|
HC ALLOGRAFT, MRSLZD, OR PLCMT OF OP MTRL FOR SPNE SX
|
Facility
OP
|
$20,441.00
|
|
|
Service Code
|
CPT 20930
|
| Hospital Charge Code |
909000930
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$874.00 |
| Max. Negotiated Rate |
$17,374.85 |
| Rate for Payer: Adventist Health Commercial |
$4,088.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14,042.97
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17,374.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11,242.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15,330.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,517.28
|
| Rate for Payer: Blue Shield of California EPN |
$3,022.94
|
| Rate for Payer: Cash Price |
$9,198.45
|
| Rate for Payer: Cash Price |
$9,198.45
|
| Rate for Payer: Cash Price |
$9,198.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13,286.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17,374.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$17,374.85
|
| Rate for Payer: Dignity Health Senior |
$17,374.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$12,652.98
|
| Rate for Payer: Heritage Provider Network Senior |
$12,652.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,852.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,699.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,110.25
|
| Rate for Payer: Multiplan Commercial |
$15,330.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,040.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$874.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17,374.85
|
| Rate for Payer: Vantage Medical Group Senior |
$17,374.85
|
|
|
HC ALLOGRAFT, MRSLZD, OR PLCMT OF OP MTRL FOR SPNE SX
|
Facility
IP
|
$20,441.00
|
|
|
Service Code
|
CPT 20930
|
| Hospital Charge Code |
909000930
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,699.82 |
| Max. Negotiated Rate |
$15,330.75 |
| Rate for Payer: Adventist Health Commercial |
$4,088.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14,042.97
|
| Rate for Payer: Cash Price |
$9,198.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$13,838.56
|
| Rate for Payer: Heritage Provider Network Senior |
$13,838.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,699.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,110.25
|
| Rate for Payer: Multiplan Commercial |
$15,330.75
|
|
|
HC ALLOPATCH MTF 1.5CMX1.5CM AG DRML MTX
|
Facility
IP
|
$363.00
|
|
|
Service Code
|
CPT Q4128
|
| Hospital Charge Code |
900104022
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$65.70 |
| Max. Negotiated Rate |
$272.25 |
| Rate for Payer: Adventist Health Commercial |
$72.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$249.38
|
| Rate for Payer: Cash Price |
$163.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$166.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$196.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$245.75
|
| Rate for Payer: Heritage Provider Network Senior |
$245.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$65.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.75
|
| Rate for Payer: Multiplan Commercial |
$272.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$132.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$121.28
|
|
|
HC ALLOPATCH MTF 1.5CMX1.5CM AG DRML MTX
|
Facility
OP
|
$363.00
|
|
|
Service Code
|
CPT Q4128
|
| Hospital Charge Code |
900104022
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.86 |
| Max. Negotiated Rate |
$308.55 |
| Rate for Payer: Adventist Health Commercial |
$72.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$75.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$249.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$308.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$199.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$272.25
|
| Rate for Payer: Blue Shield of California Commercial |
$225.42
|
| Rate for Payer: Blue Shield of California EPN |
$213.08
|
| Rate for Payer: Cash Price |
$163.35
|
| Rate for Payer: Cash Price |
$163.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$166.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$308.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$308.55
|
| Rate for Payer: Dignity Health Senior |
$308.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$232.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$168.07
|
| Rate for Payer: Heritage Provider Network Senior |
$168.07
|
| Rate for Payer: IEHP Medi-Cal |
$47.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$174.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$65.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.75
|
| Rate for Payer: Multiplan Commercial |
$272.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$132.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$121.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$308.55
|
| Rate for Payer: Vantage Medical Group Senior |
$308.55
|
|
|
HC ALLOPATCH MTF 2.0CMX2.0CM AG DRML MTX
|
Facility
IP
|
$409.00
|
|
|
Service Code
|
CPT Q4128
|
| Hospital Charge Code |
900104023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$74.03 |
| Max. Negotiated Rate |
$306.75 |
| Rate for Payer: Adventist Health Commercial |
$81.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$280.98
|
| Rate for Payer: Cash Price |
$184.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$188.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$220.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$276.89
|
