|
HC CHECKOUT ORTHO/PROSTH USE 15MIN OT
|
Facility
|
OP
|
$101.00
|
|
|
Service Code
|
CPT 97763
|
| Hospital Charge Code |
905104155
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$18.28 |
| Max. Negotiated Rate |
$343.00 |
| Rate for Payer: Adventist Health Commercial |
$20.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$115.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$85.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$55.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$75.75
|
| 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 |
$45.45
|
| Rate for Payer: Cash Price |
$45.45
|
| Rate for Payer: Cash Price |
$45.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$65.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$85.85
|
| Rate for Payer: Dignity Health Senior |
$85.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$62.52
|
| Rate for Payer: Heritage Provider Network Senior |
$62.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$48.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.25
|
| Rate for Payer: Multiplan Commercial |
$75.75
|
| 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 |
$248.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$209.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$85.85
|
| Rate for Payer: Vantage Medical Group Senior |
$85.85
|
|
|
HC CHECKOUT ORTHO/PROSTH USE 15MIN OT
|
Facility
|
IP
|
$101.00
|
|
|
Service Code
|
CPT 97763
|
| Hospital Charge Code |
905104155
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$18.28 |
| Max. Negotiated Rate |
$75.75 |
| Rate for Payer: Adventist Health Commercial |
$20.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.39
|
| Rate for Payer: Cash Price |
$45.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$68.38
|
| Rate for Payer: Heritage Provider Network Senior |
$68.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.25
|
| Rate for Payer: Multiplan Commercial |
$75.75
|
|
|
HC CHECKOUT ORTHO/PROSTH USE 15MIN PT
|
Facility
|
OP
|
$101.00
|
|
|
Service Code
|
CPT 97763
|
| Hospital Charge Code |
905103155
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$18.28 |
| Max. Negotiated Rate |
$343.00 |
| Rate for Payer: Adventist Health Commercial |
$20.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$115.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$85.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$55.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$75.75
|
| 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 |
$45.45
|
| Rate for Payer: Cash Price |
$45.45
|
| Rate for Payer: Cash Price |
$45.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$65.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$85.85
|
| Rate for Payer: Dignity Health Senior |
$85.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$62.52
|
| Rate for Payer: Heritage Provider Network Senior |
$62.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$48.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.25
|
| Rate for Payer: Multiplan Commercial |
$75.75
|
| 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 |
$248.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$209.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$85.85
|
| Rate for Payer: Vantage Medical Group Senior |
$85.85
|
|
|
HC CHECKOUT ORTHO/PROSTH USE 15MIN PT
|
Facility
|
IP
|
$267.00
|
|
|
Service Code
|
CPT 97763
|
| Hospital Charge Code |
900417703
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$48.33 |
| Max. Negotiated Rate |
$200.25 |
| Rate for Payer: Adventist Health Commercial |
$53.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$183.43
|
| Rate for Payer: Cash Price |
$120.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$180.76
|
| Rate for Payer: Heritage Provider Network Senior |
$180.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.75
|
| Rate for Payer: Multiplan Commercial |
$200.25
|
|
|
HC CHECKOUT ORTHO/PROSTH USE 15MIN PT
|
Facility
|
OP
|
$267.00
|
|
|
Service Code
|
CPT 97763
|
| Hospital Charge Code |
900417703
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$48.33 |
| Max. Negotiated Rate |
$343.00 |
| Rate for Payer: Adventist Health Commercial |
$53.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$115.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$183.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$226.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$146.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$200.25
|
| 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 |
$120.15
|
| Rate for Payer: Cash Price |
$120.15
|
| Rate for Payer: Cash Price |
$120.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$173.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$226.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$226.95
|
| Rate for Payer: Dignity Health Senior |
$226.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$173.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$165.27
|
| Rate for Payer: Heritage Provider Network Senior |
$165.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$128.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.75
|
| Rate for Payer: Multiplan Commercial |
$200.25
|
| 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 |
$248.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$209.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$226.95
|
| Rate for Payer: Vantage Medical Group Senior |
$226.95
|
|
|
HC CHECKOUT ORTHO/PROSTH USE 15MIN PT
|
Facility
|
IP
|
$101.00
|
|
|
Service Code
|
CPT 97763
|
| Hospital Charge Code |
905103155
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$18.28 |
| Max. Negotiated Rate |
$75.75 |
| Rate for Payer: Adventist Health Commercial |
$20.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.39
|
| Rate for Payer: Cash Price |
