|
HC ADJ GASTRIC BAND DIAM VIA PORT
|
Facility
|
IP
|
$5,527.00
|
|
|
Service Code
|
CPT 43999
|
| Hospital Charge Code |
906743999
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$1,000.39 |
| Max. Negotiated Rate |
$4,145.25 |
| Rate for Payer: Adventist Health Commercial |
$1,105.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,559.39
|
| Rate for Payer: Cash Price |
$2,487.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,741.78
|
| Rate for Payer: Heritage Provider Network Senior |
$3,741.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,000.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,381.75
|
| Rate for Payer: Multiplan Commercial |
$4,145.25
|
|
|
HC ADJ GASTRIC BAND DIAM VIA PORT
|
Facility
|
OP
|
$2,772.00
|
|
|
Service Code
|
CPT 43999
|
| Hospital Charge Code |
906743999
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$501.73 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$554.40
|
| Rate for Payer: Adventist Health Commercial |
$1,105.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,415.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,713.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,749.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,749.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,283.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,283.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,166.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,166.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,992.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,992.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,316.70
|
| Rate for Payer: Blue Shield of California Commercial |
$2,625.32
|
| Rate for Payer: Blue Shield of California EPN |
$1,047.82
|
| Rate for Payer: Blue Shield of California EPN |
$2,089.21
|
| Rate for Payer: Cash Price |
$2,487.15
|
| Rate for Payer: Cash Price |
$2,487.15
|
| Rate for Payer: Cash Price |
$1,247.40
|
| Rate for Payer: Cash Price |
$2,487.15
|
| Rate for Payer: Cash Price |
$1,247.40
|
| Rate for Payer: Cash Price |
$1,247.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,801.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,592.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,749.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,749.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,283.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,283.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,166.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,166.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,166.53
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,166.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,741.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,876.64
|
| Rate for Payer: Heritage Provider Network Senior |
$3,741.78
|
| Rate for Payer: Heritage Provider Network Senior |
$1,876.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,166.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,166.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,636.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,322.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,000.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$501.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,341.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,341.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,381.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$693.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,563.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,563.15
|
| Rate for Payer: Multiplan Commercial |
$4,145.25
|
| Rate for Payer: Multiplan Commercial |
$2,079.00
|
| Rate for Payer: Multiplan WC |
$1,898.06
|
| Rate for Payer: Multiplan WC |
$1,898.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,663.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,316.20
|
| Rate for Payer: TriValley Medical Group Senior |
$3,316.20
|
| Rate for Payer: TriValley Medical Group Senior |
$1,663.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,749.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,749.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,283.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,283.18
|
| Rate for Payer: Vantage Medical Group Senior |
$1,166.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1,166.53
|
|
|
HC ADJ GASTRIC BAND DIAM VIA PORT
|
Facility
|
OP
|
$1,649.00
|
|
|
Service Code
|
CPT S2083
|
| Hospital Charge Code |
909020143
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$298.47 |
| Max. Negotiated Rate |
$8,962.13 |
| Rate for Payer: Adventist Health Commercial |
$329.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,019.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,401.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$906.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,236.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$742.05
|
| Rate for Payer: Cash Price |
$742.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,071.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,401.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,401.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,401.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$989.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,020.73
|
| Rate for Payer: Heritage Provider Network Senior |
$1,020.73
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$786.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$298.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$412.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,154.30
|
| Rate for Payer: Multiplan Commercial |
$1,236.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$824.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$824.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,401.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,401.65
|
| Rate for Payer: Vantage Medical Group Senior |
$1,401.65
|
|
|
HC ADJ GASTRIC BAND DIAM VIA PORT
|
Facility
|
IP
|
$5,527.00
|
|
|
Service Code
|
CPT 43999
|
| Hospital Charge Code |
906743999
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,000.39 |
| Max. Negotiated Rate |
$4,145.25 |
| Rate for Payer: Adventist Health Commercial |
$1,105.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,559.39
|
| Rate for Payer: Cash Price |
$2,487.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,741.78
|
| Rate for Payer: Heritage Provider Network Senior |
$3,741.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,000.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,381.75
|
| Rate for Payer: Multiplan Commercial |
$4,145.25
|
|
|
HC ADJ GASTRIC BAND DIAM VIA PORT
|
Facility
|
OP
|
$5,527.00
|
|
|
Service Code
|
CPT 43999
|
| Hospital Charge Code |
906743999
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$425.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,105.40
|
| Rate for Payer: Adventist Health Commercial |
