge Code |
902100007
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$183.75 |
| Rate for Payer: Adventist Health Commercial |
$49.00
|
| Rate for Payer: Cash Price |
$134.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$165.87
|
| Rate for Payer: Heritage Provider Network Senior |
$165.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.25
|
| Rate for Payer: Multiplan Commercial |
$183.75
|
|
|
HC ADM FR D LOW A/D SAME DT-HR
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
CPT 99234
|
| Hospital Charge Code |
902100007
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$5,498.00 |
| Rate for Payer: Adventist Health Commercial |
$49.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,276.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$168.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$208.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$134.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$183.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,061.00
|
| Rate for Payer: Blue Shield of California Commercial |
$149.45
|
| Rate for Payer: Blue Shield of California EPN |
$119.56
|
| Rate for Payer: Cash Price |
$134.75
|
| Rate for Payer: Cash Price |
$134.75
|
| Rate for Payer: Cash Price |
$134.75
|
| Rate for Payer: Cash Price |
$134.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$159.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$208.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$208.25
|
| Rate for Payer: Dignity Health Senior |
$208.25
|
| 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 |
$121.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,498.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$171.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$171.50
|
| Rate for Payer: Multiplan Commercial |
$183.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$122.50
|
| Rate for Payer: TriValley Medical Group Senior |
$122.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,078.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,432.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$208.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$208.25
|
| Rate for Payer: Vantage Medical Group Senior |
$208.25
|
|
|
HC ADM FR H-COMP A/D SAME/ HR
|
Facility
|
IP
|
$269.00
|
|
|
Service Code
|
CPT G0378
|
| Hospital Charge Code |
902100009
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$48.69 |
| Max. Negotiated Rate |
$201.75 |
| Rate for Payer: Adventist Health Commercial |
$53.80
|
| Rate for Payer: Cash Price |
$147.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$182.11
|
| Rate for Payer: Heritage Provider Network Senior |
$182.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.25
|
| Rate for Payer: Multiplan Commercial |
$201.75
|
|
|
HC ADM FR H-COMP A/D SAME/ HR
|
Facility
|
OP
|
$269.00
|
|
|
Service Code
|
CPT G0378
|
| Hospital Charge Code |
902100009
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$48.69 |
| Max. Negotiated Rate |
$5,498.00 |
| Rate for Payer: Adventist Health Commercial |
$53.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,276.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$184.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$228.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$147.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$201.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,061.00
|
| Rate for Payer: Blue Shield of California Commercial |
$164.09
|
| Rate for Payer: Blue Shield of California EPN |
$131.27
|
| Rate for Payer: Cash Price |
$147.95
|
| Rate for Payer: Cash Price |
$147.95
|
| Rate for Payer: Cash Price |
$147.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$174.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$228.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.65
|
| Rate for Payer: Dignity Health Senior |
$228.65
|
| 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 |
$5,498.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$188.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$188.30
|
| Rate for Payer: Multiplan Commercial |
$201.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$134.50
|
| Rate for Payer: TriValley Medical Group Senior |
$134.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,078.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,432.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$228.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.65
|
| Rate for Payer: Vantage Medical Group Senior |
$228.65
|
|
|
HC ADM FR HIGH A/D 2DATES/ HR
|
Facility
|
OP
|
$269.00
|
|
|
Service Code
|
CPT G0378
|
| Hospital Charge Code |
902100006
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$48.69 |
| Max. Negotiated Rate |
$5,498.00 |
| Rate for Payer: Adventist Health Commercial |
$53.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,276.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$184.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$228.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$147.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$201.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,061.00
|
| Rate for Payer: Blue Shield of California Commercial |
$164.09
|
| Rate for Payer: Blue Shield of California EPN |
$131.27
|
| Rate for Payer: Cash Price |
$147.95
|
| Rate for Payer: Cash Price |
$147.95
|
| Rate for Payer: Cash Price |
$147.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$174.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$228.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.65
|
| Rate for Payer: Dignity Health Senior |
$228.65
|
| 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 |
$5,498.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$188.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$188.30
|
| Rate for Payer: Multiplan Commercial |
$201.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$134.50
|
| Rate for Payer: TriValley Medical Group Senior |
$134.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,078.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,432.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$228.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.65
|
| Rate for Payer: Vantage Medical Group Senior |
$228.65
|
|
|
HC ADM FR HIGH A/D 2DATES/ HR
|
Facility
|
IP
|
$269.00
|
|
|
Service Code
|
CPT G0378
|
| Hospital Charge Code |
902100006
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$48.69 |
| Max. Negotiated Rate |
$201.75 |
| Rate for Payer: Adventist Health Commercial |
$53.80
|
| Rate for Payer: Cash Price |
$147.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$182.11
|
| Rate for Payer: Heritage Provider Network Senior |
$182.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.25
|
| Rate for Payer: Multiplan Commercial |
$201.75