| Rate for Payer: Heritage Provider Network Senior |
$276.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$74.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$102.25
|
| Rate for Payer: Multiplan Commercial |
$306.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$149.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$136.65
|
|
|
HC ALLOPATCH MTF 2.0CMX2.0CM AG DRML MTX
|
Facility
OP
|
$409.00
|
|
|
Service Code
|
CPT Q4128
|
| Hospital Charge Code |
900104023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.86 |
| Max. Negotiated Rate |
$347.65 |
| Rate for Payer: Adventist Health Commercial |
$81.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$75.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$280.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$347.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$224.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$306.75
|
| Rate for Payer: Blue Shield of California Commercial |
$253.99
|
| Rate for Payer: Blue Shield of California EPN |
$240.08
|
| Rate for Payer: Cash Price |
$184.05
|
| Rate for Payer: Cash Price |
$184.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$188.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$347.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$347.65
|
| Rate for Payer: Dignity Health Senior |
$347.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$261.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$189.37
|
| Rate for Payer: Heritage Provider Network Senior |
$189.37
|
| Rate for Payer: IEHP Medi-Cal |
$47.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$197.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$74.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$102.25
|
| Rate for Payer: Multiplan Commercial |
$306.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$149.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$136.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$347.65
|
| Rate for Payer: Vantage Medical Group Senior |
$347.65
|
|
|
HC ALLOPATCH MTF 4.0CMX4.0CM AG DRML MTX
|
Facility
IP
|
$248.00
|
|
|
Service Code
|
CPT Q4128
|
| Hospital Charge Code |
900104024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.89 |
| Max. Negotiated Rate |
$186.00 |
| Rate for Payer: Adventist Health Commercial |
$49.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$170.38
|
| Rate for Payer: Cash Price |
$111.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$114.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$133.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$167.90
|
| Rate for Payer: Heritage Provider Network Senior |
$167.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.00
|
| Rate for Payer: Multiplan Commercial |
$186.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$90.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$82.86
|
|
|
HC ALLOPATCH MTF 4.0CMX4.0CM AG DRML MTX
|
Facility
OP
|
$248.00
|
|
|
Service Code
|
CPT Q4128
|
| Hospital Charge Code |
900104024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.89 |
| Max. Negotiated Rate |
$210.80 |
| Rate for Payer: Adventist Health Commercial |
$49.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$75.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$170.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$210.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$136.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$186.00
|
| Rate for Payer: Blue Shield of California Commercial |
$154.01
|
| Rate for Payer: Blue Shield of California EPN |
$145.58
|
| Rate for Payer: Cash Price |
$111.60
|
| Rate for Payer: Cash Price |
$111.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$114.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$210.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$210.80
|
| Rate for Payer: Dignity Health Senior |
$210.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$158.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$114.82
|
| Rate for Payer: Heritage Provider Network Senior |
$114.82
|
| Rate for Payer: IEHP Medi-Cal |
$47.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$119.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.00
|
| Rate for Payer: Multiplan Commercial |
$186.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$90.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$82.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$210.80
|
| Rate for Payer: Vantage Medical Group Senior |
$210.80
|
|
|
HC ALLOPATCH MTF 4.0CMX8.0CM AG DRML MTX
|
Facility
IP
|
$158.00
|
|
|
Service Code
|
CPT Q4128
|
| Hospital Charge Code |
900104025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.60 |
| Max. Negotiated Rate |
$118.50 |
| Rate for Payer: Adventist Health Commercial |
$31.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$108.55
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$106.97
|
| Rate for Payer: Heritage Provider Network Senior |
$106.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.50
|
| Rate for Payer: Multiplan Commercial |
$118.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$57.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$52.79
|
|
|
HC ALLOPATCH MTF 4.0CMX8.0CM AG DRML MTX
|
Facility
OP
|
$158.00
|
|
|
Service Code
|
CPT Q4128
|
| Hospital Charge Code |
900104025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.60 |
| Max. Negotiated Rate |
$134.30 |
| Rate for Payer: Adventist Health Commercial |
