|
HC BAG DRAINAGE URESIL GRAVITY
|
Facility
IP
|
$69.00
|
|
| Hospital Charge Code |
909001098
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.49 |
| Max. Negotiated Rate |
$51.75 |
| Rate for Payer: Adventist Health Commercial |
$13.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$47.40
|
| Rate for Payer: Cash Price |
$31.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.71
|
| Rate for Payer: Heritage Provider Network Senior |
$46.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.25
|
| Rate for Payer: Multiplan Commercial |
$51.75
|
|
|
HC BAG DRAINAGE URESIL GRAVITY
|
Facility
OP
|
$69.00
|
|
| Hospital Charge Code |
909001098
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.49 |
| Max. Negotiated Rate |
$58.65 |
| Rate for Payer: Adventist Health Commercial |
$13.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$36.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$47.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$58.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$37.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$51.75
|
| Rate for Payer: Blue Shield of California Commercial |
$42.85
|
| Rate for Payer: Blue Shield of California EPN |
$40.50
|
| Rate for Payer: Cash Price |
$31.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$58.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$58.65
|
| Rate for Payer: Dignity Health Senior |
$58.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$42.71
|
| Rate for Payer: Heritage Provider Network Senior |
$42.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$33.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.25
|
| Rate for Payer: Multiplan Commercial |
$51.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$58.65
|
| Rate for Payer: Vantage Medical Group Senior |
$58.65
|
|
|
HC BAG DRAINAGE URESIL SUCTION
|
Facility
OP
|
$88.00
|
|
| Hospital Charge Code |
909002002
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.93 |
| Max. Negotiated Rate |
$74.80 |
| Rate for Payer: Adventist Health Commercial |
$17.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$47.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$60.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$74.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$48.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$66.00
|
| Rate for Payer: Blue Shield of California Commercial |
$54.65
|
| Rate for Payer: Blue Shield of California EPN |
$51.66
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$74.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$74.80
|
| Rate for Payer: Dignity Health Senior |
$74.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.47
|
| Rate for Payer: Heritage Provider Network Senior |
$54.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$42.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.00
|
| Rate for Payer: Multiplan Commercial |
$66.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$74.80
|
| Rate for Payer: Vantage Medical Group Senior |
$74.80
|
|
|
HC BAG DRAINAGE URESIL SUCTION
|
Facility
IP
|
$88.00
|
|
| Hospital Charge Code |
909002002
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.93 |
| Max. Negotiated Rate |
$66.00 |
| Rate for Payer: Adventist Health Commercial |
$17.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$60.46
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$59.58
|
| Rate for Payer: Heritage Provider Network Senior |
$59.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.00
|
| Rate for Payer: Multiplan Commercial |
$66.00
|
|
|
HC BAG URETERAL DRAINAGE
|
Facility
OP
|
$24.00
|
|
| Hospital Charge Code |
909001074
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$20.40 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$13.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.00
|
| Rate for Payer: Blue Shield of California Commercial |
$14.90
|
| Rate for Payer: Blue Shield of California EPN |
$14.09
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.40
|
| Rate for Payer: Dignity Health Senior |
$20.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.86
|
| Rate for Payer: Heritage Provider Network Senior |
$14.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.40
|
| Rate for Payer: Vantage Medical Group Senior |
$20.40
|
|
|
HC BAG URETERAL DRAINAGE
|
Facility
IP
|
$24.00
|
|
| Hospital Charge Code |
909001074
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.49
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.25
|
| Rate for Payer: Heritage Provider Network Senior |
$16.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
|
|
HC BAKER'S YEAST IGE
|
Facility
OP
|
$64.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
900913633
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$132.31 |
| Rate for Payer: Adventist Health Commercial |
$12.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$43.97
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.83
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$132.31
|
| Rate for Payer: Blue Shield of California Commercial |
$40.81
|
| Rate for Payer: Blue Shield of California EPN |
$31.90
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$41.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.74
|
| Rate for Payer: Dignity Health Senior |
$5.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$5.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$39.62
|
| Rate for Payer: Heritage Provider Network Senior |
$39.62
|
| Rate for Payer: Humana Medicare |
$5.22
|
| Rate for Payer: IEHP Medi-Cal |
$7.24
|
| Rate for Payer: IEHP Medicare Advantage |
$5.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.58
|
| Rate for Payer: Multiplan Commercial |
$48.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.22
|
| Rate for Payer: TriValley Medical Group Senior |
$5.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.74
|
| Rate for Payer: Vantage Medical Group Senior |
$5.22
|
|
|
HC BAKER'S YEAST IGE
|
Facility
IP
|
$64.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
900913633
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$11.58 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Adventist Health Commercial |
$12.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$43.97
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$43.33
|
| Rate for Payer: Heritage Provider Network Senior |
$43.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.00
|
| Rate for Payer: Multiplan Commercial |
$48.00
|
|
|
HC BALLOON 3 IN ONE
|
Facility
IP
|
