|
HC CT BONE L-SPINE W/O CONTRAST
|
Facility
|
OP
|
$2,550.00
|
|
|
Service Code
|
CPT 72131
|
| Hospital Charge Code |
909201007
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$135.12 |
| Max. Negotiated Rate |
$1,912.50 |
| Rate for Payer: Adventist Health Commercial |
$510.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,024.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,751.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$135.12
|
| Rate for Payer: Blue Shield of California Commercial |
$1,242.62
|
| Rate for Payer: Blue Shield of California EPN |
$999.28
|
| Rate for Payer: Cash Price |
$1,147.50
|
| Rate for Payer: Cash Price |
$1,147.50
|
| Rate for Payer: Cash Price |
$1,147.50
|
| Rate for Payer: Cash Price |
$1,147.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$910.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$202.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$148.63
|
| Rate for Payer: Dignity Health Senior |
$135.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$874.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$135.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$573.00
|
| Rate for Payer: Heritage Provider Network Senior |
$521.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$201.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$135.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,216.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$461.55
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$155.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$637.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$170.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$170.25
|
| Rate for Payer: Multiplan Commercial |
$1,912.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$225.00
|
| Rate for Payer: TriValley Medical Group Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$307.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$307.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Vantage Medical Group Senior |
$135.12
|
|
|
HC CT BONE L-SPINE W/WO CONTRAST
|
Facility
|
OP
|
$3,004.00
|
|
|
Service Code
|
CPT 72133
|
| Hospital Charge Code |
909201009
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$2,253.00 |
| Rate for Payer: Adventist Health Commercial |
$600.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,024.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,063.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$339.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$248.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$226.19
|
| Rate for Payer: Blue Shield of California Commercial |
$1,860.19
|
| Rate for Payer: Blue Shield of California EPN |
$1,495.90
|
| Rate for Payer: Cash Price |
$1,351.80
|
| Rate for Payer: Cash Price |
$1,351.80
|
| Rate for Payer: Cash Price |
$1,351.80
|
| Rate for Payer: Cash Price |
$1,351.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$910.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$339.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$248.81
|
| Rate for Payer: Dignity Health Senior |
$226.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$874.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$226.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$573.00
|
| Rate for Payer: Heritage Provider Network Senior |
$521.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$311.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$226.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,432.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$543.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$260.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$751.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$285.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$285.00
|
| Rate for Payer: Multiplan Commercial |
$2,253.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$225.00
|
| Rate for Payer: TriValley Medical Group Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$534.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$534.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$339.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$248.81
|
| Rate for Payer: Vantage Medical Group Senior |
$226.19
|
|
|
HC CT BONE L-SPINE W/WO CONTRAST
|
Facility
|
IP
|
$2,905.00
|
|
|
Service Code
|
CPT 72133
|
| Hospital Charge Code |
909201009
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$525.80 |
| Max. Negotiated Rate |
$2,178.75 |
| Rate for Payer: Adventist Health Commercial |
$581.00
|
| Rate for Payer: Cash Price |
$1,307.25
|
| Rate for Payer: Cash Price |
$1,307.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$711.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,966.68
|
| Rate for Payer: Heritage Provider Network Senior |
$1,966.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$525.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$726.25
|
| Rate for Payer: Multiplan Commercial |
$2,178.75
|
|
|
HC CT BONE PELVIS W CONTRAST
|
Facility
|
IP
|
$2,213.00
|
|
|
Service Code
|
CPT 72193
|
| Hospital Charge Code |
909201931
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$400.55 |
| Max. Negotiated Rate |
$1,659.75 |
| Rate for Payer: Adventist Health Commercial |
$442.60
|
| Rate for Payer: Cash Price |
$995.85
|
| Rate for Payer: Cash Price |
$995.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$711.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,498.20
|
| Rate for Payer: Heritage Provider Network Senior |
$1,498.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$400.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$553.25
|
| Rate for Payer: Multiplan Commercial |
$1,659.75
|
|
|
HC CT BONE PELVIS W CONTRAST
|
Facility
|
OP
|
$2,761.00
|
|
|
Service Code
|
CPT 72193
|
| Hospital Charge Code |
909201931
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$2,070.75 |
| Rate for Payer: Adventist Health Commercial |