$31.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$75.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$108.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$134.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$86.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$118.50
|
| Rate for Payer: Blue Shield of California Commercial |
$98.12
|
| Rate for Payer: Blue Shield of California EPN |
$92.75
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$134.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$134.30
|
| Rate for Payer: Dignity Health Senior |
$134.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$101.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$73.15
|
| Rate for Payer: Heritage Provider Network Senior |
$73.15
|
| Rate for Payer: IEHP Medi-Cal |
$47.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$76.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.50
|
| Rate for Payer: Multiplan Commercial |
$118.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$57.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$52.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$134.30
|
| Rate for Payer: Vantage Medical Group Senior |
$134.30
|
|
|
HC ALPHA 1 ANTITRYPSN
|
Facility
IP
|
$156.00
|
|
|
Service Code
|
CPT 82103
|
| Hospital Charge Code |
900910838
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$28.24 |
| Max. Negotiated Rate |
$117.00 |
| Rate for Payer: Adventist Health Commercial |
$31.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$107.17
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$105.61
|
| Rate for Payer: Heritage Provider Network Senior |
$105.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.00
|
| Rate for Payer: Multiplan Commercial |
$117.00
|
|
|
HC ALPHA 1 ANTITRYPSN
|
Facility
OP
|
$52.00
|
|
|
Service Code
|
CPT 82103
|
| Hospital Charge Code |
900910838
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.41 |
| Max. Negotiated Rate |
$112.36 |
| Rate for Payer: Adventist Health Commercial |
$10.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$39.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.72
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$20.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$112.36
|
| Rate for Payer: Blue Shield of California Commercial |
$104.92
|
| Rate for Payer: Blue Shield of California EPN |
$82.02
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.78
|
| Rate for Payer: Dignity Health Senior |
$13.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.19
|
| Rate for Payer: Heritage Provider Network Senior |
$32.19
|
| Rate for Payer: Humana Medicare |
$13.44
|
| Rate for Payer: IEHP Medi-Cal |
$18.63
|
| Rate for Payer: IEHP Medicare Advantage |
$13.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$25.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.93
|
| Rate for Payer: Multiplan Commercial |
$39.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.44
|
| Rate for Payer: TriValley Medical Group Senior |
$13.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.78
|
| Rate for Payer: Vantage Medical Group Senior |
$13.44
|
|
|
HC ALPHA-FETOPROTEIN BLOOD
|
Facility
IP
|
$244.00
|
|
|
Service Code
|
CPT 82105
|
| Hospital Charge Code |
900910947
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$44.16 |
| Max. Negotiated Rate |
$183.00 |
| Rate for Payer: Adventist Health Commercial |
$48.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$167.63
|
| Rate for Payer: Cash Price |
$109.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$165.19
|
| Rate for Payer: Heritage Provider Network Senior |
$165.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.00
|
| Rate for Payer: Multiplan Commercial |
$183.00
|
|
|
HC ALPHA-FETOPROTEIN BLOOD
|
Facility
OP
|
$60.00
|
|
|
Service Code
|
CPT 82105
|
| Hospital Charge Code |
900910947
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.86 |
| Max. Negotiated Rate |
$140.43 |
| Rate for Payer: Adventist Health Commercial |
$12.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$48.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$25.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$140.43
|
| Rate for Payer: Blue Shield of California Commercial |
$131.03
|
| Rate for Payer: Blue Shield of California EPN |
$102.43
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$39.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.45
|
| Rate for Payer: Dignity Health Senior |
$16.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.14
|
| Rate for Payer: Heritage Provider Network Senior |
$37.14
|
| Rate for Payer: Humana Medicare |
$16.77
|
| Rate for Payer: IEHP Medi-Cal |
$132.60
|
| Rate for Payer: IEHP Medicare Advantage |
$16.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$31.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.13
|
| Rate for Payer: Multiplan Commercial |
$45.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.77
|
| Rate for Payer: TriValley Medical Group Senior |
$16.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.45
|
| Rate for Payer: Vantage Medical Group Senior |
$16.77
|
|
|
HC ALT
|
Facility
IP
|
$89.00
|
|
|
Service Code
|
CPT 84460
|
| Hospital Charge Code |
900910233
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.11 |
| Max. Negotiated Rate |
$66.75 |
| Rate for Payer: Adventist Health Commercial |
$17.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$61.14
|
| Rate for Payer: Cash Price |
$40.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.25
|
| Rate for Payer: Heritage Provider Network Senior |
