|
HC CUTTING BALLOON
|
Facility
|
IP
|
$1,920.00
|
|
|
Service Code
|
CPT C1714
|
| Hospital Charge Code |
909080044
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$347.52 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Adventist Health Commercial |
$384.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,319.04
|
| Rate for Payer: Cash Price |
$864.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,299.84
|
| Rate for Payer: Heritage Provider Network Senior |
$1,299.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$347.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$480.00
|
| Rate for Payer: Multiplan Commercial |
$1,440.00
|
|
|
HC CVP-R & L TESSO CATH
|
Facility
|
OP
|
$1,019.00
|
|
|
Service Code
|
CPT C1750
|
| Hospital Charge Code |
909081702
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$184.44 |
| Max. Negotiated Rate |
$1,016.87 |
| Rate for Payer: Adventist Health Commercial |
$203.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,016.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$700.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$866.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$560.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$764.25
|
| Rate for Payer: Blue Shield of California Commercial |
$632.80
|
| Rate for Payer: Blue Shield of California EPN |
$598.15
|
| Rate for Payer: Cash Price |
$458.55
|
| Rate for Payer: Cash Price |
$458.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$662.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$866.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$866.15
|
| Rate for Payer: Dignity Health Senior |
$866.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$662.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$630.76
|
| Rate for Payer: Heritage Provider Network Senior |
$630.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$491.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$184.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$254.75
|
| Rate for Payer: Multiplan Commercial |
$764.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$866.15
|
| Rate for Payer: Vantage Medical Group Senior |
$866.15
|
|
|
HC CVP-R & L TESSO CATH
|
Facility
|
IP
|
$1,019.00
|
|
|
Service Code
|
CPT C1750
|
| Hospital Charge Code |
909081702
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$184.44 |
| Max. Negotiated Rate |
$764.25 |
| Rate for Payer: Adventist Health Commercial |
$203.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$700.05
|
| Rate for Payer: Cash Price |
$458.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$689.86
|
| Rate for Payer: Heritage Provider Network Senior |
$689.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$184.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$254.75
|
| Rate for Payer: Multiplan Commercial |
$764.25
|
|
|
HC CYCLIC CITRUL PEPT AB
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
CPT 86200
|
| Hospital Charge Code |
900913652
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$106.00 |
| Rate for Payer: Adventist Health Commercial |
$7.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$37.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$106.00
|
| Rate for Payer: Blue Shield of California Commercial |
$101.12
|
| Rate for Payer: Blue Shield of California EPN |
$79.05
|
| Rate for Payer: Cash Price |
$17.55
|
| Rate for Payer: Cash Price |
$17.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.24
|
| Rate for Payer: Dignity Health Senior |
$12.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.14
|
| Rate for Payer: Heritage Provider Network Senior |
$24.14
|
| Rate for Payer: Humana Medicare |
$12.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$24.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.32
|
| Rate for Payer: Multiplan Commercial |
$29.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.95
|
| Rate for Payer: TriValley Medical Group Senior |
$12.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.24
|
| Rate for Payer: Vantage Medical Group Senior |
$12.95
|
|
|
HC CYCLIC CITRUL PEPT AB
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 86200
|
| Hospital Charge Code |
900913652
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$43.50 |
| Rate for Payer: Adventist Health Commercial |
$11.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$39.85
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$39.27
|
| Rate for Payer: Heritage Provider Network Senior |
$39.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.50
|
| Rate for Payer: Multiplan Commercial |
$43.50
|
|
|
HC CYCLOSPORINE A (EMIT)
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
CPT 80158
|
| Hospital Charge Code |
900910933
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.49 |
| Max. Negotiated Rate |
$151.13 |
| Rate for Payer: Adventist Health Commercial |
$13.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$52.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$47.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$151.13
|
| Rate for Payer: Blue Shield of California Commercial |
$141.04
|
| Rate for Payer: Blue Shield of California EPN |
$110.26
|
| Rate for Payer: Cash Price |
$31.05
|
| Rate for Payer: Cash Price |
$31.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.86
|
| Rate for Payer: Dignity Health Senior |
$18.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$42.71
|
| Rate for Payer: Heritage Provider Network Senior |
$42.71
|
| Rate for Payer: Humana Medicare |
$18.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$34.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.74
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.74
|
| Rate for Payer: Multiplan Commercial |
$51.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.05
|
| Rate for Payer: TriValley Medical Group Senior |
$18.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.86
|
| Rate for Payer: Vantage Medical Group Senior |
$18.05
|
|
|
HC CYCLOSPORINE A (EMIT)
|
Facility
|
IP
|
$248.00
|
|
|
Service Code
|
CPT 80158
|
| Hospital Charge Code |
900910933
|
|
Hospital Revenue Code
|
301
|
| 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: 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
|
|
|
HC CYSTOGRAM, INJECTION
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
909000171
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$104.66 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$132.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$104.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$453.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$561.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$363.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$495.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Blue Shield of California Commercial |
$409.86
|
| Rate for Payer: Blue Shield of California EPN |