$45.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$68.38
|
| Rate for Payer: Heritage Provider Network Senior |
$68.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.25
|
| Rate for Payer: Multiplan Commercial |
$75.75
|
|
|
HC CHEM CAUT OF GRANULATION TISS
|
Facility
|
IP
|
$1,146.00
|
|
|
Service Code
|
CPT 17250
|
| Hospital Charge Code |
900501050
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$207.43 |
| Max. Negotiated Rate |
$859.50 |
| Rate for Payer: Adventist Health Commercial |
$229.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$787.30
|
| Rate for Payer: Cash Price |
$515.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$775.84
|
| Rate for Payer: Heritage Provider Network Senior |
$775.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$207.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$286.50
|
| Rate for Payer: Multiplan Commercial |
$859.50
|
|
|
HC CHEM CAUT OF GRANULATION TISS
|
Facility
|
OP
|
$1,146.00
|
|
|
Service Code
|
CPT 17250
|
| Hospital Charge Code |
900501050
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$31.36 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$229.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$787.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,086.22
|
| Rate for Payer: Blue Shield of California EPN |
$933.56
|
| Rate for Payer: Cash Price |
$515.70
|
| Rate for Payer: Cash Price |
$515.70
|
| Rate for Payer: Cash Price |
$515.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$744.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: Dignity Health Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$250.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$709.37
|
| Rate for Payer: Heritage Provider Network Senior |
$307.67
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$31.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$475.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$207.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$295.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$286.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.18
|
| Rate for Payer: Multiplan Commercial |
$859.50
|
| 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 |
$1,040.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$874.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Vantage Medical Group Senior |
$250.14
|
|
|
HC CHEM CAUT OF GRANULATION TISS
|
Facility
|
OP
|
$1,146.00
|
|
|
Service Code
|
CPT 17250
|
| Hospital Charge Code |
900501050
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$207.43 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$229.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$787.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$515.70
|
| Rate for Payer: Cash Price |
$515.70
|
| Rate for Payer: Cash Price |
$515.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$744.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: Dignity Health Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$250.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$775.84
|
| Rate for Payer: Heritage Provider Network Senior |
$775.84
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$552.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$207.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$295.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$286.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.18
|
| Rate for Payer: Multiplan Commercial |
$859.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$416.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$382.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Vantage Medical Group Senior |
$250.14
|
|
|
HC CHEM CAUT OF GRANULATION TISS
|
Facility
|
IP
|
$1,146.00
|
|
|
Service Code
|
CPT 17250
|
| Hospital Charge Code |
900501050
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$207.43 |
| Max. Negotiated Rate |
$859.50 |
| Rate for Payer: Adventist Health Commercial |
$229.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$787.30
|
| Rate for Payer: Cash Price |
$515.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$775.84
|
| Rate for Payer: Heritage Provider Network Senior |
$775.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$207.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$286.50
|
| Rate for Payer: Multiplan Commercial |
$859.50
|
|
|
HC CHEMO ADMIN CNS W SPINAL TAP
|
Facility
|
OP
|
$2,616.00
|
|
|
Service Code
|
CPT 96450
|
| Hospital Charge Code |
911800816
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$199.11 |
| Max. Negotiated Rate |
$1,962.00 |
| Rate for Payer: Adventist Health Commercial |
$523.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$199.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,797.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$634.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$465.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$423.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$449.00
|
| Rate for Payer: Blue Shield of California Commercial |
$618.00
|
| Rate for Payer: Blue Shield of California EPN |
$530.00
|
| Rate for Payer: Cash Price |
$1,177.20
|
| Rate for Payer: Cash Price |
$1,177.20
|
| Rate for Payer: Cash Price |
$1,177.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,700.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$634.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$465.45
|
| Rate for Payer: Dignity Health Senior |
$423.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,700.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$423.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,619.30
|
| Rate for Payer: Heritage Provider Network Senior |
$1,619.30
|
| Rate for Payer: Humana Medicare |
