|
HC FOOT COMPLETE
|
Facility
|
OP
|
$605.00
|
|
|
Service Code
|
CPT 73630
|
| Hospital Charge Code |
909001631
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$37.78 |
| Max. Negotiated Rate |
$453.75 |
| Rate for Payer: Adventist Health Commercial |
$121.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$51.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$415.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$113.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$127.02
|
| Rate for Payer: Blue Shield of California Commercial |
$106.76
|
| Rate for Payer: Blue Shield of California EPN |
$60.71
|
| Rate for Payer: Cash Price |
$272.25
|
| Rate for Payer: Cash Price |
$272.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$393.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.89
|
| Rate for Payer: Dignity Health Senior |
$113.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$393.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$374.50
|
| Rate for Payer: Heritage Provider Network Senior |
$374.50
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$37.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$113.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$109.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$151.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$143.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$143.06
|
| Rate for Payer: Multiplan Commercial |
$453.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$113.54
|
| Rate for Payer: TriValley Medical Group Senior |
$113.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Vantage Medical Group Senior |
$113.54
|
|
|
HC FOOT COMPLETE
|
Facility
|
IP
|
$605.00
|
|
|
Service Code
|
CPT 73630
|
| Hospital Charge Code |
909001631
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$109.50 |
| Max. Negotiated Rate |
$453.75 |
| Rate for Payer: Adventist Health Commercial |
$121.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$415.64
|
| Rate for Payer: Cash Price |
$272.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$409.58
|
| Rate for Payer: Heritage Provider Network Senior |
$409.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$109.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$151.25
|
| Rate for Payer: Multiplan Commercial |
$453.75
|
|
|
HC FOOT LIMITED 2 VIEWS
|
Facility
|
IP
|
$446.00
|
|
|
Service Code
|
CPT 73620
|
| Hospital Charge Code |
909001632
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$80.73 |
| Max. Negotiated Rate |
$334.50 |
| Rate for Payer: Adventist Health Commercial |
$89.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$306.40
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$301.94
|
| Rate for Payer: Heritage Provider Network Senior |
$301.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.50
|
| Rate for Payer: Multiplan Commercial |
$334.50
|
|
|
HC FOOT LIMITED 2 VIEWS
|
Facility
|
OP
|
$446.00
|
|
|
Service Code
|
CPT 73620
|
| Hospital Charge Code |
909001632
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$26.99 |
| Max. Negotiated Rate |
$334.50 |
| Rate for Payer: Adventist Health Commercial |
$89.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$306.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$113.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$118.11
|
| Rate for Payer: Blue Shield of California Commercial |
$98.89
|
| Rate for Payer: Blue Shield of California EPN |
$56.23
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$289.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.89
|
| Rate for Payer: Dignity Health Senior |
$113.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$289.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$276.07
|
| Rate for Payer: Heritage Provider Network Senior |
$276.07
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$26.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$113.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$143.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$143.06
|
| Rate for Payer: Multiplan Commercial |
$334.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$113.54
|
| Rate for Payer: TriValley Medical Group Senior |
$113.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Vantage Medical Group Senior |
$113.54
|
|
|
HC FOREARM
|
Facility
|
OP
|
$514.00
|
|
|
Service Code
|
CPT 73090
|
| Hospital Charge Code |
909001513
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$32.42 |
| Max. Negotiated Rate |
$385.50 |
| Rate for Payer: Adventist Health Commercial |
$102.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$44.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$353.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$113.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$124.99
|
| Rate for Payer: Blue Shield of California Commercial |
$104.76
|
| Rate for Payer: Blue Shield of California EPN |
$59.57
|
| Rate for Payer: Cash Price |
$231.30
|
| Rate for Payer: Cash Price |
$231.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$334.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.89
|
| Rate for Payer: Dignity Health Senior |
$113.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$334.10
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$318.17
|
| Rate for Payer: Heritage Provider Network Senior |
$318.17
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$32.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$113.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$93.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$128.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$143.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$143.06
|
| Rate for Payer: Multiplan Commercial |
$385.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$113.54
|
| Rate for Payer: TriValley Medical Group Senior |
$113.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Vantage Medical Group Senior |
$113.54
|
|
|
HC FOREARM
|
Facility
|
IP
|
$514.00
|
|
|
Service Code
|
CPT 73090
|
| Hospital Charge Code |
909001513
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$93.03 |
| Max. Negotiated Rate |
$385.50 |
| Rate for Payer: Adventist Health Commercial |
$102.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$353.12
|
| Rate for Payer: Cash Price |
$231.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$347.98
|
| Rate for Payer: Heritage Provider Network Senior |
$347.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$93.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$128.50
|
| Rate for Payer: Multiplan Commercial |
$385.50
|
|
|
HC FOREIGN BODY NOSE/RECTUM CHILD
|
Facility
|
OP
|
$439.00