$552.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,024.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,896.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$339.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$248.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$226.19
|
| Rate for Payer: Blue Shield of California Commercial |
$1,439.71
|
| Rate for Payer: Blue Shield of California EPN |
$1,157.77
|
| Rate for Payer: Cash Price |
$1,242.45
|
| Rate for Payer: Cash Price |
$1,242.45
|
| Rate for Payer: Cash Price |
$1,242.45
|
| Rate for Payer: Cash Price |
$1,242.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$910.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$339.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$248.81
|
| Rate for Payer: Dignity Health Senior |
$226.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$874.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$226.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$573.00
|
| Rate for Payer: Heritage Provider Network Senior |
$521.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$331.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$226.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,317.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$499.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$260.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$690.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$285.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$285.00
|
| Rate for Payer: Multiplan Commercial |
$2,070.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$225.00
|
| Rate for Payer: TriValley Medical Group Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$480.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$480.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$339.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$248.81
|
| Rate for Payer: Vantage Medical Group Senior |
$226.19
|
|
|
HC CT BONE PELVIS W/O CONTRAST
|
Facility
|
OP
|
$2,541.00
|
|
|
Service Code
|
CPT 72192
|
| Hospital Charge Code |
909201930
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$135.12 |
| Max. Negotiated Rate |
$1,905.75 |
| Rate for Payer: Adventist Health Commercial |
$508.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,024.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,745.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$135.12
|
| Rate for Payer: Blue Shield of California Commercial |
$1,242.62
|
| Rate for Payer: Blue Shield of California EPN |
$999.28
|
| Rate for Payer: Cash Price |
$1,143.45
|
| Rate for Payer: Cash Price |
$1,143.45
|
| Rate for Payer: Cash Price |
$1,143.45
|
| Rate for Payer: Cash Price |
$1,143.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$910.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$202.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$148.63
|
| Rate for Payer: Dignity Health Senior |
$135.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$874.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$135.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$573.00
|
| Rate for Payer: Heritage Provider Network Senior |
$521.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$206.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$135.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,212.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$459.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$155.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$635.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$170.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$170.25
|
| Rate for Payer: Multiplan Commercial |
$1,905.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$225.00
|
| Rate for Payer: TriValley Medical Group Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$307.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$307.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Vantage Medical Group Senior |
$135.12
|
|
|
HC CT BONE PELVIS W/O CONTRAST
|
Facility
|
IP
|
$2,088.00
|
|
|
Service Code
|
CPT 72192
|
| Hospital Charge Code |
909201930
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$377.93 |
| Max. Negotiated Rate |
$1,566.00 |
| Rate for Payer: Adventist Health Commercial |
$417.60
|
| Rate for Payer: Cash Price |
$939.60
|
| Rate for Payer: Cash Price |
$939.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$711.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,413.58
|
| Rate for Payer: Heritage Provider Network Senior |
$1,413.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$377.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$522.00
|
| Rate for Payer: Multiplan Commercial |
$1,566.00
|
|
|
HC CT BONE PELVIS W/WO CONTRAST
|
Facility
|
IP
|
$2,480.00
|
|
|
Service Code
|
CPT 72194
|
| Hospital Charge Code |
909201932
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$448.88 |
| Max. Negotiated Rate |
$1,860.00 |
| Rate for Payer: Adventist Health Commercial |
$496.00
|
| Rate for Payer: Cash Price |
$1,116.00
|
| Rate for Payer: Cash Price |
$1,116.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$711.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,678.96
|
| Rate for Payer: Heritage Provider Network Senior |
$1,678.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$448.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$620.00
|
| Rate for Payer: Multiplan Commercial |
$1,860.00
|
|
|
HC CT BONE PELVIS W/WO CONTRAST
|
Facility
|
OP
|
$3,018.00
|
|
|
Service Code
|
CPT 72194
|
| Hospital Charge Code |
909201932
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$2,263.50 |
| Rate for Payer: Adventist Health Commercial |
$603.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,024.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,073.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$339.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$248.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$226.19
|
| Rate for Payer: Blue Shield of California Commercial |
$1,783.10
|
| Rate for Payer: Blue Shield of California EPN |
$1,433.91
|
| Rate for Payer: Cash Price |
$1,358.10
|
| Rate for Payer: Cash Price |