|
|
|
HC ADM FR LOW A/D 2 DATES/ HR
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
CPT 99218
|
| Hospital Charge Code |
902100001
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$5,498.00 |
| Rate for Payer: Adventist Health Commercial |
$49.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,276.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$168.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$208.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$134.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$183.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,061.00
|
| Rate for Payer: Blue Shield of California Commercial |
$149.45
|
| Rate for Payer: Blue Shield of California EPN |
$119.56
|
| Rate for Payer: Cash Price |
$134.75
|
| Rate for Payer: Cash Price |
$134.75
|
| Rate for Payer: Cash Price |
$134.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$159.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$208.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$208.25
|
| Rate for Payer: Dignity Health Senior |
$208.25
|
| 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 |
$5,498.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$171.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$171.50
|
| Rate for Payer: Multiplan Commercial |
$183.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$122.50
|
| Rate for Payer: TriValley Medical Group Senior |
$122.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,078.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,432.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$208.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$208.25
|
| Rate for Payer: Vantage Medical Group Senior |
$208.25
|
|
|
HC ADM FR LOW A/D 2 DATES/ HR
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
CPT 99218
|
| Hospital Charge Code |
902100001
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$183.75 |
| Rate for Payer: Adventist Health Commercial |
$49.00
|
| Rate for Payer: Cash Price |
$134.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$165.87
|
| Rate for Payer: Heritage Provider Network Senior |
$165.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.25
|
| Rate for Payer: Multiplan Commercial |
$183.75
|
|
|
HC ADM FR MOD A/D 2 DATES/ HR
|
Facility
|
OP
|
$272.00
|
|
|
Service Code
|
CPT 99219
|
| Hospital Charge Code |
902100005
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$49.23 |
| Max. Negotiated Rate |
$5,498.00 |
| Rate for Payer: Adventist Health Commercial |
$54.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,276.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$186.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$231.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$149.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$204.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,061.00
|
| Rate for Payer: Blue Shield of California Commercial |
$165.92
|
| Rate for Payer: Blue Shield of California EPN |
$132.74
|
| Rate for Payer: Cash Price |
$149.60
|
| Rate for Payer: Cash Price |
$149.60
|
| Rate for Payer: Cash Price |
$149.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$176.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$231.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$231.20
|
| Rate for Payer: Dignity Health Senior |
$231.20
|
| 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 |
$5,498.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$190.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$190.40
|
| Rate for Payer: Multiplan Commercial |
$204.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$136.00
|
| Rate for Payer: TriValley Medical Group Senior |
$136.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,078.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,432.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$231.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231.20
|
| Rate for Payer: Vantage Medical Group Senior |
$231.20
|
|
|
HC ADM FR MOD A/D 2 DATES/ HR
|
Facility
|
IP
|
$272.00
|
|
|
Service Code
|
CPT 99219
|
| Hospital Charge Code |
902100005
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$49.23 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Adventist Health Commercial |
$54.40
|
| Rate for Payer: Cash Price |
$149.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$184.14
|
| Rate for Payer: Heritage Provider Network Senior |
$184.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.00
|
| Rate for Payer: Multiplan Commercial |
$204.00
|
|
|
HC ADM FR MOD A/D SAME DT/HR
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
CPT 99235
|
| Hospital Charge Code |
902100008
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$183.75 |
| Rate for Payer: Adventist Health Commercial |
$49.00
|
| Rate for Payer: Cash Price |
$134.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$165.87
|
| Rate for Payer: Heritage Provider Network Senior |
$165.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.25
|
| Rate for Payer: Multiplan Commercial |
$183.75
|
|
|
HC ADM FR MOD A/D SAME DT/HR
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
CPT 99235
|
| Hospital Charge Code |
902100008
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$5,498.00 |
| Rate for Payer: Adventist Health Commercial |
$49.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,276.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$168.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$208.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$134.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$183.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,061.00
|
| Rate for Payer: Blue Shield of California Commercial |
$149.45
|
| Rate for Payer: Blue Shield of California EPN |
$119.56
|
| Rate for Payer: Cash Price |
$134.75
|
| Rate for Payer: Cash Price |
$134.75
|
| Rate for Payer: Cash Price |
$134.75
|
| Rate for Payer: Cash Price |
$134.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$159.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$208.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$208.25
|
| Rate for Payer: Dignity Health Senior |
$208.25
|
| 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 |
$167.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,498.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$171.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$171.50
|
| Rate for Payer: Multiplan Commercial |
$183.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$122.50
|
| Rate for Payer: TriValley Medical Group Senior |
$122.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,078.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,432.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$208.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$208.25