$423.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$203.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$423.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$803.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$473.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$499.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$654.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$533.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$533.16
|
| Rate for Payer: Multiplan Commercial |
$1,962.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$465.45
|
| Rate for Payer: TriValley Medical Group Senior |
$423.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$727.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$610.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$634.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$465.45
|
| Rate for Payer: Vantage Medical Group Senior |
$423.14
|
|
|
HC CHEMO ADMIN CNS W SPINAL TAP
|
Facility
|
IP
|
$2,616.00
|
|
|
Service Code
|
CPT 96450
|
| Hospital Charge Code |
911800816
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$473.50 |
| Max. Negotiated Rate |
$1,962.00 |
| Rate for Payer: Adventist Health Commercial |
$523.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,797.19
|
| Rate for Payer: Cash Price |
$1,177.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,771.03
|
| Rate for Payer: Heritage Provider Network Senior |
$1,771.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$473.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$654.00
|
| Rate for Payer: Multiplan Commercial |
$1,962.00
|
|
|
HC CHEMO ADMIN INTRA-ART PUSH
|
Facility
|
IP
|
$1,109.00
|
|
|
Service Code
|
CPT 96420
|
| Hospital Charge Code |
911800810
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$200.73 |
| Max. Negotiated Rate |
$831.75 |
| Rate for Payer: Adventist Health Commercial |
$221.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$761.88
|
| Rate for Payer: Cash Price |
$499.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$750.79
|
| Rate for Payer: Heritage Provider Network Senior |
$750.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$200.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$277.25
|
| Rate for Payer: Multiplan Commercial |
$831.75
|
|
|
HC CHEMO ADMIN INTRA-ART PUSH
|
Facility
|
OP
|
$1,109.00
|
|
|
Service Code
|
CPT 96420
|
| Hospital Charge Code |
911800810
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$65.79 |
| Max. Negotiated Rate |
$831.75 |
| Rate for Payer: Adventist Health Commercial |
$221.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$264.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$761.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$634.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$465.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$423.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$449.00
|
| Rate for Payer: Blue Shield of California Commercial |
$688.69
|
| Rate for Payer: Blue Shield of California EPN |
$650.98
|
| Rate for Payer: Cash Price |
$499.05
|
| Rate for Payer: Cash Price |
$499.05
|
| Rate for Payer: Cash Price |
$499.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$720.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$634.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$465.45
|
| Rate for Payer: Dignity Health Senior |
$423.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$720.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$423.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$686.47
|
| Rate for Payer: Heritage Provider Network Senior |
$686.47
|
| Rate for Payer: Humana Medicare |
$423.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$65.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$423.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$803.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$200.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$499.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$277.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$533.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$533.16
|
| Rate for Payer: Multiplan Commercial |
$831.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$465.45
|
| Rate for Payer: TriValley Medical Group Senior |
$423.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$727.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$610.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$634.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$465.45
|
| Rate for Payer: Vantage Medical Group Senior |
$423.14
|
|
|
HC CHEST 2 VIEWS
|
Facility
|
OP
|
$884.00
|
|
|
Service Code
|
CPT 71046
|
| Hospital Charge Code |
909001407
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$42.87 |
| Max. Negotiated Rate |
$663.00 |
| Rate for Payer: Adventist Health Commercial |
$176.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$607.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$113.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$195.26
|
| Rate for Payer: Blue Shield of California Commercial |
$107.32
|
| Rate for Payer: Blue Shield of California EPN |
$61.03
|
| Rate for Payer: Cash Price |
$397.80
|
| Rate for Payer: Cash Price |
$397.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$574.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.89
|
| Rate for Payer: Dignity Health Senior |
$113.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$574.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$547.20
|
| Rate for Payer: Heritage Provider Network Senior |
$547.20
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$42.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$113.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$160.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$221.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$143.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$143.06