$554.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,713.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,415.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,749.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,749.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,283.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,283.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,166.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,166.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,764.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,386.55
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$2,487.15
|
| Rate for Payer: Cash Price |
$1,247.40
|
| Rate for Payer: Cash Price |
$1,247.40
|
| Rate for Payer: Cash Price |
$2,487.15
|
| Rate for Payer: Cash Price |
$1,247.40
|
| Rate for Payer: Cash Price |
$2,487.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,801.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,592.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,749.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,749.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,283.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,283.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,166.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,166.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,166.53
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,166.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,421.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,715.87
|
| Rate for Payer: Heritage Provider Network Senior |
$1,434.83
|
| Rate for Payer: Heritage Provider Network Senior |
$1,434.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,166.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,166.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,322.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,636.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,000.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$501.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,341.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,341.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$693.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,381.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,563.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,563.15
|
| Rate for Payer: Multiplan Commercial |
$4,145.25
|
| Rate for Payer: Multiplan Commercial |
$2,079.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$425.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$425.00
|
| Rate for Payer: TriValley Medical Group Senior |
$425.00
|
| Rate for Payer: TriValley Medical Group Senior |
$425.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,749.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,749.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,283.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,283.18
|
| Rate for Payer: Vantage Medical Group Senior |
$1,166.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1,166.53
|
|
|
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: Aetna of CA Non-Gatekeeper |
$4,723.10
|
| Rate for Payer: Cash Price |
$3,300.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,965.12
|
| Rate for Payer: Heritage Provider Network Senior |
$4,965.12
|
| Rate for Payer: Kaiser Foundation Hospitals 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 ADJ TISS TRNSFR 10 SQ CM OR LT
|
Facility
|
OP
|
$7,334.00
|
|
|
Service Code
|
CPT 14060
|
| Hospital Charge Code |
900501331
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,327.45 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,466.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,532.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,653.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,245.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,483.65
|
| Rate for Payer: Blue Shield of California EPN |
$2,772.25
|
| Rate for Payer: Cash Price |
$3,300.30
|
| Rate for Payer: Cash Price |
$3,300.30
|
| Rate for Payer: Cash Price |
$3,300.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,767.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,919.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,653.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,653.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,965.12
|
| Rate for Payer: Heritage Provider Network Senior |
$4,965.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3,498.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,327.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,051.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,833.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,555.98
|
| Rate for Payer: Multiplan Commercial |
$5,500.50
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,400.40
|
| Rate for Payer: TriValley Medical Group Senior |
$4,400.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2,653.72
|
|
|
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 Non-Gatekeeper |
$151.41
|
| 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 |
$2,144.00
|
| 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 |
$110.25
|
| Rate for Payer: Cash Price |
$110.25
|
| Rate for Payer: Cash Price |
$110.25
|
| 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 Medicare Advantage |
$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 |
$67.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,498.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$44.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 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: Aetna of CA Non-Gatekeeper |
$157.78
|
| Rate for Payer: Cash Price |
$110.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$165.87
|
| Rate for Payer: Heritage Provider Network Senior |
$165.87
|
| Rate for Payer: Kaiser Foundation Hospitals 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 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: Aetna of CA Non-Gatekeeper |
$173.24
|
| Rate for Payer: Cash Price |
$121.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$182.11
|
| Rate for Payer: Heritage Provider Network Senior |
$182.11
|
| Rate for Payer: Kaiser Foundation Hospitals 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 Non-Gatekeeper |
$166.24
|
| 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 |
$2,144.00
|
| 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 |
$121.05
|
| Rate for Payer: Cash Price |
$121.05
|
| Rate for Payer: Cash Price |
$121.05
|
| 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 Medicare Advantage |
$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 |
$67.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,498.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$48.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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: Aetna of CA Non-Gatekeeper |
$173.24
|
| Rate for Payer: Cash Price |
$121.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$182.11
|
| Rate for Payer: Heritage Provider Network Senior |
$182.11
|
