|
HC CESAREAN DELIVERY ONLY
|
Facility
|
IP
|
$7,016.00
|
|
|
Service Code
|
CPT 59514
|
| Hospital Charge Code |
900501514
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$1,269.90 |
| Max. Negotiated Rate |
$5,262.00 |
| Rate for Payer: Adventist Health Commercial |
$1,403.20
|
| Rate for Payer: Cash Price |
$3,858.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,749.83
|
| Rate for Payer: Heritage Provider Network Senior |
$4,749.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,269.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,754.00
|
| Rate for Payer: Multiplan Commercial |
$5,262.00
|
|
|
HC CHANGE EXT/INT URETER STENT
|
Facility
|
OP
|
$5,750.00
|
|
|
Service Code
|
CPT 50387
|
| Hospital Charge Code |
909081852
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,150.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,950.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,904.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,863.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,602.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,959.00
|
| 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 |
$3,162.50
|
| Rate for Payer: Cash Price |
$3,162.50
|
| Rate for Payer: Cash Price |
$3,162.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,737.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,904.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,863.12
|
| Rate for Payer: Dignity Health Senior |
$2,602.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,602.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,559.25
|
| Rate for Payer: Heritage Provider Network Senior |
$3,201.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$731.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,602.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,945.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,040.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,993.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,437.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,279.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,279.58
|
| Rate for Payer: Multiplan Commercial |
$4,312.50
|
| Rate for Payer: Multiplan WC |
$4,147.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,863.12
|
| Rate for Payer: TriValley Medical Group Senior |
$2,863.12
|
| 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: Vantage Medical Group Commercial/Exchange |
$3,904.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,863.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2,602.84
|
|
|
HC CHANGE EXT/INT URETER STENT
|
Facility
|
IP
|
$5,750.00
|
|
|
Service Code
|
CPT 50387
|
| Hospital Charge Code |
909081852
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,040.75 |
| Max. Negotiated Rate |
$4,312.50 |
| Rate for Payer: Adventist Health Commercial |
$1,150.00
|
| Rate for Payer: Cash Price |
$3,162.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,892.75
|
| Rate for Payer: Heritage Provider Network Senior |
$3,892.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,040.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,437.50
|
| Rate for Payer: Multiplan Commercial |
$4,312.50
|
|
|
HC CHANGE G-TUBE TO G-J TUBE
|
Facility
|
IP
|
$2,837.00
|
|
|
Service Code
|
CPT 49446
|
| Hospital Charge Code |
909020004
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$513.50 |
| Max. Negotiated Rate |
$2,127.75 |
| Rate for Payer: Adventist Health Commercial |
$567.40
|
| Rate for Payer: Cash Price |
$1,560.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,920.65
|
| Rate for Payer: Heritage Provider Network Senior |
$1,920.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$513.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$709.25
|
| Rate for Payer: Multiplan Commercial |
$2,127.75
|
|
|
HC CHANGE G-TUBE TO G-J TUBE
|
Facility
|
OP
|
$2,837.00
|
|
|
Service Code
|
CPT 49446
|
| Hospital Charge Code |
909020004
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$567.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,949.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,615.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,651.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,410.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,959.00
|
| 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 |
$1,560.35
|
| Rate for Payer: Cash Price |
$1,560.35
|
| Rate for Payer: Cash Price |
$1,560.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,844.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,615.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,651.35
|
| Rate for Payer: Dignity Health Senior |
$2,410.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,410.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,756.10
|
| Rate for Payer: Heritage Provider Network Senior |
$2,964.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,478.27
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,410.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,579.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$513.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,771.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$709.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,037.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,037.00
|
| Rate for Payer: Multiplan Commercial |
$2,127.75
|
| Rate for Payer: Multiplan WC |
$3,840.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,651.35
|
| Rate for Payer: TriValley Medical Group Senior |
$2,651.35
|
| 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: Vantage Medical Group Commercial/Exchange |
$3,615.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,651.35
|
| Rate for Payer: Vantage Medical Group Senior |
$2,410.32
|
|
|
HC CHANGE URETEROSTOMY TUBE
|
Facility
|
OP
|
$5,413.00
|
|
|
Service Code
|
CPT 50688
|
| Hospital Charge Code |
900501678
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,082.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,718.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,904.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,863.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,602.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| Rate for Payer: Cash Price |
$2,977.15
|
| Rate for Payer: Cash Price |
$2,977.15
|
| Rate for Payer: Cash Price |
$2,977.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,518.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,904.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,863.12
|
| Rate for Payer: Dignity Health Senior |
$2,602.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,602.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,664.60
|
| Rate for Payer: Heritage Provider Network Senior |
$3,664.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$973.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,602.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,582.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$979.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,993.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,353.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,279.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,279.58