$1,358.10
|
| Rate for Payer: Cash Price |
$1,358.10
|
| Rate for Payer: Cash Price |
$1,358.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$910.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$339.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$248.81
|
| Rate for Payer: Dignity Health Senior |
$226.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$874.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$226.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$573.00
|
| Rate for Payer: Heritage Provider Network Senior |
$521.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$382.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$226.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,439.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$546.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$260.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$754.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$285.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$285.00
|
| Rate for Payer: Multiplan Commercial |
$2,263.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$225.00
|
| Rate for Payer: TriValley Medical Group Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$534.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$534.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$339.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$248.81
|
| Rate for Payer: Vantage Medical Group Senior |
$226.19
|
|
|
HC CT CARDIAC SCORING
|
Facility
|
IP
|
$1,204.00
|
|
|
Service Code
|
CPT 75571
|
| Hospital Charge Code |
909201981
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$217.92 |
| Max. Negotiated Rate |
$903.00 |
| Rate for Payer: Adventist Health Commercial |
$240.80
|
| Rate for Payer: Cash Price |
$541.80
|
| Rate for Payer: Cash Price |
$541.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$711.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$815.11
|
| Rate for Payer: Heritage Provider Network Senior |
$815.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$217.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$301.00
|
| Rate for Payer: Multiplan Commercial |
$903.00
|
|
|
HC CT CARDIAC SCORING
|
Facility
|
OP
|
$540.00
|
|
|
Service Code
|
CPT 75571
|
| Hospital Charge Code |
909201981
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$73.02 |
| Max. Negotiated Rate |
$1,024.00 |
| Rate for Payer: Adventist Health Commercial |
$108.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,024.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$370.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$167.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$123.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$111.88
|
| Rate for Payer: Blue Shield of California Commercial |
$516.53
|
| Rate for Payer: Blue Shield of California EPN |
$415.37
|
| Rate for Payer: Cash Price |
$243.00
|
| Rate for Payer: Cash Price |
$243.00
|
| Rate for Payer: Cash Price |
$243.00
|
| Rate for Payer: Cash Price |
$243.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$910.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$167.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$123.07
|
| Rate for Payer: Dignity Health Senior |
$111.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$874.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$111.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$573.00
|
| Rate for Payer: Heritage Provider Network Senior |
$521.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$131.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$111.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$257.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$128.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$135.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$140.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$140.97
|
| Rate for Payer: Multiplan Commercial |
$405.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$225.00
|
| Rate for Payer: TriValley Medical Group Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$73.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$73.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$167.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$123.07
|
| Rate for Payer: Vantage Medical Group Senior |
$111.88
|
|
|
HC CT CHEST W/O CONTRAST
|
Facility
|
IP
|
$2,320.00
|
|
|
Service Code
|
CPT 71250
|
| Hospital Charge Code |
909201912
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$419.92 |
| Max. Negotiated Rate |
$1,740.00 |
| Rate for Payer: Adventist Health Commercial |
$464.00
|
| Rate for Payer: Cash Price |
$1,044.00
|
| Rate for Payer: Cash Price |
$1,044.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$711.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,570.64
|
| Rate for Payer: Heritage Provider Network Senior |
$1,570.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$419.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$580.00
|
| Rate for Payer: Multiplan Commercial |
$1,740.00
|
|
|
HC CT CHEST W/O CONTRAST
|
Facility
|
OP
|
$2,248.00
|
|
|
Service Code
|
CPT 71250
|
| Hospital Charge Code |
909201912
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$135.12 |
| Max. Negotiated Rate |
$1,686.00 |
| Rate for Payer: Adventist Health Commercial |
$449.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,024.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,544.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$135.12
|
| Rate for Payer: Blue Shield of California Commercial |
$1,242.62
|
| Rate for Payer: Blue Shield of California EPN |
$999.28
|
| Rate for Payer: Cash Price |
$1,011.60
|
| Rate for Payer: Cash Price |
$1,011.60
|
| Rate for Payer: Cash Price |
$1,011.60
|
| Rate for Payer: Cash Price |
$1,011.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$910.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$202.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$148.63
|
| Rate for Payer: Dignity Health Senior |
