|
HC GRAFT COMPOSITE EAR OR NASAL
|
Facility
|
IP
|
$7,462.00
|
|
|
Service Code
|
CPT 15760
|
| Hospital Charge Code |
900515760
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,350.62 |
| Max. Negotiated Rate |
$5,596.50 |
| Rate for Payer: Adventist Health Commercial |
$1,492.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,126.39
|
| Rate for Payer: Cash Price |
$3,357.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,051.77
|
| Rate for Payer: Heritage Provider Network Senior |
$5,051.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,350.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,865.50
|
| Rate for Payer: Multiplan Commercial |
$5,596.50
|
|
|
HC GRAFT COMPOSITE EAR OR NASAL
|
Facility
|
OP
|
$7,462.00
|
|
|
Service Code
|
CPT 15760
|
| Hospital Charge Code |
900515760
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$936.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,492.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,126.39
|
| 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 |
$3,357.90
|
| Rate for Payer: Cash Price |
$3,357.90
|
| Rate for Payer: Cash Price |
$3,357.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,850.30
|
| 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 |
$5,051.77
|
| Rate for Payer: Heritage Provider Network Senior |
$5,051.77
|
| 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 |
$3,596.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,350.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,865.50
|
| 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 |
$5,596.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,709.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,493.05
|
| 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 GRAFT DERMA-FAT-FASCIA
|
Facility
|
OP
|
$7,185.00
|
|
|
Service Code
|
CPT 15770
|
| Hospital Charge Code |
900501750
|
|
Hospital Revenue Code
|
451
|
| Min. Negotiated Rate |
$936.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,437.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,936.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,482.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Cash Price |
$3,233.25
|
| Rate for Payer: Cash Price |
$3,233.25
|
| Rate for Payer: Cash Price |
$3,233.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,670.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,930.75
|
| Rate for Payer: Dignity Health Senior |
$4,482.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,482.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,864.24
|
| Rate for Payer: Heritage Provider Network Senior |
$4,864.24
|
| Rate for Payer: Humana Medicare |
$4,482.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,482.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,463.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,300.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,289.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,796.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,647.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,647.95
|
| Rate for Payer: Multiplan Commercial |
$5,388.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,608.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,400.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4,482.50
|
|
|
HC GRAFT DERMA-FAT-FASCIA
|
Facility
|
IP
|
$7,185.00
|
|
|
Service Code
|
CPT 15770
|
| Hospital Charge Code |
900501750
|
|
Hospital Revenue Code
|
451
|
| Min. Negotiated Rate |
$1,300.48 |
| Max. Negotiated Rate |
$5,388.75 |
| Rate for Payer: Adventist Health Commercial |
$1,437.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,936.10
|
| Rate for Payer: Cash Price |
$3,233.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,864.24
|
| Rate for Payer: Heritage Provider Network Senior |
$4,864.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,300.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,796.25
|
| Rate for Payer: Multiplan Commercial |
$5,388.75
|
|
|
HC GRAFT, IM, CONDUIT
|
Facility
|
OP
|
$737.00
|
|
|
Service Code
|
CPT 93564
|
| Hospital Charge Code |
906820070
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$74.30 |
| Max. Negotiated Rate |
$8,689.75 |
| Rate for Payer: Adventist Health Commercial |
$147.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7,402.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$506.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$626.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$405.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$552.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| 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 |
$331.65
|
| Rate for Payer: Cash Price |
$331.65
|
| Rate for Payer: Cash Price |
$331.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,340.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$626.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$626.45
|
| Rate for Payer: Dignity Health Senior |
$626.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$479.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$456.20
|
| Rate for Payer: Heritage Provider Network Senior |
$456.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$74.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$355.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$133.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$184.25
|
| Rate for Payer: Multiplan Commercial |
$552.75
|
| 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 |
$626.45
|
| Rate for Payer: Vantage Medical Group Senior |
$626.45
|
|
|
HC GRAFT, IM, CONDUIT
|
Facility
|
OP
|
$27,338.00
|
|
|
Service Code
|
CPT 93564
|
| Hospital Charge Code |
906811413