$387.42
|
| Rate for Payer: Cash Price |
$297.00
|
| Rate for Payer: Cash Price |
$297.00
|
| Rate for Payer: Cash Price |
$297.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$429.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$561.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$561.00
|
| Rate for Payer: Dignity Health Senior |
$561.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$408.54
|
| Rate for Payer: Heritage Provider Network Senior |
$408.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$400.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$318.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$119.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$165.00
|
| Rate for Payer: Multiplan Commercial |
$495.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$561.00
|
| Rate for Payer: Vantage Medical Group Senior |
$561.00
|
|
|
HC CYSTOGRAM, INJECTION
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
909000171
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$119.46 |
| Max. Negotiated Rate |
$495.00 |
| Rate for Payer: Adventist Health Commercial |
$132.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$453.42
|
| Rate for Payer: Cash Price |
$297.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$446.82
|
| Rate for Payer: Heritage Provider Network Senior |
$446.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$119.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$165.00
|
| Rate for Payer: Multiplan Commercial |
$495.00
|
|
|
HC CYSTOGRAPH MIN 3 VIEWS
|
Facility
|
OP
|
$1,272.00
|
|
|
Service Code
|
CPT 74430
|
| Hospital Charge Code |
909001901
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$51.73 |
| Max. Negotiated Rate |
$954.00 |
| Rate for Payer: Adventist Health Commercial |
$254.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$101.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$873.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$720.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$528.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$480.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$251.38
|
| Rate for Payer: Blue Shield of California Commercial |
$216.27
|
| Rate for Payer: Blue Shield of California EPN |
$122.99
|
| Rate for Payer: Cash Price |
$572.40
|
| Rate for Payer: Cash Price |
$572.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$826.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$720.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$528.55
|
| Rate for Payer: Dignity Health Senior |
$480.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$826.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$480.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$787.37
|
| Rate for Payer: Heritage Provider Network Senior |
$787.37
|
| Rate for Payer: Humana Medicare |
$480.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$51.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$480.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$912.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$230.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$566.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$318.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$605.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$605.43
|
| Rate for Payer: Multiplan Commercial |
$954.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$480.50
|
| Rate for Payer: TriValley Medical Group Senior |
$480.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$294.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$294.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$720.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$528.55
|
| Rate for Payer: Vantage Medical Group Senior |
$480.50
|
|
|
HC CYSTOGRAPH MIN 3 VIEWS
|
Facility
|
IP
|
$1,272.00
|
|
|
Service Code
|
CPT 74430
|
| Hospital Charge Code |
909001901
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$230.23 |
| Max. Negotiated Rate |
$954.00 |
| Rate for Payer: Adventist Health Commercial |
$254.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$873.86
|
| Rate for Payer: Cash Price |
$572.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$861.14
|
| Rate for Payer: Heritage Provider Network Senior |
$861.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$230.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$318.00
|
| Rate for Payer: Multiplan Commercial |
$954.00
|
|
|
HC CYSTOSTOMY TUBE CHG SIMPLE
|
Facility
|
OP
|
$728.00
|
|
|
Service Code
|
CPT 51705
|
| Hospital Charge Code |
900501165
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$131.77 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$145.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$500.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$463.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$339.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$308.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$473.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$463.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$339.67
|
| Rate for Payer: Dignity Health Senior |
$308.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$308.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$492.86
|
| Rate for Payer: Heritage Provider Network Senior |
$492.86
|
| Rate for Payer: Humana Medicare |
$308.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$308.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$350.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$131.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$364.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$182.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$389.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$389.08
|
| Rate for Payer: Multiplan Commercial |
$546.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$264.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$243.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$463.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$339.67
|
| Rate for Payer: Vantage Medical Group Senior |
$308.79
|
|
|
HC CYSTOSTOMY TUBE CHG SIMPLE
|
Facility
|
IP
|
$728.00
|
|
|
Service Code
|
CPT 51705
|
| Hospital Charge Code |
900501165
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$131.77 |
| Max. Negotiated Rate |
$546.00 |
| Rate for Payer: Adventist Health Commercial |
$145.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$500.14
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$492.86
|
| Rate for Payer: Heritage Provider Network Senior |
$492.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$131.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$182.00
|
| Rate for Payer: Multiplan Commercial |
$546.00
|
|
|
HC CYSTOSTOMY W DRAINAGE
|
Facility
|
IP
|
$6,470.00
|
|
|
Service Code
|
CPT 51040
|
| Hospital Charge Code |