|
| Rate for Payer: Vantage Medical Group Senior |
$208.25
|
|
|
HC ADMIN BEBTELOVIMAB INJ
|
Facility
|
IP
|
$756.00
|
|
|
Service Code
|
CPT M0222
|
| Hospital Charge Code |
949001336
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$136.84 |
| Max. Negotiated Rate |
$567.00 |
| Rate for Payer: Adventist Health Commercial |
$151.20
|
| Rate for Payer: Cash Price |
$415.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$511.81
|
| Rate for Payer: Heritage Provider Network Senior |
$511.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$136.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.00
|
| Rate for Payer: Multiplan Commercial |
$567.00
|
|
|
HC ADMIN BEBTELOVIMAB INJ
|
Facility
|
OP
|
$756.00
|
|
|
Service Code
|
CPT M0222
|
| Hospital Charge Code |
949001336
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$136.84 |
| Max. Negotiated Rate |
$642.60 |
| Rate for Payer: Adventist Health Commercial |
$151.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$404.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$519.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$642.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$415.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$567.00
|
| Rate for Payer: Blue Shield of California Commercial |
$461.16
|
| Rate for Payer: Blue Shield of California EPN |
$368.93
|
| Rate for Payer: Cash Price |
$415.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$491.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$642.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$642.60
|
| Rate for Payer: Dignity Health Senior |
$642.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$491.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$467.96
|
| Rate for Payer: Heritage Provider Network Senior |
$467.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$360.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$136.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$529.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$529.20
|
| Rate for Payer: Multiplan Commercial |
$567.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$642.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$642.60
|
| Rate for Payer: Vantage Medical Group Senior |
$642.60
|
|
|
HC ADMINISTRATION OF XOFIGO
|
Facility
|
OP
|
$799.00
|
|
|
Service Code
|
CPT 79101
|
| Hospital Charge Code |
909301549
|
|
Hospital Revenue Code
|
342
|
| Min. Negotiated Rate |
$144.62 |
| Max. Negotiated Rate |
$599.25 |
| Rate for Payer: Adventist Health Commercial |
$159.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$427.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$548.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$427.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$313.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$284.78
|
| Rate for Payer: Blue Shield of California Commercial |
$549.46
|
| Rate for Payer: Blue Shield of California EPN |
$441.85
|
| Rate for Payer: Cash Price |
$439.45
|
| Rate for Payer: Cash Price |
$439.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$519.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$427.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$313.26
|
| Rate for Payer: Dignity Health Senior |
$284.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$519.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$284.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$494.58
|
| Rate for Payer: Heritage Provider Network Senior |
$494.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$204.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$284.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$381.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$144.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$327.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$199.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$358.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$358.82
|
| Rate for Payer: Multiplan Commercial |
$599.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$313.26
|
| Rate for Payer: TriValley Medical Group Senior |
$284.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$399.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$399.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$427.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$313.26
|
| Rate for Payer: Vantage Medical Group Senior |
$284.78
|
|
|
HC ADMINISTRATION OF XOFIGO
|
Facility
|
IP
|
$799.00
|
|
|
Service Code
|
CPT 79101
|
| Hospital Charge Code |
909301549
|
|
Hospital Revenue Code
|
342
|
| Min. Negotiated Rate |
$144.62 |
| Max. Negotiated Rate |
$599.25 |
| Rate for Payer: Adventist Health Commercial |
$159.80
|
| Rate for Payer: Cash Price |
$439.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$540.92
|
| Rate for Payer: Heritage Provider Network Senior |
$540.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$144.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$199.75
|
| Rate for Payer: Multiplan Commercial |
$599.25
|
|
|
HC ADMIN SOTROVIMAB INFUSION MA
|
Facility
|
OP
|
$970.00
|
|
|
Service Code
|
CPT M0247
|
| Hospital Charge Code |
949001325
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$175.57 |
| Max. Negotiated Rate |
$824.50 |
| Rate for Payer: Adventist Health Commercial |
$194.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$518.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$666.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$824.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$533.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$727.50
|
| Rate for Payer: Blue Shield of California Commercial |
$591.70
|
| Rate for Payer: Blue Shield of California EPN |
$473.36
|
| Rate for Payer: Cash Price |
$533.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$630.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$824.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$824.50
|
| Rate for Payer: Dignity Health Senior |
$824.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$630.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$600.43
|
| Rate for Payer: Heritage Provider Network Senior |
$600.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$462.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$175.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$242.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$679.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$679.00
|
| Rate for Payer: Multiplan Commercial |
$727.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$824.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$824.50
|
| Rate for Payer: Vantage Medical Group Senior |
$824.50
|
|
|
HC ADMIN SOTROVIMAB INFUSION MA
|
Facility
|
IP
|
$970.00
|
|
|
Service Code