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$74.30 |
| Max. Negotiated Rate |
$23,237.30 |
| Rate for Payer: Adventist Health Commercial |
$5,467.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7,402.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18,781.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23,237.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15,035.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20,503.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| 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 |
$12,302.10
|
| Rate for Payer: Cash Price |
$12,302.10
|
| Rate for Payer: Cash Price |
$12,302.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,340.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23,237.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$23,237.30
|
| Rate for Payer: Dignity Health Senior |
$23,237.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$17,769.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$16,922.22
|
| Rate for Payer: Heritage Provider Network Senior |
$16,922.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$74.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,176.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,948.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,834.50
|
| Rate for Payer: Multiplan Commercial |
$20,503.50
|
| 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 |
$23,237.30
|
| Rate for Payer: Vantage Medical Group Senior |
$23,237.30
|
|
|
HC GRAFT, IM, CONDUIT
|
Facility
|
IP
|
$27,338.00
|
|
|
Service Code
|
CPT 93564
|
| Hospital Charge Code |
906811413
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$4,948.18 |
| Max. Negotiated Rate |
$20,503.50 |
| Rate for Payer: Adventist Health Commercial |
$5,467.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18,781.21
|
| Rate for Payer: Cash Price |
$12,302.10
|
| Rate for Payer: Cash Price |
$12,302.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,478.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,982.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,948.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,834.50
|
| Rate for Payer: Multiplan Commercial |
$20,503.50
|
|
|
HC GRAFT, IM, CONDUIT
|
Facility
|
IP
|
$737.00
|
|
|
Service Code
|
CPT 93564
|
| Hospital Charge Code |
906820070
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$133.40 |
| Max. Negotiated Rate |
$5,478.00 |
| Rate for Payer: Adventist Health Commercial |
$147.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$506.32
|
| Rate for Payer: Cash Price |
$331.65
|
| Rate for Payer: Cash Price |
$331.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,478.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,982.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$133.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$184.25
|
| Rate for Payer: Multiplan Commercial |
$552.75
|
|
|
HC GRAM POSITIVE SENSITIVITY MIC
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
900912491
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Adventist Health Commercial |
$6.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.98
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.66
|
| Rate for Payer: Heritage Provider Network Senior |
$21.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.00
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
|
|
HC GRAM POSITIVE SENSITIVITY MIC
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
900912491
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.98 |
| Max. Negotiated Rate |
$72.35 |
| Rate for Payer: Adventist Health Commercial |
$4.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$72.35
|
| Rate for Payer: Blue Shield of California Commercial |
$67.53
|
| Rate for Payer: Blue Shield of California EPN |
$52.79
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.52
|
| Rate for Payer: Dignity Health Senior |
$8.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.30
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.62
|
| Rate for Payer: Heritage Provider Network Senior |
$13.62
|
| Rate for Payer: Humana Medicare |
$8.65
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.90
|
| Rate for Payer: Multiplan Commercial |
$16.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.65
|
| Rate for Payer: TriValley Medical Group Senior |
$8.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.52
|
| Rate for Payer: Vantage Medical Group Senior |
$8.65
|
|
|
HC GRAM STAIN
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
CPT 87205
|
| Hospital Charge Code |
900911705
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$28.96 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Adventist Health Commercial |
$32.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$109.92
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$108.32
|
| Rate for Payer: Heritage Provider Network Senior |
$108.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.00
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
|
|
HC GRAM STAIN
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
CPT 87205
|
| Hospital Charge Code |
900911705
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$35.73 |
| Rate for Payer: Adventist Health Commercial |
$2.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$35.73
|
| Rate for Payer: Blue Shield of California Commercial |
$33.32
|
| Rate for Payer: Blue Shield of California EPN |
$26.05
|
| Rate for Payer: Cash Price |
$5.85
|
| Rate for Payer: Cash Price |
$5.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.70
|
| Rate for Payer: Dignity Health Senior |
$4.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.05
|