900551040
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,171.07 |
| Max. Negotiated Rate |
$4,852.50 |
| Rate for Payer: Adventist Health Commercial |
$1,294.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,444.89
|
| Rate for Payer: Cash Price |
$2,911.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,380.19
|
| Rate for Payer: Heritage Provider Network Senior |
$4,380.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,171.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,617.50
|
| Rate for Payer: Multiplan Commercial |
$4,852.50
|
|
|
HC CYSTOSTOMY W DRAINAGE
|
Facility
|
OP
|
$6,470.00
|
|
|
Service Code
|
CPT 51040
|
| Hospital Charge Code |
900551040
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$936.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,294.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,444.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,544.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Cash Price |
$2,911.50
|
| Rate for Payer: Cash Price |
$2,911.50
|
| Rate for Payer: Cash Price |
$2,911.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,205.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,799.36
|
| Rate for Payer: Dignity Health Senior |
$2,544.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,544.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,380.19
|
| Rate for Payer: Heritage Provider Network Senior |
$4,380.19
|
| Rate for Payer: Humana Medicare |
$2,544.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,544.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,118.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,171.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,002.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,617.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,206.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,206.54
|
| Rate for Payer: Multiplan Commercial |
$4,852.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,349.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,161.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Vantage Medical Group Senior |
$2,544.87
|
|
|
HC CYSTOSTOMY W INSERTION CATH OR STNT
|
Facility
|
OP
|
$2,470.00
|
|
|
Service Code
|
CPT 51045
|
| Hospital Charge Code |
900551045
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$447.07 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$494.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,696.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,544.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Cash Price |
$1,111.50
|
| Rate for Payer: Cash Price |
$1,111.50
|
| Rate for Payer: Cash Price |
$1,111.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,605.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,799.36
|
| Rate for Payer: Dignity Health Senior |
$2,544.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,544.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,672.19
|
| Rate for Payer: Heritage Provider Network Senior |
$1,672.19
|
| Rate for Payer: Humana Medicare |
$2,544.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,544.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,190.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$447.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,002.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$617.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,206.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,206.54
|
| Rate for Payer: Multiplan Commercial |
$1,852.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$896.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$825.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Vantage Medical Group Senior |
$2,544.87
|
|
|
HC CYSTOSTOMY W INSERTION CATH OR STNT
|
Facility
|
IP
|
$2,470.00
|
|
|
Service Code
|
CPT 51045
|
| Hospital Charge Code |
900551045
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$447.07 |
| Max. Negotiated Rate |
$1,852.50 |
| Rate for Payer: Adventist Health Commercial |
$494.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,696.89
|
| Rate for Payer: Cash Price |
$1,111.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,672.19
|
| Rate for Payer: Heritage Provider Network Senior |
$1,672.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$447.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$617.50
|
| Rate for Payer: Multiplan Commercial |
$1,852.50
|
|
|
HC CYSTOURETHROSCOPY
|
Facility
|
IP
|
$4,210.00
|
|
|
Service Code
|
CPT 52000
|
| Hospital Charge Code |
900501353
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$762.01 |
| Max. Negotiated Rate |
$3,157.50 |
| Rate for Payer: Adventist Health Commercial |
$842.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,892.27
|
| Rate for Payer: Cash Price |
$1,894.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,850.17
|
| Rate for Payer: Heritage Provider Network Senior |
$2,850.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$762.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,052.50
|
| Rate for Payer: Multiplan Commercial |
$3,157.50
|
|
|
HC CYSTOURETHROSCOPY
|
Facility
|
OP
|
$4,210.00
|
|
|
Service Code
|
CPT 52000
|
| Hospital Charge Code |
900501353
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$762.01 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$842.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,892.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,280.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$938.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$853.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Cash Price |
$1,894.50
|
| Rate for Payer: Cash Price |
$1,894.50
|
| Rate for Payer: Cash Price |
$1,894.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,736.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,280.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$938.85
|
| Rate for Payer: Dignity Health Senior |
$853.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$853.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,850.17
|
| Rate for Payer: Heritage Provider Network Senior |
$2,850.17
|
| Rate for Payer: Humana Medicare |
$853.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$853.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,029.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$762.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,007.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,052.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,075.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,075.41
|
| Rate for Payer: Multiplan Commercial |
$3,157.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,528.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,406.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,280.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$938.85
|