|
| Rate for Payer: Multiplan Commercial |
$663.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$113.54
|
| Rate for Payer: TriValley Medical Group Senior |
$113.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$99.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$99.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Vantage Medical Group Senior |
$113.54
|
|
|
HC CHEST 2 VIEWS
|
Facility
|
IP
|
$884.00
|
|
|
Service Code
|
CPT 71046
|
| Hospital Charge Code |
909001407
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$160.00 |
| Max. Negotiated Rate |
$663.00 |
| Rate for Payer: Adventist Health Commercial |
$176.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$607.31
|
| Rate for Payer: Cash Price |
$397.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$598.47
|
| Rate for Payer: Heritage Provider Network Senior |
$598.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$160.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$221.00
|
| Rate for Payer: Multiplan Commercial |
$663.00
|
|
|
HC CHEST COMP 4 VIEWS
|
Facility
|
OP
|
$1,002.00
|
|
|
Service Code
|
CPT 71048
|
| Hospital Charge Code |
909001402
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$57.26 |
| Max. Negotiated Rate |
$751.50 |
| Rate for Payer: Adventist Health Commercial |
$200.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$57.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$688.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$206.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$151.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$137.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$256.06
|
| Rate for Payer: Blue Shield of California Commercial |
$140.64
|
| Rate for Payer: Blue Shield of California EPN |
$79.98
|
| Rate for Payer: Cash Price |
$450.90
|
| Rate for Payer: Cash Price |
$450.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$651.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$206.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$151.10
|
| Rate for Payer: Dignity Health Senior |
$137.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$651.30
|
| Rate for Payer: EPIC Health Plan Medicare |
$137.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$620.24
|
| Rate for Payer: Heritage Provider Network Senior |
$620.24
|
| Rate for Payer: Humana Medicare |
$137.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$59.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$137.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$260.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$181.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$162.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$250.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$173.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$173.07
|
| Rate for Payer: Multiplan Commercial |
$751.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$137.36
|
| Rate for Payer: TriValley Medical Group Senior |
$137.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$189.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$189.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$206.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$151.10
|
| Rate for Payer: Vantage Medical Group Senior |
$137.36
|
|
|
HC CHEST COMP 4 VIEWS
|
Facility
|
IP
|
$1,002.00
|
|
|
Service Code
|
CPT 71048
|
| Hospital Charge Code |
909001402
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$181.36 |
| Max. Negotiated Rate |
$751.50 |
| Rate for Payer: Adventist Health Commercial |
$200.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$688.37
|
| Rate for Payer: Cash Price |
$450.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$678.35
|
| Rate for Payer: Heritage Provider Network Senior |
$678.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$181.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$751.50
|
|
|
HC CHEST FLUORO/PACEMKR
|
Facility
|
OP
|
$823.00
|
|
| Hospital Charge Code |
909001469
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$148.96 |
| Max. Negotiated Rate |
$12,620.00 |
| Rate for Payer: Adventist Health Commercial |
$164.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12,620.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$565.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$699.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$452.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$617.25
|
| 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 |
$370.35
|
| Rate for Payer: Cash Price |
$370.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$534.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$699.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$699.55
|
| Rate for Payer: Dignity Health Senior |
$699.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$493.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$509.44
|
| Rate for Payer: Heritage Provider Network Senior |
$509.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$396.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$148.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$205.75
|
| Rate for Payer: Multiplan Commercial |
$617.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$699.55
|
| Rate for Payer: Vantage Medical Group Senior |
$699.55
|
|
|
HC CHEST FLUORO/PACEMKR
|
Facility
|
IP
|
$823.00
|
|
| Hospital Charge Code |
909001469
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$148.96 |
| Max. Negotiated Rate |
$617.25 |
| Rate for Payer: Adventist Health Commercial |
$164.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$565.40
|
| Rate for Payer: Cash Price |
$370.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$557.17
|
| Rate for Payer: Heritage Provider Network Senior |
$557.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$148.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$205.75