|
| Rate for Payer: Multiplan Commercial |
$4,059.75
|
| Rate for Payer: Multiplan WC |
$4,147.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,947.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,792.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,904.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,863.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2,602.84
|
|
|
HC CHANGE URETEROSTOMY TUBE
|
Facility
|
IP
|
$5,413.00
|
|
|
Service Code
|
CPT 50688
|
| Hospital Charge Code |
900501678
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$979.75 |
| Max. Negotiated Rate |
$4,059.75 |
| Rate for Payer: Adventist Health Commercial |
$1,082.60
|
| Rate for Payer: Cash Price |
$2,977.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,664.60
|
| Rate for Payer: Heritage Provider Network Senior |
$3,664.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$979.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,353.25
|
| Rate for Payer: Multiplan Commercial |
$4,059.75
|
|
|
HC CHECKOUT ORTHO PROSTH USE 15MIN MCAL
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
CPT 97763
|
| Hospital Charge Code |
900400050
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$354.00 |
| Rate for Payer: Adventist Health Commercial |
$33.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$69.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$61.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$334.00
|
| Rate for Payer: Blue Shield of California Commercial |
$354.00
|
| Rate for Payer: Blue Shield of California EPN |
$284.00
|
| Rate for Payer: Cash Price |
$45.10
|
| Rate for Payer: Cash Price |
$45.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.70
|
| Rate for Payer: Dignity Health Senior |
$69.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.76
|
| Rate for Payer: Heritage Provider Network Senior |
$50.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$39.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$57.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$57.40
|
| Rate for Payer: Multiplan Commercial |
$61.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$261.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$220.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$69.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.70
|
| Rate for Payer: Vantage Medical Group Senior |
$69.70
|
|
|
HC CHECKOUT ORTHO PROSTH USE 15MIN MCAL
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
CPT 97763
|
| Hospital Charge Code |
900400050
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$61.50 |
| Rate for Payer: Adventist Health Commercial |
$16.40
|
| Rate for Payer: Cash Price |
$45.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.51
|
| Rate for Payer: Heritage Provider Network Senior |
$55.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.50
|
| Rate for Payer: Multiplan Commercial |
$61.50
|
|
|
HC CHECKOUT ORTHO/PROSTH USE 15MIN MCAL
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
CPT 97763
|
| Hospital Charge Code |
901300080
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$354.00 |
| Rate for Payer: Adventist Health Commercial |
$33.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$69.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$61.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$334.00
|
| Rate for Payer: Blue Shield of California Commercial |
$354.00
|
| Rate for Payer: Blue Shield of California EPN |
$284.00
|
| Rate for Payer: Cash Price |
$45.10
|
| Rate for Payer: Cash Price |
$45.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.70
|
| Rate for Payer: Dignity Health Senior |
$69.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.76
|
| Rate for Payer: Heritage Provider Network Senior |
$50.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$39.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$57.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$57.40
|
| Rate for Payer: Multiplan Commercial |
$61.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$261.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$220.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$69.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.70
|
| Rate for Payer: Vantage Medical Group Senior |
$69.70
|
|
|
HC CHECKOUT ORTHO/PROSTH USE 15MIN MCAL
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
CPT 97763
|
| Hospital Charge Code |
901300080
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$61.50 |
| Rate for Payer: Adventist Health Commercial |
$16.40
|
| Rate for Payer: Cash Price |
$45.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.51
|
| Rate for Payer: Heritage Provider Network Senior |
$55.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.50
|
| Rate for Payer: Multiplan Commercial |
$61.50
|
|
|
HC CHECKOUT ORTHO/PROSTH USE 15MIN OT
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
CPT 97763
|
| Hospital Charge Code |
905104155
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$61.50 |
| Rate for Payer: Adventist Health Commercial |
$16.40
|
| Rate for Payer: Cash Price |
$45.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.51
|
| Rate for Payer: Heritage Provider Network Senior |
$55.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.50
|
| Rate for Payer: Multiplan Commercial |
$61.50
|
|
|
HC CHECKOUT ORTHO/PROSTH USE 15MIN OT
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
CPT 97763
|
| Hospital Charge Code |
905104155
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$354.00 |
| Rate for Payer: Adventist Health Commercial |
$33.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$69.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$61.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$334.00
|
| Rate for Payer: Blue Shield of California Commercial |
$354.00
|
| Rate for Payer: Blue Shield of California EPN |
$284.00
|
| Rate for Payer: Cash Price |
$45.10
|
| Rate for Payer: Cash Price |
$45.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.70
|
| Rate for Payer: Dignity Health Senior |
$69.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.76
|
| Rate for Payer: Heritage Provider Network Senior |
$50.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$39.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$57.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$57.40
|
| Rate for Payer: Multiplan Commercial |
$61.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$261.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$220.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$69.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.70
|
| Rate for Payer: Vantage Medical Group Senior |
$69.70
|
|
|
HC CHECKOUT ORTHO/PROSTH USE 15MIN PT
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
CPT 97763
|
| Hospital Charge Code |
905103155
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$354.00 |
| Rate for Payer: Adventist Health Commercial |