$60.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.25
|
| Rate for Payer: Multiplan Commercial |
$66.75
|
|
|
HC ALT
|
Facility
OP
|
$15.00
|
|
|
Service Code
|
CPT 84460
|
| Hospital Charge Code |
900910233
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$43.78 |
| Rate for Payer: Adventist Health Commercial |
$3.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$43.78
|
| Rate for Payer: Blue Shield of California Commercial |
$41.37
|
| Rate for Payer: Blue Shield of California EPN |
$32.34
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.83
|
| Rate for Payer: Dignity Health Senior |
$5.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$5.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.28
|
| Rate for Payer: Heritage Provider Network Senior |
$9.28
|
| Rate for Payer: Humana Medicare |
$5.30
|
| Rate for Payer: IEHP Medi-Cal |
$7.14
|
| Rate for Payer: IEHP Medicare Advantage |
$5.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.68
|
| Rate for Payer: Multiplan Commercial |
$11.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.30
|
| Rate for Payer: TriValley Medical Group Senior |
$5.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.83
|
| Rate for Payer: Vantage Medical Group Senior |
$5.30
|
|
|
HC ALT SINGLE
|
Facility
IP
|
$89.00
|
|
|
Service Code
|
CPT 84460
|
| Hospital Charge Code |
900910510
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.11 |
| Max. Negotiated Rate |
$66.75 |
| Rate for Payer: Adventist Health Commercial |
$17.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$61.14
|
| Rate for Payer: Cash Price |
$40.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.25
|
| Rate for Payer: Heritage Provider Network Senior |
$60.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.25
|
| Rate for Payer: Multiplan Commercial |
$66.75
|
|
|
HC ALT SINGLE
|
Facility
OP
|
$15.00
|
|
|
Service Code
|
CPT 84460
|
| Hospital Charge Code |
900910510
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$43.78 |
| Rate for Payer: Adventist Health Commercial |
$3.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$43.78
|
| Rate for Payer: Blue Shield of California Commercial |
$41.37
|
| Rate for Payer: Blue Shield of California EPN |
$32.34
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.83
|
| Rate for Payer: Dignity Health Senior |
$5.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$5.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.28
|
| Rate for Payer: Heritage Provider Network Senior |
$9.28
|
| Rate for Payer: Humana Medicare |
$5.30
|
| Rate for Payer: IEHP Medi-Cal |
$7.14
|
| Rate for Payer: IEHP Medicare Advantage |
$5.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.68
|
| Rate for Payer: Multiplan Commercial |
$11.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.30
|
| Rate for Payer: TriValley Medical Group Senior |
$5.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.83
|
| Rate for Payer: Vantage Medical Group Senior |
$5.30
|
|
|
HC AMIKACIN
|
Facility
IP
|
$176.00
|
|
|
Service Code
|
CPT 80150
|
| Hospital Charge Code |
900910405
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.86 |
| Max. Negotiated Rate |
$132.00 |
| Rate for Payer: Adventist Health Commercial |
$35.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$120.91
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$119.15
|
| Rate for Payer: Heritage Provider Network Senior |
$119.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.00
|
| Rate for Payer: Multiplan Commercial |
$132.00
|
|
|
HC AMIKACIN
|
Facility
OP
|
$50.00
|
|
|
Service Code
|
CPT 80150
|
| Hospital Charge Code |
900910405
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$126.17 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$22.62
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$16.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$126.17
|
| Rate for Payer: Blue Shield of California Commercial |
$117.73
|
| Rate for Payer: Blue Shield of California EPN |
$92.03
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.59
|
| Rate for Payer: Dignity Health Senior |
$15.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$15.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.95
|
| Rate for Payer: Heritage Provider Network Senior |
$30.95
|
| Rate for Payer: Humana Medicare |
$15.08
|
| Rate for Payer: IEHP Medi-Cal |
$20.90
|
| Rate for Payer: IEHP Medicare Advantage |
$15.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$28.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$19.00
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.08
|
| Rate for Payer: TriValley Medical Group Senior |
$15.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.59
|
| Rate for Payer: Vantage Medical Group Senior |
$15.08
|
|
|
HC AMMONIA
|
Facility
IP
|
$406.00
|
|
|
Service Code
|
CPT 82140
|
| Hospital Charge Code |
900910276
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$73.49 |
| Max. Negotiated Rate |
$304.50 |
| Rate for Payer: Adventist Health Commercial |
$81.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$278.92
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$274.86
|
| Rate for Payer: Heritage Provider Network Senior |
$274.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$73.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$101.50
|
| Rate for Payer: Multiplan Commercial |
$304.50
|
|
|
HC AMMONIA
|
Facility
OP
|
$56.00
|
|
|
Service Code
|
CPT 82140
|
| Hospital Charge Code |
900910276