|
|
|
Service Code
|
CPT 76010
|
| Hospital Charge Code |
909001710
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$36.41 |
| Max. Negotiated Rate |
$329.25 |
| Rate for Payer: Adventist Health Commercial |
$87.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$41.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$301.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$113.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$132.26
|
| Rate for Payer: Blue Shield of California Commercial |
$104.76
|
| Rate for Payer: Blue Shield of California EPN |
$59.57
|
| Rate for Payer: Cash Price |
$197.55
|
| Rate for Payer: Cash Price |
$197.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$285.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.89
|
| Rate for Payer: Dignity Health Senior |
$113.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$285.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$271.74
|
| Rate for Payer: Heritage Provider Network Senior |
$271.74
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$36.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$113.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$79.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$143.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$143.06
|
| Rate for Payer: Multiplan Commercial |
$329.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$113.54
|
| Rate for Payer: TriValley Medical Group Senior |
$113.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Vantage Medical Group Senior |
$113.54
|
|
|
HC FOREIGN BODY NOSE/RECTUM CHILD
|
Facility
|
IP
|
$439.00
|
|
|
Service Code
|
CPT 76010
|
| Hospital Charge Code |
909001710
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$79.46 |
| Max. Negotiated Rate |
$329.25 |
| Rate for Payer: Adventist Health Commercial |
$87.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$301.59
|
| Rate for Payer: Cash Price |
$197.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$297.20
|
| Rate for Payer: Heritage Provider Network Senior |
$297.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$79.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.75
|
| Rate for Payer: Multiplan Commercial |
$329.25
|
|
|
HC FORESKIN MANIPULATION
|
Facility
|
IP
|
$939.00
|
|
|
Service Code
|
CPT 54450
|
| Hospital Charge Code |
908710164
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$169.96 |
| Max. Negotiated Rate |
$704.25 |
| Rate for Payer: Adventist Health Commercial |
$187.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$645.09
|
| Rate for Payer: Cash Price |
$422.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$635.70
|
| Rate for Payer: Heritage Provider Network Senior |
$635.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$169.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$234.75
|
| Rate for Payer: Multiplan Commercial |
$704.25
|
|
|
HC FORESKIN MANIPULATION
|
Facility
|
OP
|
$939.00
|
|
|
Service Code
|
CPT 54450
|
| Hospital Charge Code |
908710164
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$169.96 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$187.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$645.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$463.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$339.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$308.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$422.55
|
| Rate for Payer: Cash Price |
$422.55
|
| Rate for Payer: Cash Price |
$422.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$610.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$463.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$339.67
|
| Rate for Payer: Dignity Health Senior |
$308.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$308.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$635.70
|
| Rate for Payer: Heritage Provider Network Senior |
$635.70
|
| Rate for Payer: Humana Medicare |
$308.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$308.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$452.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$169.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$364.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$234.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$389.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$389.08
|
| Rate for Payer: Multiplan Commercial |
$704.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$340.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$313.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$463.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$339.67
|
| Rate for Payer: Vantage Medical Group Senior |
$308.79
|
|
|
HC FO SAFETY PIN WIRE
|
Facility
|
IP
|
$145.00
|
|
|
Service Code
|
CPT L3925
|
| Hospital Charge Code |
901309135
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$29.00 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$29.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$69.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$99.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$66.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$78.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$98.16
|
| Rate for Payer: Heritage Provider Network Senior |
$7,571.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$72.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$72.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.25
|
| Rate for Payer: Multiplan Commercial |
$108.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$52.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$48.44
|
|
|
HC FO SAFETY PIN WIRE
|
Facility
|
OP
|
$145.00
|
|
|
Service Code
|
CPT L3925
|
| Hospital Charge Code |
901309135
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$29.00 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$29.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$69.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$99.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$123.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$79.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$108.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$90.04
|
| Rate for Payer: Blue Shield of California EPN |
$85.12
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$66.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$123.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$123.25
|
| Rate for Payer: Dignity Health Senior |
$123.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$92.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$67.14
|
| Rate for Payer: Heritage Provider Network Senior |