$135.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$874.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$135.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$573.00
|
| Rate for Payer: Heritage Provider Network Senior |
$521.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$206.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$135.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,072.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$406.89
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$155.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$562.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$170.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$170.25
|
| Rate for Payer: Multiplan Commercial |
$1,686.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$225.00
|
| Rate for Payer: TriValley Medical Group Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$307.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$307.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Vantage Medical Group Senior |
$135.12
|
|
|
HC CT CHEST W WO CONTRA
|
Facility
|
OP
|
$3,274.00
|
|
|
Service Code
|
CPT 71270
|
| Hospital Charge Code |
909201914
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$2,455.50 |
| Rate for Payer: Adventist Health Commercial |
$654.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,024.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,249.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$339.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$248.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$226.19
|
| Rate for Payer: Blue Shield of California Commercial |
$1,860.19
|
| Rate for Payer: Blue Shield of California EPN |
$1,495.90
|
| Rate for Payer: Cash Price |
$1,473.30
|
| Rate for Payer: Cash Price |
$1,473.30
|
| Rate for Payer: Cash Price |
$1,473.30
|
| Rate for Payer: Cash Price |
$1,473.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$910.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$339.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$248.81
|
| Rate for Payer: Dignity Health Senior |
$226.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$874.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$226.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$573.00
|
| Rate for Payer: Heritage Provider Network Senior |
$521.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$310.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$226.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,561.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$592.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$260.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$818.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$285.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$285.00
|
| Rate for Payer: Multiplan Commercial |
$2,455.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$225.00
|
| Rate for Payer: TriValley Medical Group Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$534.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$534.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$339.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$248.81
|
| Rate for Payer: Vantage Medical Group Senior |
$226.19
|
|
|
HC CT CHEST W WO CONTRA
|
Facility
|
IP
|
$2,652.00
|
|
|
Service Code
|
CPT 71270
|
| Hospital Charge Code |
909201914
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$480.01 |
| Max. Negotiated Rate |
$1,989.00 |
| Rate for Payer: Adventist Health Commercial |
$530.40
|
| Rate for Payer: Cash Price |
$1,193.40
|
| Rate for Payer: Cash Price |
$1,193.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$711.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,795.40
|
| Rate for Payer: Heritage Provider Network Senior |
$1,795.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$480.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$663.00
|
| Rate for Payer: Multiplan Commercial |
$1,989.00
|
|
|
HC CT COLONOGRAPHY SCREEN
|
Facility
|
OP
|
$1,172.00
|
|
|
Service Code
|
CPT 74263
|
| Hospital Charge Code |
909201813
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$212.13 |
| Max. Negotiated Rate |
$3,301.97 |
| Rate for Payer: Adventist Health Commercial |
$234.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,024.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$805.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$460.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$337.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$307.13
|
| Rate for Payer: Blue Shield of California Commercial |
$3,301.97
|
| Rate for Payer: Blue Shield of California EPN |
$2,655.33
|
| Rate for Payer: Cash Price |
$527.40
|
| Rate for Payer: Cash Price |
$527.40
|
| Rate for Payer: Cash Price |
$527.40
|
| Rate for Payer: Cash Price |
$527.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$910.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$460.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$337.84
|
| Rate for Payer: Dignity Health Senior |
$307.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$874.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$307.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$573.00
|
| Rate for Payer: Heritage Provider Network Senior |
$521.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$307.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$559.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$212.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$353.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$293.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$386.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$386.98
|
| Rate for Payer: Multiplan Commercial |
$879.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$225.00
|
| Rate for Payer: TriValley Medical Group Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,113.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,113.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$460.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$337.84
|