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$122.00 |
| Rate for Payer: Adventist Health Commercial |
$11.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$42.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$21.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$16.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$122.00
|
| Rate for Payer: Blue Shield of California Commercial |
$113.81
|
| Rate for Payer: Blue Shield of California EPN |
$88.97
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.03
|
| Rate for Payer: Dignity Health Senior |
$14.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$14.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.66
|
| Rate for Payer: Heritage Provider Network Senior |
$34.66
|
| Rate for Payer: Humana Medicare |
$14.57
|
| Rate for Payer: IEHP Medi-Cal |
$20.20
|
| Rate for Payer: IEHP Medicare Advantage |
$14.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$27.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.36
|
| Rate for Payer: Multiplan Commercial |
$42.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.57
|
| Rate for Payer: TriValley Medical Group Senior |
$14.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.03
|
| Rate for Payer: Vantage Medical Group Senior |
$14.57
|
|
|
HC AMNIOBAND MTF 10MM MEMBRANE AG MTX DISK
|
Facility
OP
|
$618.00
|
|
|
Service Code
|
CPT Q4151
|
| Hospital Charge Code |
900104026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$111.86 |
| Max. Negotiated Rate |
$525.30 |
| Rate for Payer: Adventist Health Commercial |
$123.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$326.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$424.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$525.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$339.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$463.50
|
| Rate for Payer: Blue Shield of California Commercial |
$383.78
|
| Rate for Payer: Blue Shield of California EPN |
$362.77
|
| Rate for Payer: Cash Price |
$278.10
|
| Rate for Payer: Cash Price |
$278.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$284.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$525.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$525.30
|
| Rate for Payer: Dignity Health Senior |
$525.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$395.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$286.13
|
| Rate for Payer: Heritage Provider Network Senior |
$286.13
|
| Rate for Payer: IEHP Medi-Cal |
$188.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$297.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$111.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.50
|
| Rate for Payer: Multiplan Commercial |
$463.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$225.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$206.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$525.30
|
| Rate for Payer: Vantage Medical Group Senior |
$525.30
|
|
|
HC AMNIOBAND MTF 10MM MEMBRANE AG MTX DISK
|
Facility
IP
|
$618.00
|
|
|
Service Code
|
CPT Q4151
|
| Hospital Charge Code |
900104026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$111.86 |
| Max. Negotiated Rate |
$463.50 |
| Rate for Payer: Adventist Health Commercial |
$123.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$424.57
|
| Rate for Payer: Cash Price |
$278.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$284.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$333.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$418.39
|
| Rate for Payer: Heritage Provider Network Senior |
$418.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$111.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.50
|
| Rate for Payer: Multiplan Commercial |
$463.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$225.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$206.47
|
|
|
HC AMNIOBAND MTF 14MM MEMBRANE AG MTX DISK
|
Facility
OP
|
$900.00
|
|
|
Service Code
|
CPT Q4151
|
| Hospital Charge Code |
900104027
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$162.90 |
| Max. Negotiated Rate |
$765.00 |
| Rate for Payer: Adventist Health Commercial |
$180.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$326.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$618.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$765.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$495.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$675.00
|
| Rate for Payer: Blue Shield of California Commercial |
$558.90
|
| Rate for Payer: Blue Shield of California EPN |
$528.30
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$414.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$765.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$765.00
|
| Rate for Payer: Dignity Health Senior |
$765.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$576.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$416.70
|
| Rate for Payer: Heritage Provider Network Senior |
$416.70
|
| Rate for Payer: IEHP Medi-Cal |
$188.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$433.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$162.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$225.00
|
| Rate for Payer: Multiplan Commercial |
$675.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$328.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$300.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$765.00
|
| Rate for Payer: Vantage Medical Group Senior |
$765.00
|
|