| Rate for Payer: Heritage Provider Network Senior |
$8.05
|
| Rate for Payer: Humana Medicare |
$4.27
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.38
|
| Rate for Payer: Multiplan Commercial |
$9.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.27
|
| Rate for Payer: TriValley Medical Group Senior |
$4.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.70
|
| Rate for Payer: Vantage Medical Group Senior |
$4.27
|
|
|
HC GUID CATH/NEURO ENDOVASCULAR
|
Facility
|
IP
|
$3,900.00
|
|
|
Service Code
|
CPT C1887
|
| Hospital Charge Code |
909081802
|
|
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 GUID CATH/NEURO ENDOVASCULAR
|
Facility
|
OP
|
$3,900.00
|
|
|
Service Code
|
CPT C1887
|
| Hospital Charge Code |
909081802
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$74.67 |
| Max. Negotiated Rate |
$3,315.00 |
| Rate for Payer: Adventist Health Commercial |
$780.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$74.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,679.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,315.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,145.00
|
| Rate for Payer: Alpha Care 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 GUIDEWIRE ASAHI CHAKAI
|
Facility
|
OP
|
$2,070.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909000019
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$157.10 |
| Max. Negotiated Rate |
$1,759.50 |
| Rate for Payer: Adventist Health Commercial |
$414.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$157.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,422.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,759.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,138.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,552.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1,285.47
|
| Rate for Payer: Blue Shield of California EPN |
$1,215.09
|
| Rate for Payer: Cash Price |
$931.50
|
| Rate for Payer: Cash Price |
$931.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,345.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,759.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,759.50
|
| Rate for Payer: Dignity Health Senior |
$1,759.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,345.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,281.33
|
| Rate for Payer: Heritage Provider Network Senior |
$1,281.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$997.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$374.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$517.50
|
| Rate for Payer: Multiplan Commercial |
$1,552.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,759.50
|
| Rate for Payer: Vantage Medical Group Senior |
$1,759.50
|
|
|
HC GUIDEWIRE ASAHI CHAKAI
|
Facility
|
IP
|
$2,070.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909000019
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$374.67 |
| Max. Negotiated Rate |
$1,552.50 |
| Rate for Payer: Adventist Health Commercial |
$414.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,422.09
|
| Rate for Payer: Cash Price |
$931.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,401.39
|
| Rate for Payer: Heritage Provider Network Senior |
$1,401.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$374.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$517.50
|
| Rate for Payer: Multiplan Commercial |
$1,552.50
|
|
|
HC GUIDEWIRE/DIAG STARTER
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909081225
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.19 |
| Max. Negotiated Rate |
$157.10 |
| Rate for Payer: Adventist Health Commercial |
$21.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$157.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$58.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$79.50
|
| Rate for Payer: Blue Shield of California Commercial |
$65.83
|
| Rate for Payer: Blue Shield of California EPN |
$62.22
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$68.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$90.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$90.10
|
| Rate for Payer: Dignity Health Senior |
$90.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.61
|
| Rate for Payer: Heritage Provider Network Senior |
$65.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$51.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.50
|
| Rate for Payer: Multiplan Commercial |
$79.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$90.10
|
| Rate for Payer: Vantage Medical Group Senior |
$90.10
|
|
|
HC GUIDEWIRE/DIAG STARTER
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909081225
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.19 |
| Max. Negotiated Rate |
$79.50 |
| Rate for Payer: Adventist Health Commercial |
$21.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.82
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.76
|
| Rate for Payer: Heritage Provider Network Senior |
$71.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.50
|
| Rate for Payer: Multiplan Commercial |
$79.50
|
|
|
HC GUIDEWIRE EXCELSIOR 18
|
Facility
|
IP
|
$3,842.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909000021
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$695.40 |
| Max. Negotiated Rate |
$2,881.50 |
| Rate for Payer: Adventist Health Commercial |
$768.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,639.45
|
| Rate for Payer: Cash Price |
$1,728.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,601.03
|
| Rate for Payer: Heritage Provider Network Senior |
$2,601.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$695.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$960.50
|
| Rate for Payer: Multiplan Commercial |