| Rate for Payer: Vantage Medical Group Senior |
$307.13
|
|
|
HC CT COLONOGRAPHY SCREEN
|
Facility
|
IP
|
$1,204.00
|
|
|
Service Code
|
CPT 74263
|
| Hospital Charge Code |
909201813
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$217.92 |
| Max. Negotiated Rate |
$903.00 |
| Rate for Payer: Adventist Health Commercial |
$240.80
|
| Rate for Payer: Cash Price |
$541.80
|
| Rate for Payer: Cash Price |
$541.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$711.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$815.11
|
| Rate for Payer: Heritage Provider Network Senior |
$815.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$217.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$301.00
|
| Rate for Payer: Multiplan Commercial |
$903.00
|
|
|
HC CT COLONOGRAPHY W/CONTRAST
|
Facility
|
IP
|
$5,613.00
|
|
|
Service Code
|
CPT 74262
|
| Hospital Charge Code |
909202000
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$711.00 |
| Max. Negotiated Rate |
$4,209.75 |
| Rate for Payer: Adventist Health Commercial |
$1,122.60
|
| Rate for Payer: Cash Price |
$2,525.85
|
| Rate for Payer: Cash Price |
$2,525.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$711.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,800.00
|
| Rate for Payer: Heritage Provider Network Senior |
$3,800.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,015.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,403.25
|
| Rate for Payer: Multiplan Commercial |
$4,209.75
|
|
|
HC CT COLONOGRAPHY W/CONTRAST
|
Facility
|
OP
|
$3,484.00
|
|
|
Service Code
|
CPT 74262
|
| Hospital Charge Code |
909202000
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$3,124.22 |
| Rate for Payer: Adventist Health Commercial |
$696.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,024.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,393.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$339.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$248.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$226.19
|
| Rate for Payer: Blue Shield of California Commercial |
$3,124.22
|
| Rate for Payer: Blue Shield of California EPN |
$2,512.40
|
| Rate for Payer: Cash Price |
$1,567.80
|
| Rate for Payer: Cash Price |
$1,567.80
|
| Rate for Payer: Cash Price |
$1,567.80
|
| Rate for Payer: Cash Price |
$1,567.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$910.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$339.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$248.81
|
| Rate for Payer: Dignity Health Senior |
$226.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$874.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$226.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$573.00
|
| Rate for Payer: Heritage Provider Network Senior |
$521.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$759.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$226.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,661.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$630.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$260.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$871.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$285.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$285.00
|
| Rate for Payer: Multiplan Commercial |
$2,613.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$225.00
|
| Rate for Payer: TriValley Medical Group Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$480.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$480.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$339.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$248.81
|
| Rate for Payer: Vantage Medical Group Senior |
$226.19
|
|
|
HC CT COLONOGRAPHY W/O CONTRAST
|
Facility
|
IP
|
$1,204.00
|
|
|
Service Code
|
CPT 74261
|
| Hospital Charge Code |
909201811
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$217.92 |
| Max. Negotiated Rate |
$903.00 |
| Rate for Payer: Adventist Health Commercial |
$240.80
|
| Rate for Payer: Cash Price |
$541.80
|
| Rate for Payer: Cash Price |
$541.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$711.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$815.11
|
| Rate for Payer: Heritage Provider Network Senior |
$815.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$217.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$301.00
|
| Rate for Payer: Multiplan Commercial |
$903.00
|
|
|
HC CT COLONOGRAPHY W/O CONTRAST
|
Facility
|
OP
|
$3,151.00
|
|
|
Service Code
|
CPT 74261
|
| Hospital Charge Code |
909201811
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$135.12 |
| Max. Negotiated Rate |
$2,778.82 |
| Rate for Payer: Adventist Health Commercial |
$630.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,024.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,164.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$135.12
|
| Rate for Payer: Blue Shield of California Commercial |
$2,778.82
|
| Rate for Payer: Blue Shield of California EPN |
$2,234.63
|
| Rate for Payer: Cash Price |
$1,417.95
|
| Rate for Payer: Cash Price |
$1,417.95
|
| Rate for Payer: Cash Price |
$1,417.95
|
| Rate for Payer: Cash Price |
$1,417.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$910.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$202.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$148.63
|
| Rate for Payer: Dignity Health Senior |
$135.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$874.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$135.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$573.00
|
| Rate for Payer: Heritage Provider Network Senior |
$521.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$670.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$135.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,503.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$570.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$155.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$787.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$170.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$170.25