| Rate for Payer: Vantage Medical Group Senior |
$853.50
|
|
|
HC CYSTOURETHROSCOPY, W/DILATION
|
Facility
|
OP
|
$4,004.00
|
|
|
Service Code
|
CPT 52281
|
| Hospital Charge Code |
900501303
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$724.72 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$800.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,750.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,544.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Cash Price |
$1,801.80
|
| Rate for Payer: Cash Price |
$1,801.80
|
| Rate for Payer: Cash Price |
$1,801.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,602.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,799.36
|
| Rate for Payer: Dignity Health Senior |
$2,544.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,544.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,710.71
|
| Rate for Payer: Heritage Provider Network Senior |
$2,710.71
|
| Rate for Payer: Humana Medicare |
$2,544.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,544.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,929.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$724.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,002.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,001.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,206.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,206.54
|
| Rate for Payer: Multiplan Commercial |
$3,003.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,453.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,337.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Vantage Medical Group Senior |
$2,544.87
|
|
|
HC CYSTOURETHROSCOPY, W/DILATION
|
Facility
|
IP
|
$4,004.00
|
|
|
Service Code
|
CPT 52281
|
| Hospital Charge Code |
900501303
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$724.72 |
| Max. Negotiated Rate |
$3,003.00 |
| Rate for Payer: Adventist Health Commercial |
$800.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,750.75
|
| Rate for Payer: Cash Price |
$1,801.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,710.71
|
| Rate for Payer: Heritage Provider Network Senior |
$2,710.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$724.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,001.00
|
| Rate for Payer: Multiplan Commercial |
$3,003.00
|
|
|
HC CYSTOURETHROSCOPY W/RMVL F B
|
Facility
|
IP
|
$4,004.00
|
|
|
Service Code
|
CPT 52310
|
| Hospital Charge Code |
900501293
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$724.72 |
| Max. Negotiated Rate |
$3,003.00 |
| Rate for Payer: Adventist Health Commercial |
$800.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,750.75
|
| Rate for Payer: Cash Price |
$1,801.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,710.71
|
| Rate for Payer: Heritage Provider Network Senior |
$2,710.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$724.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,001.00
|
| Rate for Payer: Multiplan Commercial |
$3,003.00
|
|
|
HC CYSTOURETHROSCOPY W/RMVL F B
|
Facility
|
OP
|
$4,004.00
|
|
|
Service Code
|
CPT 52310
|
| Hospital Charge Code |
900501293
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$724.72 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$800.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,750.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,544.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Cash Price |
$1,801.80
|
| Rate for Payer: Cash Price |
$1,801.80
|
| Rate for Payer: Cash Price |
$1,801.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,602.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,799.36
|
| Rate for Payer: Dignity Health Senior |
$2,544.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,544.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,710.71
|
| Rate for Payer: Heritage Provider Network Senior |
$2,710.71
|
| Rate for Payer: Humana Medicare |
$2,544.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,544.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,929.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$724.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,002.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,001.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,206.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,206.54
|
| Rate for Payer: Multiplan Commercial |
$3,003.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,453.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,337.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Vantage Medical Group Senior |
$2,544.87
|
|
|
HC CYSTOURETHROSCOPY,W/UTERAL CAT
|
Facility
|
OP
|
$6,683.00
|
|
|
Service Code
|
CPT 52005
|
| Hospital Charge Code |
900501312
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$936.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,336.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,591.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,544.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Cash Price |
$3,007.35
|
| Rate for Payer: Cash Price |
$3,007.35
|
| Rate for Payer: Cash Price |
$3,007.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,343.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,799.36
|
| Rate for Payer: Dignity Health Senior |
$2,544.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,544.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,524.39
|
| Rate for Payer: Heritage Provider Network Senior |
$4,524.39
|
| Rate for Payer: Humana Medicare |
$2,544.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,544.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,221.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,209.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,002.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,670.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,206.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,206.54
|
| Rate for Payer: Multiplan Commercial |
$5,012.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,426.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,232.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Vantage Medical Group Senior |
$2,544.87
|
|
|
HC CYSTOURETHROSCOPY,W/UTERAL CAT
|
Facility
|
IP
|
$6,683.00
|
|
|
Service Code
|
CPT 52005
|
| Hospital Charge Code |
900501312
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,209.62 |
| Max. Negotiated Rate |
$5,012.25 |
| Rate for Payer: Adventist Health Commercial |
$1,336.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,591.22
|
| Rate for Payer: Cash Price |
$3,007.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,524.39
|
| Rate for Payer: Heritage Provider Network Senior |
$4,524.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,209.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,670.75
|
| Rate for Payer: Multiplan Commercial |
$5,012.25
|
|