$1,242.00
|
|
|
Service Code
|
CPT C1726
|
| Hospital Charge Code |
900803814
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$224.80 |
| Max. Negotiated Rate |
$931.50 |
| Rate for Payer: Adventist Health Commercial |
$248.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$853.25
|
| Rate for Payer: Cash Price |
$558.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$840.83
|
| Rate for Payer: Heritage Provider Network Senior |
$840.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$224.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$310.50
|
| Rate for Payer: Multiplan Commercial |
$931.50
|
|
|
HC BALLOON 3 IN ONE
|
Facility
OP
|
$1,242.00
|
|
|
Service Code
|
CPT C1726
|
| Hospital Charge Code |
900803814
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$171.02 |
| Max. Negotiated Rate |
$1,055.70 |
| Rate for Payer: Adventist Health Commercial |
$248.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$171.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$853.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,055.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$683.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$931.50
|
| Rate for Payer: Blue Shield of California Commercial |
$771.28
|
| Rate for Payer: Blue Shield of California EPN |
$729.05
|
| Rate for Payer: Cash Price |
$558.90
|
| Rate for Payer: Cash Price |
$558.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$807.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,055.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,055.70
|
| Rate for Payer: Dignity Health Senior |
$1,055.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$807.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$768.80
|
| Rate for Payer: Heritage Provider Network Senior |
$768.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$598.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$224.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$310.50
|
| Rate for Payer: Multiplan Commercial |
$931.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,055.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1,055.70
|
|
|
HC BALLOON, AMPHIRION
|
Facility
OP
|
$1,840.00
|
|
|
Service Code
|
CPT C1725
|
| Hospital Charge Code |
909020111
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$333.04 |
| Max. Negotiated Rate |
$1,564.00 |
| Rate for Payer: Adventist Health Commercial |
$368.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,062.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,264.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,564.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,012.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,380.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,142.64
|
| Rate for Payer: Blue Shield of California EPN |
$1,080.08
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,196.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,564.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,564.00
|
| Rate for Payer: Dignity Health Senior |
$1,564.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,196.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,138.96
|
| Rate for Payer: Heritage Provider Network Senior |
$1,138.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$886.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$333.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$460.00
|
| Rate for Payer: Multiplan Commercial |
$1,380.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,564.00
|
| Rate for Payer: Vantage Medical Group Senior |
$1,564.00
|
|
|
HC BALLOON, AMPHIRION
|
Facility
IP
|
$1,840.00
|
|
|
Service Code
|
CPT C1725
|
| Hospital Charge Code |
909020111
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$333.04 |
| Max. Negotiated Rate |
$1,380.00 |
| Rate for Payer: Adventist Health Commercial |
$368.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,264.08
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,245.68
|
| Rate for Payer: Heritage Provider Network Senior |
$1,245.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$333.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$460.00
|
| Rate for Payer: Multiplan Commercial |
$1,380.00
|
|
|
HC BALLOON, ASCENT
|
Facility
OP
|
$3,900.00
|
|
|
Service Code
|
CPT C1725
|
| Hospital Charge Code |
909020097
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$705.90 |
| Max. Negotiated Rate |
$3,315.00 |
| Rate for Payer: Adventist Health Commercial |
$780.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,062.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,679.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,315.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,145.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,925.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,421.90
|
| Rate for Payer: Blue Shield of California EPN |
$2,289.30
|
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,535.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,315.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,315.00
|
| Rate for Payer: Dignity Health Senior |
$3,315.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,535.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,414.10
|
| Rate for Payer: Heritage Provider Network Senior |
$2,414.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,879.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$705.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$975.00
|
| Rate for Payer: Multiplan Commercial |
$2,925.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,315.00
|
| Rate for Payer: Vantage Medical Group Senior |
$3,315.00
|
|
|
HC BALLOON, ASCENT
|
Facility
IP
|
$3,900.00
|
|
|
Service Code
|
CPT C1725
|
| Hospital Charge Code |
909020097
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$705.90 |
| Max. Negotiated Rate |
$2,925.00 |
| Rate for Payer: Adventist Health Commercial |
$780.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,679.30
|
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,640.30
|
| Rate for Payer: Heritage Provider Network Senior |
$2,640.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$705.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$975.00
|
| Rate for Payer: Multiplan Commercial |
$2,925.00
|
|
|
HC BALLOON DILATATION CATHETER
|
Facility
OP
|
$1,620.00
|
|
|
Service Code
|
CPT C1726
|
| Hospital Charge Code |
900803804
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$171.02 |
| Max. Negotiated Rate |
$1,377.00 |