|
| Rate for Payer: Multiplan Commercial |
$2,363.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$225.00
|
| Rate for Payer: TriValley Medical Group Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$307.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$307.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Vantage Medical Group Senior |
$135.12
|
|
|
HC CT CSPINE WITH CONTRAST
|
Facility
|
OP
|
$2,889.00
|
|
|
Service Code
|
CPT 72126
|
| Hospital Charge Code |
909201916
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$2,166.75 |
| Rate for Payer: Adventist Health Commercial |
$577.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,024.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,984.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$680.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$499.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$453.77
|
| Rate for Payer: Blue Shield of California Commercial |
$1,487.62
|
| Rate for Payer: Blue Shield of California EPN |
$1,196.29
|
| Rate for Payer: Cash Price |
$1,300.05
|
| Rate for Payer: Cash Price |
$1,300.05
|
| Rate for Payer: Cash Price |
$1,300.05
|
| Rate for Payer: Cash Price |
$1,300.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$910.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$680.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$499.15
|
| Rate for Payer: Dignity Health Senior |
$453.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$874.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$453.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$573.00
|
| Rate for Payer: Heritage Provider Network Senior |
$521.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$264.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$453.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,378.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$522.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$521.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$722.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$571.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$571.75
|
| Rate for Payer: Multiplan Commercial |
$2,166.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$225.00
|
| Rate for Payer: TriValley Medical Group Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$480.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$480.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$680.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$499.15
|
| Rate for Payer: Vantage Medical Group Senior |
$453.77
|
|
|
HC CT CSPINE WITH CONTRAST
|
Facility
|
IP
|
$3,516.00
|
|
|
Service Code
|
CPT 72126
|
| Hospital Charge Code |
909201916
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$636.40 |
| Max. Negotiated Rate |
$2,637.00 |
| Rate for Payer: Adventist Health Commercial |
$703.20
|
| Rate for Payer: Cash Price |
$1,582.20
|
| Rate for Payer: Cash Price |
$1,582.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$711.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,380.33
|
| Rate for Payer: Heritage Provider Network Senior |
$2,380.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$636.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$879.00
|
| Rate for Payer: Multiplan Commercial |
$2,637.00
|
|
|
HC CT CSPINE WO CONTRAST
|
Facility
|
OP
|
$2,684.00
|
|
|
Service Code
|
CPT 72125
|
| Hospital Charge Code |
909201915
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$135.12 |
| Max. Negotiated Rate |
$2,013.00 |
| Rate for Payer: Adventist Health Commercial |
$536.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,024.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,843.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$135.12
|
| Rate for Payer: Blue Shield of California Commercial |
$1,242.62
|
| Rate for Payer: Blue Shield of California EPN |
$999.28
|
| Rate for Payer: Cash Price |
$1,207.80
|
| Rate for Payer: Cash Price |
$1,207.80
|
| Rate for Payer: Cash Price |
$1,207.80
|
| Rate for Payer: Cash Price |
$1,207.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$910.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$202.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$148.63
|
| Rate for Payer: Dignity Health Senior |
$135.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$874.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$135.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$573.00
|
| Rate for Payer: Heritage Provider Network Senior |
$521.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$202.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$135.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,280.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$485.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$155.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$671.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$170.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$170.25
|
| Rate for Payer: Multiplan Commercial |
$2,013.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$225.00
|
| Rate for Payer: TriValley Medical Group Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$307.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$307.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Vantage Medical Group Senior |
$135.12
|
|
|
HC CT CSPINE WO CONTRAST
|
Facility
|
IP
|
$3,296.00
|
|
|
Service Code
|
CPT 72125
|
| Hospital Charge Code |
909201915
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$596.58 |
| Max. Negotiated Rate |
$2,472.00 |
| Rate for Payer: Adventist Health Commercial |
$659.20
|
| Rate for Payer: Cash Price |
$1,483.20
|
| Rate for Payer: Cash Price |
$1,483.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$711.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,231.39
|
| Rate for Payer: Heritage Provider Network Senior |
$2,231.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$596.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$824.00
|
| Rate for Payer: Multiplan Commercial |
$2,472.00
|
|