$2,881.50
|
|
|
HC GUIDEWIRE EXCELSIOR 18
|
Facility
|
OP
|
$3,842.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909000021
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$157.10 |
| Max. Negotiated Rate |
$3,265.70 |
| Rate for Payer: Adventist Health Commercial |
$768.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$157.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,639.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,265.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,113.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,881.50
|
| Rate for Payer: Blue Shield of California Commercial |
$2,385.88
|
| Rate for Payer: Blue Shield of California EPN |
$2,255.25
|
| Rate for Payer: Cash Price |
$1,728.90
|
| Rate for Payer: Cash Price |
$1,728.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,497.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,265.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,265.70
|
| Rate for Payer: Dignity Health Senior |
$3,265.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,497.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,378.20
|
| Rate for Payer: Heritage Provider Network Senior |
$2,378.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,851.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$695.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$960.50
|
| Rate for Payer: Multiplan Commercial |
$2,881.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,265.70
|
| Rate for Payer: Vantage Medical Group Senior |
$3,265.70
|
|
|
HC GUIDEWIRE/GLIDE/AMPLATZ
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909081288
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.03 |
| Max. Negotiated Rate |
$157.10 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$157.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$39.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$54.00
|
| Rate for Payer: Blue Shield of California Commercial |
$44.71
|
| Rate for Payer: Blue Shield of California EPN |
$42.26
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$46.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$61.20
|
| Rate for Payer: Dignity Health Senior |
$61.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.57
|
| Rate for Payer: Heritage Provider Network Senior |
$44.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$34.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61.20
|
| Rate for Payer: Vantage Medical Group Senior |
$61.20
|
|
|
HC GUIDEWIRE/GLIDE/AMPLATZ
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909081288
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.03 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.46
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.74
|
| Rate for Payer: Heritage Provider Network Senior |
$48.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
|
|
HC GUIDEWIRE GOLD TIP
|
Facility
|
OP
|
$1,334.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909000011
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$157.10 |
| Max. Negotiated Rate |
$1,133.90 |
| Rate for Payer: Adventist Health Commercial |
$266.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$157.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$916.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,133.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$733.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,000.50
|
| Rate for Payer: Blue Shield of California Commercial |
$828.41
|
| Rate for Payer: Blue Shield of California EPN |
$783.06
|
| Rate for Payer: Cash Price |
$600.30
|
| Rate for Payer: Cash Price |
$600.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$867.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,133.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,133.90
|
| Rate for Payer: Dignity Health Senior |
$1,133.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$867.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$825.75
|
| Rate for Payer: Heritage Provider Network Senior |
$825.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$642.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$241.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$333.50
|
| Rate for Payer: Multiplan Commercial |
$1,000.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,133.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1,133.90
|
|
|
HC GUIDEWIRE GOLD TIP
|
Facility
|
IP
|
$1,334.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909000011
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$241.45 |
| Max. Negotiated Rate |
$1,000.50 |
| Rate for Payer: Adventist Health Commercial |
$266.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$916.46
|
| Rate for Payer: Cash Price |
$600.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$903.12
|
| Rate for Payer: Heritage Provider Network Senior |
$903.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$241.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$333.50
|
| Rate for Payer: Multiplan Commercial |
$1,000.50
|
|
|
HC GUIDEWIRE, JINDO TAPERED
|
Facility
|
IP
|
$432.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909081418
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$78.19 |
| Max. Negotiated Rate |
$324.00 |
| Rate for Payer: Adventist Health Commercial |
$86.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$296.78
|
| Rate for Payer: Cash Price |
$194.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$292.46
|
| Rate for Payer: Heritage Provider Network Senior |
$292.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$78.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.00
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
|