$33.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$69.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$61.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$334.00
|
| Rate for Payer: Blue Shield of California Commercial |
$354.00
|
| Rate for Payer: Blue Shield of California EPN |
$284.00
|
| Rate for Payer: Cash Price |
$45.10
|
| Rate for Payer: Cash Price |
$45.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.70
|
| Rate for Payer: Dignity Health Senior |
$69.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.76
|
| Rate for Payer: Heritage Provider Network Senior |
$50.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$39.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$57.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$57.40
|
| Rate for Payer: Multiplan Commercial |
$61.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$261.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$220.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$69.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.70
|
| Rate for Payer: Vantage Medical Group Senior |
$69.70
|
|
|
HC CHECKOUT ORTHO/PROSTH USE 15MIN PT
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
CPT 97763
|
| Hospital Charge Code |
905103155
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$61.50 |
| Rate for Payer: Adventist Health Commercial |
$16.40
|
| Rate for Payer: Cash Price |
$45.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.51
|
| Rate for Payer: Heritage Provider Network Senior |
$55.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.50
|
| Rate for Payer: Multiplan Commercial |
$61.50
|
|
|
HC CHECKOUT ORTHO/PROSTH USE 15MIN PT
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
CPT 97763
|
| Hospital Charge Code |
900417703
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$61.50 |
| Rate for Payer: Adventist Health Commercial |
$16.40
|
| Rate for Payer: Cash Price |
$45.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.51
|
| Rate for Payer: Heritage Provider Network Senior |
$55.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.50
|
| Rate for Payer: Multiplan Commercial |
$61.50
|
|
|
HC CHECKOUT ORTHO/PROSTH USE 15MIN PT
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
CPT 97763
|
| Hospital Charge Code |
900417703
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$354.00 |
| Rate for Payer: Adventist Health Commercial |
$33.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$69.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$61.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$334.00
|
| Rate for Payer: Blue Shield of California Commercial |
$354.00
|
| Rate for Payer: Blue Shield of California EPN |
$284.00
|
| Rate for Payer: Cash Price |
$45.10
|
| Rate for Payer: Cash Price |
$45.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.70
|
| Rate for Payer: Dignity Health Senior |
$69.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.76
|
| Rate for Payer: Heritage Provider Network Senior |
$50.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$39.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$57.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$57.40
|
| Rate for Payer: Multiplan Commercial |
$61.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$261.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$220.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$69.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.70
|
| Rate for Payer: Vantage Medical Group Senior |
$69.70
|
|
|
HC CHEM CAUT OF GRANULATION TISS
|
Facility
|
OP
|
$1,252.00
|
|
|
Service Code
|
CPT 17250
|
| Hospital Charge Code |
900501050
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$250.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$860.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$378.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$277.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$252.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| Rate for Payer: Cash Price |
$688.60
|
| Rate for Payer: Cash Price |
$688.60
|
| Rate for Payer: Cash Price |
$688.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$813.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$277.72
|
| Rate for Payer: Dignity Health Senior |
$252.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$252.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$847.60
|
| Rate for Payer: Heritage Provider Network Senior |
$847.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$973.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$252.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$597.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$226.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$290.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$313.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$318.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$318.11
|
| Rate for Payer: Multiplan Commercial |
$939.00
|
| Rate for Payer: Multiplan WC |
$402.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$450.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$414.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$378.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$277.72
|
| Rate for Payer: Vantage Medical Group Senior |
$252.47
|
|
|
HC CHEM CAUT OF GRANULATION TISS
|
Facility
|
IP
|
$1,252.00
|
|
|
Service Code
|
CPT 17250
|
| Hospital Charge Code |
900501050
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$226.61 |
| Max. Negotiated Rate |
$939.00 |
| Rate for Payer: Adventist Health Commercial |
$250.40
|
| Rate for Payer: Cash Price |
$688.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$847.60
|
| Rate for Payer: Heritage Provider Network Senior |
$847.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$226.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$313.00
|
| Rate for Payer: Multiplan Commercial |
$939.00
|
|
|
HC CHEM CAUT OF GRANULATION TISS
|
Facility
|
IP
|
$1,252.00
|
|
|
Service Code
|
CPT 17250
|
| Hospital Charge Code |
900501050
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$226.61 |
| Max. Negotiated Rate |
$939.00 |
| Rate for Payer: Adventist Health Commercial |
$250.40
|
| Rate for Payer: Cash Price |
$688.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$847.60
|
| Rate for Payer: Heritage Provider Network Senior |
$847.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$226.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$313.00
|
| Rate for Payer: Multiplan Commercial |
$939.00
|
|
|
HC CHEM CAUT OF GRANULATION TISS
|
Facility
|
OP
|
$1,252.00
|
|
|
Service Code
|
CPT 17250
|
| Hospital Charge Code |
900501050
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$250.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$860.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$378.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$277.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$252.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| 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 |