|
CPT M0247
|
| Hospital Charge Code |
949001325
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$175.57 |
| Max. Negotiated Rate |
$727.50 |
| Rate for Payer: Adventist Health Commercial |
$194.00
|
| Rate for Payer: Cash Price |
$533.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$656.69
|
| Rate for Payer: Heritage Provider Network Senior |
$656.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$175.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$242.50
|
| Rate for Payer: Multiplan Commercial |
$727.50
|
|
|
HC ADMIN VACCINE EA ADDIT
|
Facility
|
IP
|
$71.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
908600205
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$12.85 |
| Max. Negotiated Rate |
$53.25 |
| Rate for Payer: Adventist Health Commercial |
$14.20
|
| Rate for Payer: Cash Price |
$39.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.07
|
| Rate for Payer: Heritage Provider Network Senior |
$48.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.75
|
| Rate for Payer: Multiplan Commercial |
$53.25
|
|
|
HC ADMIN VACCINE EA ADDIT
|
Facility
|
OP
|
$71.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
908600205
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$12.85 |
| Max. Negotiated Rate |
$60.35 |
| Rate for Payer: Adventist Health Commercial |
$14.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$37.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$48.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$60.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$39.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$53.25
|
| Rate for Payer: Blue Shield of California Commercial |
$43.31
|
| Rate for Payer: Blue Shield of California EPN |
$34.65
|
| Rate for Payer: Cash Price |
$39.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$46.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$60.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$60.35
|
| Rate for Payer: Dignity Health Senior |
$60.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$43.95
|
| Rate for Payer: Heritage Provider Network Senior |
$43.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$33.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$49.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$49.70
|
| Rate for Payer: Multiplan Commercial |
$53.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$60.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$60.35
|
| Rate for Payer: Vantage Medical Group Senior |
$60.35
|
|
|
HC ADMIN VACCINE EA ADDIT
|
Facility
|
IP
|
$71.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
900501278
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$12.85 |
| Max. Negotiated Rate |
$53.25 |
| Rate for Payer: Adventist Health Commercial |
$14.20
|
| Rate for Payer: Cash Price |
$39.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.07
|
| Rate for Payer: Heritage Provider Network Senior |
$48.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.75
|
| Rate for Payer: Multiplan Commercial |
$53.25
|
|
|
HC ADMIN VACCINE EA ADDIT
|
Facility
|
OP
|
$71.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
900501278
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$12.85 |
| Max. Negotiated Rate |
$60.35 |
| Rate for Payer: Adventist Health Commercial |
$14.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$37.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$48.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$60.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$39.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$53.25
|
| Rate for Payer: Blue Shield of California Commercial |
$43.31
|
| Rate for Payer: Blue Shield of California EPN |
$34.65
|
| Rate for Payer: Cash Price |
$39.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$46.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$60.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$60.35
|
| Rate for Payer: Dignity Health Senior |
$60.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$43.95
|
| Rate for Payer: Heritage Provider Network Senior |
$43.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$33.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$49.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$49.70
|
| Rate for Payer: Multiplan Commercial |
$53.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$60.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$60.35
|
| Rate for Payer: Vantage Medical Group Senior |
$60.35
|
|
|
HC ADMIN VACCINE FLU
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
CPT G0008
|
| Hospital Charge Code |
908600208
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$90.75 |
| Rate for Payer: Adventist Health Commercial |
$24.20
|
| Rate for Payer: Cash Price |
$66.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.92
|
| Rate for Payer: Heritage Provider Network Senior |
$81.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.25
|
| Rate for Payer: Multiplan Commercial |
$90.75
|
|
|
HC ADMIN VACCINE FLU
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
CPT G0008
|
| Hospital Charge Code |
908600208
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$90.75 |
| Rate for Payer: Adventist Health Commercial |
$24.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$64.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$83.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$87.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$64.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$58.63
|
| Rate for Payer: Blue Shield of California Commercial |
$73.81
|
| Rate for Payer: Blue Shield of California EPN |
$59.05
|
| Rate for Payer: Cash Price |
$66.55
|
| Rate for Payer: Cash Price |
$66.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$78.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$87.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$64.49
|
| Rate for Payer: Dignity Health Senior |
$58.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$78.65
|
| Rate for Payer: EPIC Health Plan Medicare |
$58.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$74.90
|
| Rate for Payer: Heritage Provider Network Senior |
$74.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$58.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$57.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$67.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$73.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$73.87
|
| Rate for Payer: Multiplan Commercial |
$90.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$64.49
|
| Rate for Payer: TriValley Medical Group Senior |
$58.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$87.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$64.49
|
| Rate for Payer: Vantage Medical Group Senior |
$58.63
|
|