| Rate for Payer: Kaiser Foundation Hospitals 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 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 Non-Gatekeeper |
$166.24
|
| 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 |
$2,144.00
|
| 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 |
$121.05
|
| Rate for Payer: Cash Price |
$121.05
|
| Rate for Payer: Cash Price |
$121.05
|
| 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 Medicare Advantage |
$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 |
$67.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,498.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$48.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 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 Non-Gatekeeper |
$151.41
|
| 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 |
$2,144.00
|
| 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 |
$110.25
|
| Rate for Payer: Cash Price |
$110.25
|
| Rate for Payer: Cash Price |
$110.25
|
| 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 Medicare Advantage |
$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 |
$67.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,498.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$44.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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: Aetna of CA Non-Gatekeeper |
$157.78
|
| Rate for Payer: Cash Price |
$110.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$165.87
|
| Rate for Payer: Heritage Provider Network Senior |
$165.87
|
| Rate for Payer: Kaiser Foundation Hospitals 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 Non-Gatekeeper |
$168.10
|
| 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 |
$2,144.00
|
| 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 |
$122.40
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Cash Price |
$122.40
|
| 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 Medicare Advantage |
$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 |
$67.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,498.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$49.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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: Aetna of CA Non-Gatekeeper |
$175.17
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$184.14
|
| Rate for Payer: Heritage Provider Network Senior |
$184.14
|
| Rate for Payer: Kaiser Foundation Hospitals 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
|
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 Non-Gatekeeper |
$151.41
|
| 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 |
$2,144.00
|
| 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 |
$110.25
|
| Rate for Payer: Cash Price |
$110.25
|
| Rate for Payer: Cash Price |
$110.25
|
| 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 Medicare Advantage |
$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 |
$67.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,498.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$44.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 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: Aetna of CA Non-Gatekeeper |
$157.78
|
| Rate for Payer: Cash Price |
$110.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$165.87
|
| Rate for Payer: Heritage Provider Network Senior |
$165.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$44.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.25
|
| Rate for Payer: Multiplan Commercial |
$183.75
|
|
|
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: Aetna of CA Non-Gatekeeper |
$486.86
|
| Rate for Payer: Cash Price |
$340.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$511.81
|
| Rate for Payer: Heritage Provider Network Senior |
$511.81
|
| Rate for Payer: Kaiser Foundation Hospitals 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 Non-Gatekeeper |
$467.21
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$378.15
|
| 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 |
$340.20
|
| 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 Medicare Advantage |
$642.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$446.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$467.96
|
| Rate for Payer: Heritage Provider Network Senior |
$467.96
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$360.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$136.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 Non-Gatekeeper |
$493.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$450.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$330.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$300.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$399.66
|
| 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 |
$359.55
|
| Rate for Payer: Cash Price |
$359.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$519.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$450.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$330.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$300.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$519.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$300.11
|
| 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) Medicare Advantage |
$300.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$381.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$144.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$345.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$199.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$402.15
|
| Rate for Payer: Multiplan Commercial |
$599.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$330.12
|
| Rate for Payer: TriValley Medical Group Senior |
$300.11
|
| 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 |
$450.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$330.12
|
| Rate for Payer: Vantage Medical Group Senior |
$300.11
|
|
|
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: Aetna of CA Non-Gatekeeper |
$514.56
|
| Rate for Payer: Cash Price |
$359.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$540.92
|
| Rate for Payer: Heritage Provider Network Senior |
$540.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$144.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$199.75
|
| Rate for Payer: Multiplan Commercial |
$599.25
|
|
|
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: Aetna of CA Non-Gatekeeper |
$45.72
|
| Rate for Payer: Cash Price |
$31.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.07
|
| Rate for Payer: Heritage Provider Network Senior |
$48.07
|
| Rate for Payer: Kaiser Foundation Hospitals 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 Non-Gatekeeper |
$43.88
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$35.51
|
| 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 |
$31.95
|
| 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 Medicare Advantage |
$60.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$43.95
|
| Rate for Payer: Heritage Provider Network Senior |
$43.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$33.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