$67.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$62.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$72.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$72.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.25
|
| Rate for Payer: Multiplan Commercial |
$108.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$52.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$48.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$123.25
|
| Rate for Payer: Vantage Medical Group Senior |
$123.25
|
|
|
HC FREE T4 BY EIA
|
Facility
|
IP
|
$244.00
|
|
|
Service Code
|
CPT 84439
|
| Hospital Charge Code |
900912111
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$44.16 |
| Max. Negotiated Rate |
$183.00 |
| Rate for Payer: Adventist Health Commercial |
$48.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$167.63
|
| Rate for Payer: Cash Price |
$109.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$165.19
|
| Rate for Payer: Heritage Provider Network Senior |
$165.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.00
|
| Rate for Payer: Multiplan Commercial |
$183.00
|
|
|
HC FREE T4 BY EIA
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
CPT 84439
|
| Hospital Charge Code |
900912111
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.07 |
| Max. Negotiated Rate |
$75.45 |
| Rate for Payer: Adventist Health Commercial |
$5.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75.45
|
| Rate for Payer: Blue Shield of California Commercial |
$70.43
|
| Rate for Payer: Blue Shield of California EPN |
$55.06
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.92
|
| Rate for Payer: Dignity Health Senior |
$9.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$9.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.33
|
| Rate for Payer: Heritage Provider Network Senior |
$17.33
|
| Rate for Payer: Humana Medicare |
$9.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.37
|
| Rate for Payer: Multiplan Commercial |
$21.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.02
|
| Rate for Payer: TriValley Medical Group Senior |
$9.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.92
|
| Rate for Payer: Vantage Medical Group Senior |
$9.02
|
|
|
HC FROZEN SECTION
|
Facility
|
IP
|
$610.00
|
|
|
Service Code
|
CPT 88331
|
| Hospital Charge Code |
903800035
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$110.41 |
| Max. Negotiated Rate |
$457.50 |
| Rate for Payer: Adventist Health Commercial |
$122.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$419.07
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$412.97
|
| Rate for Payer: Heritage Provider Network Senior |
$412.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$110.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$152.50
|
| Rate for Payer: Multiplan Commercial |
$457.50
|
|
|
HC FROZEN SECTION
|
Facility
|
OP
|
$149.00
|
|
|
Service Code
|
CPT 88331
|
| Hospital Charge Code |
903800035
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$26.97 |
| Max. Negotiated Rate |
$405.48 |
| Rate for Payer: Adventist Health Commercial |
$29.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$70.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$102.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$320.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$234.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$213.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$133.27
|
| Rate for Payer: Blue Shield of California Commercial |
$92.53
|
| Rate for Payer: Blue Shield of California EPN |
$87.46
|
| Rate for Payer: Cash Price |
$67.05
|
| Rate for Payer: Cash Price |
$67.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$96.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$320.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$234.75
|
| Rate for Payer: Dignity Health Senior |
$213.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$213.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$92.23
|
| Rate for Payer: Heritage Provider Network Senior |
$92.23
|
| Rate for Payer: Humana Medicare |
$213.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$69.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$213.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$405.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$251.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$268.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$268.90
|
| Rate for Payer: Multiplan Commercial |
$111.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$213.41
|
| Rate for Payer: TriValley Medical Group Senior |
$213.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$164.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$164.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$320.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$234.75
|
| Rate for Payer: Vantage Medical Group Senior |
$213.41
|
|
|
HC FSH
|
Facility
|
IP
|
$244.00
|
|
|
Service Code
|
CPT 83001
|
| Hospital Charge Code |
900910818
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$44.16 |
| Max. Negotiated Rate |
$183.00 |
| Rate for Payer: Adventist Health Commercial |
$48.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$167.63
|
| Rate for Payer: Cash Price |
$109.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$165.19
|
| Rate for Payer: Heritage Provider Network Senior |
$165.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.00
|
| Rate for Payer: Multiplan Commercial |
$183.00
|
|
|
HC FSH
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
CPT 83001
|
| Hospital Charge Code |
900910818
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.52 |
| Max. Negotiated Rate |
$155.53 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$54.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$155.53
|
| Rate for Payer: Blue Shield of California Commercial |
$145.17
|
| Rate for Payer: Blue Shield of California EPN |
$113.49
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.44
|
| Rate for Payer: Dignity Health Senior |
$18.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.28
|
| Rate for Payer: Heritage Provider Network Senior |
$22.28
|
| Rate for Payer: Humana Medicare |
$18.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$35.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.41
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.58
|
| Rate for Payer: TriValley Medical Group Senior |
$18.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.44
|
| Rate for Payer: Vantage Medical Group Senior |
$18.58
|
|
|
HC FULL THCKNESS GRAFT LT 20SQ CM
|
Facility
|
IP
|
$6,345.00
|
|
|
Service Code
|
CPT 15240
|