| Rate for Payer: Adventist Health Commercial |
$324.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$171.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,112.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,377.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$891.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,215.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,006.02
|
| Rate for Payer: Blue Shield of California EPN |
$950.94
|
| Rate for Payer: Cash Price |
$729.00
|
| Rate for Payer: Cash Price |
$729.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,053.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,377.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,377.00
|
| Rate for Payer: Dignity Health Senior |
$1,377.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,053.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,002.78
|
| Rate for Payer: Heritage Provider Network Senior |
$1,002.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$780.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$293.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$405.00
|
| Rate for Payer: Multiplan Commercial |
$1,215.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,377.00
|
| Rate for Payer: Vantage Medical Group Senior |
$1,377.00
|
|
|
HC BALLOON DILATATION CATHETER
|
Facility
IP
|
$1,620.00
|
|
|
Service Code
|
CPT C1726
|
| Hospital Charge Code |
900803804
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$293.22 |
| Max. Negotiated Rate |
$1,215.00 |
| Rate for Payer: Adventist Health Commercial |
$324.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,112.94
|
| Rate for Payer: Cash Price |
$729.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,096.74
|
| Rate for Payer: Heritage Provider Network Senior |
$1,096.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$293.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$405.00
|
| Rate for Payer: Multiplan Commercial |
$1,215.00
|
|
|
HC BALLOON, EV3 EVERCROSS
|
Facility
IP
|
$782.00
|
|
|
Service Code
|
CPT C1725
|
| Hospital Charge Code |
909020086
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$141.54 |
| Max. Negotiated Rate |
$586.50 |
| Rate for Payer: Adventist Health Commercial |
$156.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$537.23
|
| Rate for Payer: Cash Price |
$351.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$529.41
|
| Rate for Payer: Heritage Provider Network Senior |
$529.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$141.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$195.50
|
| Rate for Payer: Multiplan Commercial |
$586.50
|
|
|
HC BALLOON, EV3 EVERCROSS
|
Facility
OP
|
$782.00
|
|
|
Service Code
|
CPT C1725
|
| Hospital Charge Code |
909020086
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$141.54 |
| Max. Negotiated Rate |
$1,062.28 |
| Rate for Payer: Adventist Health Commercial |
$156.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,062.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$537.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$664.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$430.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$586.50
|
| Rate for Payer: Blue Shield of California Commercial |
$485.62
|
| Rate for Payer: Blue Shield of California EPN |
$459.03
|
| Rate for Payer: Cash Price |
$351.90
|
| Rate for Payer: Cash Price |
$351.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$508.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$664.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$664.70
|
| Rate for Payer: Dignity Health Senior |
$664.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$508.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$484.06
|
| Rate for Payer: Heritage Provider Network Senior |
$484.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$376.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$141.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$195.50
|
| Rate for Payer: Multiplan Commercial |
$586.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$664.70
|
| Rate for Payer: Vantage Medical Group Senior |
$664.70
|
|
|
HC BALLOON GATEWAY
|
Facility
IP
|
$3,900.00
|
|
|
Service Code
|
CPT C1725
|
| Hospital Charge Code |
909020056
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$780.00 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$780.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,872.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,679.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,794.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,106.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,640.30
|
| Rate for Payer: Heritage Provider Network Senior |
$2,640.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,950.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,950.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,950.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$975.00
|
| Rate for Payer: Multiplan Commercial |
$2,925.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,421.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,302.99
|
|
|
HC BALLOON GATEWAY
|
Facility
OP
|
$3,900.00
|
|
|
Service Code
|
CPT C1725
|
| Hospital Charge Code |
909020056
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$780.00 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$780.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,872.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,679.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,315.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,145.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,925.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,421.90
|
| Rate for Payer: Blue Shield of California EPN |
$2,289.30
|
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,794.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,315.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,315.00
|
| Rate for Payer: Dignity Health Senior |
$3,315.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,496.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,805.70
|
| Rate for Payer: Heritage Provider Network Senior |
$1,805.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,950.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,950.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,950.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$975.00
|
| Rate for Payer: Multiplan Commercial |