|
| Rate for Payer: Multiplan Commercial |
$617.25
|
|
|
HC CHEST FOUR OR MORE VIEWS
|
Facility
|
OP
|
$1,141.00
|
|
|
Service Code
|
CPT 71048
|
| Hospital Charge Code |
909071048
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$57.26 |
| Max. Negotiated Rate |
$855.75 |
| Rate for Payer: Adventist Health Commercial |
$228.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$57.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$783.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$206.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$151.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$137.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$256.06
|
| Rate for Payer: Blue Shield of California Commercial |
$140.64
|
| Rate for Payer: Blue Shield of California EPN |
$79.98
|
| Rate for Payer: Cash Price |
$513.45
|
| Rate for Payer: Cash Price |
$513.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$741.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$206.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$151.10
|
| Rate for Payer: Dignity Health Senior |
$137.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$741.65
|
| Rate for Payer: EPIC Health Plan Medicare |
$137.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$706.28
|
| Rate for Payer: Heritage Provider Network Senior |
$706.28
|
| Rate for Payer: Humana Medicare |
$137.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$59.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$137.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$260.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$206.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$162.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$285.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$173.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$173.07
|
| Rate for Payer: Multiplan Commercial |
$855.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$137.36
|
| Rate for Payer: TriValley Medical Group Senior |
$137.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$189.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$189.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$206.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$151.10
|
| Rate for Payer: Vantage Medical Group Senior |
$137.36
|
|
|
HC CHEST FOUR OR MORE VIEWS
|
Facility
|
IP
|
$1,141.00
|
|
|
Service Code
|
CPT 71048
|
| Hospital Charge Code |
909071048
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$206.52 |
| Max. Negotiated Rate |
$855.75 |
| Rate for Payer: Adventist Health Commercial |
$228.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$783.87
|
| Rate for Payer: Cash Price |
$513.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$772.46
|
| Rate for Payer: Heritage Provider Network Senior |
$772.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$206.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$285.25
|
| Rate for Payer: Multiplan Commercial |
$855.75
|
|
|
HC CHEST PORT
|
Facility
|
OP
|
$2,139.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
909081700
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$387.16 |
| Max. Negotiated Rate |
$1,818.15 |
| Rate for Payer: Adventist Health Commercial |
$427.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,480.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,469.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,818.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,176.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,604.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1,328.32
|
| Rate for Payer: Blue Shield of California EPN |
$1,255.59
|
| Rate for Payer: Cash Price |
$962.55
|
| Rate for Payer: Cash Price |
$962.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,390.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,818.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,818.15
|
| Rate for Payer: Dignity Health Senior |
$1,818.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,390.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,324.04
|
| Rate for Payer: Heritage Provider Network Senior |
$1,324.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,031.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$387.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$534.75
|
| Rate for Payer: Multiplan Commercial |
$1,604.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,818.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1,818.15
|
|
|
HC CHEST PORT
|
Facility
|
IP
|
$2,139.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
909081700
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$387.16 |
| Max. Negotiated Rate |
$1,604.25 |
| Rate for Payer: Adventist Health Commercial |
$427.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,469.49
|
| Rate for Payer: Cash Price |
$962.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,448.10
|
| Rate for Payer: Heritage Provider Network Senior |
$1,448.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$387.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$534.75
|
| Rate for Payer: Multiplan Commercial |
$1,604.25
|
|
|
HC CHEST SINGLE VIEW
|
Facility
|
IP
|
$642.00
|
|
|
Service Code
|
CPT 71045
|
| Hospital Charge Code |
909001408
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$116.20 |
| Max. Negotiated Rate |
$481.50 |
| Rate for Payer: Adventist Health Commercial |
$128.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$441.05
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$434.63
|
| Rate for Payer: Heritage Provider Network Senior |
$434.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$116.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$160.50
|
| Rate for Payer: Multiplan Commercial |
$481.50
|
|