| Hospital Charge Code |
900501513
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,148.44 |
| Max. Negotiated Rate |
$4,758.75 |
| Rate for Payer: Adventist Health Commercial |
$1,269.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,359.02
|
| Rate for Payer: Cash Price |
$2,855.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,295.56
|
| Rate for Payer: Heritage Provider Network Senior |
$4,295.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,148.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,586.25
|
| Rate for Payer: Multiplan Commercial |
$4,758.75
|
|
|
HC FULL THCKNESS GRAFT LT 20SQ CM
|
Facility
|
OP
|
$6,345.00
|
|
|
Service Code
|
CPT 15240
|
| Hospital Charge Code |
900501513
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$936.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,269.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,359.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Cash Price |
$2,855.25
|
| Rate for Payer: Cash Price |
$2,855.25
|
| Rate for Payer: Cash Price |
$2,855.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,124.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,295.56
|
| Rate for Payer: Heritage Provider Network Senior |
$4,295.56
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,058.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,148.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,586.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: Multiplan Commercial |
$4,758.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,303.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,119.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
HC FULL THCKNESS GRAFT,LT 20SQ CM
|
Facility
|
IP
|
$6,345.00
|
|
|
Service Code
|
CPT 15220
|
| Hospital Charge Code |
900501388
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,148.44 |
| Max. Negotiated Rate |
$4,758.75 |
| Rate for Payer: Adventist Health Commercial |
$1,269.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,359.02
|
| Rate for Payer: Cash Price |
$2,855.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,295.56
|
| Rate for Payer: Heritage Provider Network Senior |
$4,295.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,148.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,586.25
|
| Rate for Payer: Multiplan Commercial |
$4,758.75
|
|
|
HC FULL THCKNESS GRAFT,LT 20SQ CM
|
Facility
|
OP
|
$6,345.00
|
|
|
Service Code
|
CPT 15220
|
| Hospital Charge Code |
900501388
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$936.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,269.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,359.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Cash Price |
$2,855.25
|
| Rate for Payer: Cash Price |
$2,855.25
|
| Rate for Payer: Cash Price |
$2,855.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,124.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,295.56
|
| Rate for Payer: Heritage Provider Network Senior |
$4,295.56
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,058.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,148.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,586.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: Multiplan Commercial |
$4,758.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,303.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,119.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
HC FULL THKNS GRFT LT 20SQ CM FCE
|
Facility
|
IP
|
$6,345.00
|
|
|
Service Code
|
CPT 15260
|
| Hospital Charge Code |
900501754
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,148.44 |
| Max. Negotiated Rate |
$4,758.75 |
| Rate for Payer: Adventist Health Commercial |
$1,269.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,359.02
|
| Rate for Payer: Cash Price |
$2,855.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,295.56
|
| Rate for Payer: Heritage Provider Network Senior |
$4,295.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,148.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,586.25
|
| Rate for Payer: Multiplan Commercial |
$4,758.75
|
|
|
HC FULL THKNS GRFT LT 20SQ CM FCE
|
Facility
|
OP
|
$6,345.00
|
|
|
Service Code
|
CPT 15260
|
| Hospital Charge Code |
900501754
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$936.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,269.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,359.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Cash Price |
$2,855.25
|
| Rate for Payer: Cash Price |
$2,855.25
|
| Rate for Payer: Cash Price |
$2,855.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,124.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,295.56
|
| Rate for Payer: Heritage Provider Network Senior |
$4,295.56
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,058.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,148.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,586.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: Multiplan Commercial |
$4,758.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,303.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,119.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
HC FUSION OF TENDONS AT WRIST
|
Facility
|
OP
|
$6,736.00
|
|
|
Service Code
|
CPT 25300
|
| Hospital Charge Code |
900501447
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$936.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,347.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,627.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Cash Price |
$3,031.20
|
| Rate for Payer: Cash Price |
$3,031.20
|
| Rate for Payer: Cash Price |
$3,031.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,378.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,448.63
|
| Rate for Payer: Dignity Health Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,044.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,560.27
|
| Rate for Payer: Heritage Provider Network Senior |
$4,560.27
|
| Rate for Payer: Humana Medicare |
$4,044.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,044.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,246.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,219.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,772.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,684.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,095.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,095.70
|
| Rate for Payer: Multiplan Commercial |
$5,052.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,445.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,250.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