$2,925.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,421.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,302.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,315.00
|
| Rate for Payer: Vantage Medical Group Senior |
$3,315.00
|
|
|
HC BALLOON HYPERFORM
|
Facility
OP
|
$3,900.00
|
|
|
Service Code
|
CPT C2628
|
| Hospital Charge Code |
909020050
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$705.90 |
| Max. Negotiated Rate |
$3,315.00 |
| Rate for Payer: Adventist Health Commercial |
$780.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$915.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,679.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,315.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,145.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,925.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,421.90
|
| Rate for Payer: Blue Shield of California EPN |
$2,289.30
|
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,535.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,315.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,315.00
|
| Rate for Payer: Dignity Health Senior |
$3,315.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,535.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,414.10
|
| Rate for Payer: Heritage Provider Network Senior |
$2,414.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,879.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$705.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$975.00
|
| Rate for Payer: Multiplan Commercial |
$2,925.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,315.00
|
| Rate for Payer: Vantage Medical Group Senior |
$3,315.00
|
|
|
HC BALLOON HYPERFORM
|
Facility
IP
|
$3,900.00
|
|
|
Service Code
|
CPT C2628
|
| Hospital Charge Code |
909020050
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$705.90 |
| Max. Negotiated Rate |
$2,925.00 |
| Rate for Payer: Adventist Health Commercial |
$780.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,679.30
|
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,640.30
|
| Rate for Payer: Heritage Provider Network Senior |
$2,640.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$705.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$975.00
|
| Rate for Payer: Multiplan Commercial |
$2,925.00
|
|
|
HC BALLOON NANOCROSS
|
Facility
IP
|
$810.00
|
|
|
Service Code
|
CPT C1725
|
| Hospital Charge Code |
909081414
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$162.00 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$162.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$388.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$556.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$364.50
|
| Rate for Payer: Cash Price |
$364.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$372.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$437.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$548.37
|
| Rate for Payer: Heritage Provider Network Senior |
$548.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$405.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$405.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$405.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$202.50
|
| Rate for Payer: Multiplan Commercial |
$607.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$295.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$270.62
|
|
|
HC BALLOON NANOCROSS
|
Facility
OP
|
$810.00
|
|
|
Service Code
|
CPT C1725
|
| Hospital Charge Code |
909081414
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$162.00 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$162.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$388.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$556.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$688.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$445.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$607.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$503.01
|
| Rate for Payer: Blue Shield of California EPN |
$475.47
|
| Rate for Payer: Cash Price |
$364.50
|
| Rate for Payer: Cash Price |
$364.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$372.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$688.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$688.50
|
| Rate for Payer: Dignity Health Senior |
$688.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$518.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$375.03
|
| Rate for Payer: Heritage Provider Network Senior |
$375.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$405.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$405.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$405.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$202.50
|
| Rate for Payer: Multiplan Commercial |
$607.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$295.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$270.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$688.50
|
| Rate for Payer: Vantage Medical Group Senior |
$688.50
|
|
|
HC BALLOON OCCLUSION ADDL LOBES
|
Facility
OP
|
$4,239.00
|
|
|
Service Code
|
CPT 31651
|
| Hospital Charge Code |
900531651
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$102.21 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$847.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,912.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,603.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,331.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,179.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,689.75
|
| Rate for Payer: Blue Shield of California EPN |
$7,468.44
|
| Rate for Payer: Cash Price |
$1,907.55
|
| Rate for Payer: Cash Price |
$1,907.55
|
| Rate for Payer: Cash Price |
$1,907.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,755.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,603.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,603.15
|
| Rate for Payer: Dignity Health Senior |
$3,603.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,623.94
|
| Rate for Payer: Heritage Provider Network Senior |
$2,623.94
|
| Rate for Payer: IEHP Medi-Cal |
$102.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,043.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$767.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,059.75
|
| Rate for Payer: Multiplan Commercial |
$3,179.25
|
| 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 |
$3,603.15
|
| Rate for Payer: Vantage Medical Group Senior |
$3,603.15
|
|