$688.60
|
| Rate for Payer: Cash Price |
$688.60
|
| Rate for Payer: Cash Price |
$688.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$813.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$277.72
|
| Rate for Payer: Dignity Health Senior |
$252.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$252.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$774.99
|
| Rate for Payer: Heritage Provider Network Senior |
$310.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$32.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$252.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$597.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$226.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$290.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$313.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$318.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$318.11
|
| Rate for Payer: Multiplan Commercial |
$939.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$425.00
|
| Rate for Payer: TriValley Medical Group Senior |
$425.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,093.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$378.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$277.72
|
| Rate for Payer: Vantage Medical Group Senior |
$252.47
|
|
|
HC CHEMO ADMIN CNS W SPINAL TAP
|
Facility
|
OP
|
$2,112.00
|
|
|
Service Code
|
CPT 96450
|
| Hospital Charge Code |
911800816
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$211.64 |
| Max. Negotiated Rate |
$1,584.00 |
| Rate for Payer: Adventist Health Commercial |
$422.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,128.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,450.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$632.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$463.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$421.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$490.00
|
| Rate for Payer: Blue Shield of California Commercial |
$638.00
|
| Rate for Payer: Blue Shield of California EPN |
$512.00
|
| Rate for Payer: Cash Price |
$1,161.60
|
| Rate for Payer: Cash Price |
$1,161.60
|
| Rate for Payer: Cash Price |
$1,161.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,372.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$632.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$463.60
|
| Rate for Payer: Dignity Health Senior |
$421.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,372.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$421.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,307.33
|
| Rate for Payer: Heritage Provider Network Senior |
$1,307.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$211.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$421.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,007.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$382.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$484.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$528.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$531.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$531.03
|
| Rate for Payer: Multiplan Commercial |
$1,584.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$463.60
|
| Rate for Payer: TriValley Medical Group Senior |
$421.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$764.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$641.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$632.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$463.60
|
| Rate for Payer: Vantage Medical Group Senior |
$421.45
|
|
|
HC CHEMO ADMIN CNS W SPINAL TAP
|
Facility
|
IP
|
$2,112.00
|
|
|
Service Code
|
CPT 96450
|
| Hospital Charge Code |
911800816
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$382.27 |
| Max. Negotiated Rate |
$1,584.00 |
| Rate for Payer: Adventist Health Commercial |
$422.40
|
| Rate for Payer: Cash Price |
$1,161.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,429.82
|
| Rate for Payer: Heritage Provider Network Senior |
$1,429.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$382.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$528.00
|
| Rate for Payer: Multiplan Commercial |
$1,584.00
|
|
|
HC CHEMO ADMIN INTRA-ART PUSH
|
Facility
|
IP
|
$1,084.00
|
|
|
Service Code
|
CPT 96420
|
| Hospital Charge Code |
911800810
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$196.20 |
| Max. Negotiated Rate |
$813.00 |
| Rate for Payer: Adventist Health Commercial |
$216.80
|
| Rate for Payer: Cash Price |
$596.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$733.87
|
| Rate for Payer: Heritage Provider Network Senior |
$733.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$196.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$271.00
|
| Rate for Payer: Multiplan Commercial |
$813.00
|
|
|
HC CHEMO ADMIN INTRA-ART PUSH
|
Facility
|
OP
|
$1,084.00
|
|
|
Service Code
|
CPT 96420
|
| Hospital Charge Code |
911800810
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$68.32 |
| Max. Negotiated Rate |
$813.00 |
| Rate for Payer: Adventist Health Commercial |
$216.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$579.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$744.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$632.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$463.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$421.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$490.00
|
| Rate for Payer: Blue Shield of California Commercial |
$661.24
|
| Rate for Payer: Blue Shield of California EPN |
$528.99
|
| Rate for Payer: Cash Price |
$596.20
|
| Rate for Payer: Cash Price |
$596.20
|
| Rate for Payer: Cash Price |
$596.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$704.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$632.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$463.60
|
| Rate for Payer: Dignity Health Senior |
$421.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$704.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$421.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$671.00
|
| Rate for Payer: Heritage Provider Network Senior |
$671.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$68.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$421.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$517.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$196.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$484.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$271.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$531.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$531.03
|
| Rate for Payer: Multiplan Commercial |
$813.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$463.60
|
| Rate for Payer: TriValley Medical Group Senior |
$421.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$764.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$641.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$632.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$463.60
|
| Rate for Payer: Vantage Medical Group Senior |
$421.45
|
|
