|
HC GUIDEWIRE, JINDO TAPERED
|
Facility
|
OP
|
$432.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909081418
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$78.19 |
| Max. Negotiated Rate |
$367.20 |
| Rate for Payer: Adventist Health Commercial |
$86.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$157.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$296.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$367.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$237.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$324.00
|
| Rate for Payer: Blue Shield of California Commercial |
$268.27
|
| Rate for Payer: Blue Shield of California EPN |
$253.58
|
| Rate for Payer: Cash Price |
$194.40
|
| Rate for Payer: Cash Price |
$194.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$280.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$367.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$367.20
|
| Rate for Payer: Dignity Health Senior |
$367.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$280.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$267.41
|
| Rate for Payer: Heritage Provider Network Senior |
$267.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$208.22
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$367.20
|
| Rate for Payer: Vantage Medical Group Senior |
$367.20
|
|
|
HC GUIDEWIRE, LUNDERQUIST
|
Facility
|
OP
|
$378.74
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909020084
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.55 |
| Max. Negotiated Rate |
$321.93 |
| Rate for Payer: Adventist Health Commercial |
$75.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$157.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$260.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$321.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$208.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$284.06
|
| Rate for Payer: Blue Shield of California Commercial |
$235.20
|
| Rate for Payer: Blue Shield of California EPN |
$222.32
|
| Rate for Payer: Cash Price |
$170.43
|
| Rate for Payer: Cash Price |
$170.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$246.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$321.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$321.93
|
| Rate for Payer: Dignity Health Senior |
$321.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$246.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$234.44
|
| Rate for Payer: Heritage Provider Network Senior |
$234.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$182.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$94.68
|
| Rate for Payer: Multiplan Commercial |
$284.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$321.93
|
| Rate for Payer: Vantage Medical Group Senior |
$321.93
|
|
|
HC GUIDEWIRE, LUNDERQUIST
|
Facility
|
IP
|
$378.74
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909020084
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.55 |
| Max. Negotiated Rate |
$284.06 |
| Rate for Payer: Adventist Health Commercial |
$75.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$260.19
|
| Rate for Payer: Cash Price |
$170.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$256.41
|
| Rate for Payer: Heritage Provider Network Senior |
$256.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$94.68
|
| Rate for Payer: Multiplan Commercial |
$284.06
|
|
|
HC GUIDE WIRE M
|
Facility
|
OP
|
$900.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
900803803
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$157.10 |
| Max. Negotiated Rate |
$765.00 |
| Rate for Payer: Adventist Health Commercial |
$180.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$157.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$618.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$765.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$495.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$675.00
|
| Rate for Payer: Blue Shield of California Commercial |
$558.90
|
| Rate for Payer: Blue Shield of California EPN |
$528.30
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$585.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$765.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$765.00
|
| Rate for Payer: Dignity Health Senior |
$765.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$585.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$557.10
|
| Rate for Payer: Heritage Provider Network Senior |
$557.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$433.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$162.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$225.00
|
| Rate for Payer: Multiplan Commercial |
$675.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$765.00
|
| Rate for Payer: Vantage Medical Group Senior |
$765.00
|
|
|
HC GUIDE WIRE M
|
Facility
|
IP
|
$900.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
900803803
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$162.90 |
| Max. Negotiated Rate |
$675.00 |
| Rate for Payer: Adventist Health Commercial |
$180.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$618.30
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$609.30
|
| Rate for Payer: Heritage Provider Network Senior |
$609.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$162.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$225.00
|
| Rate for Payer: Multiplan Commercial |
$675.00
|
|
|
HC GUIDEWIRE, PERSUADER
|
Facility
|
IP
|
$551.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909020116
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$99.73 |
| Max. Negotiated Rate |
$413.25 |
| Rate for Payer: Adventist Health Commercial |
$110.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$378.54
|
| Rate for Payer: Cash Price |
$247.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$373.03
|
| Rate for Payer: Heritage Provider Network Senior |
$373.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$99.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.75
|
| Rate for Payer: Multiplan Commercial |
$413.25
|
|
|
HC GUIDEWIRE, PERSUADER
|
Facility
|
OP
|
$551.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909020116
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$99.73 |
| Max. Negotiated Rate |
$468.35 |
| Rate for Payer: Adventist Health Commercial |
$110.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$157.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$378.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$468.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$303.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$413.25
|
| Rate for Payer: Blue Shield of California Commercial |
$342.17
|
| Rate for Payer: Blue Shield of California EPN |
$323.44
|
| Rate for Payer: Cash Price |
$247.95
|
| Rate for Payer: Cash Price |
$247.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$358.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$468.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$468.35
|
| Rate for Payer: Dignity Health Senior |
$468.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$358.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$341.07
|
| Rate for Payer: Heritage Provider Network Senior |
$341.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$265.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$99.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.75
|
| Rate for Payer: Multiplan Commercial |
$413.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$468.35
|
| Rate for Payer: Vantage Medical Group Senior |
$468.35
|
|
|
HC GUIDEWIRE SEPARATOR
|
Facility
|
OP
|
$5,500.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909020026
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$157.10 |
| Max. Negotiated Rate |
$4,675.00 |
| Rate for Payer: Adventist Health Commercial |
$1,100.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$157.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,778.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,675.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,025.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,125.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,415.50
|
| Rate for Payer: Blue Shield of California EPN |
$3,228.50
|
| Rate for Payer: Cash Price |
$2,475.00
|
| Rate for Payer: Cash Price |
$2,475.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,575.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,675.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,675.00
|
| Rate for Payer: Dignity Health Senior |
$4,675.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,575.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,404.50
|
| Rate for Payer: Heritage Provider Network Senior |
$3,404.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,651.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$995.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,375.00
|
| Rate for Payer: Multiplan Commercial |
$4,125.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,675.00
|
| Rate for Payer: Vantage Medical Group Senior |
$4,675.00
|
|
|
HC GUIDEWIRE SEPARATOR
|
Facility
|
IP
|
$5,500.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909020026
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$995.50 |
| Max. Negotiated Rate |
$4,125.00 |
| Rate for Payer: Adventist Health Commercial |
$1,100.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,778.50
|
| Rate for Payer: Cash Price |
$2,475.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,723.50
|
| Rate for Payer: Heritage Provider Network Senior |
$3,723.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$995.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,375.00
|
| Rate for Payer: Multiplan Commercial |
$4,125.00
|
|
|
HC GUIDEWIRE SYNCHRO
|
Facility
|
OP
|
$2,901.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909000003
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$157.10 |
| Max. Negotiated Rate |
$2,465.85 |
| Rate for Payer: Adventist Health Commercial |
$580.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$157.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,992.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,465.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,595.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,175.75
|
| Rate for Payer: Blue Shield of California Commercial |
$1,801.52
|
| Rate for Payer: Blue Shield of California EPN |
$1,702.89
|
| Rate for Payer: Cash Price |
$1,305.45
|
| Rate for Payer: Cash Price |
$1,305.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,885.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,465.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,465.85
|
| Rate for Payer: Dignity Health Senior |
$2,465.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,885.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,795.72
|
| Rate for Payer: Heritage Provider Network Senior |
$1,795.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,398.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$525.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$725.25
|
| Rate for Payer: Multiplan Commercial |
$2,175.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,465.85
|
| Rate for Payer: Vantage Medical Group Senior |
$2,465.85
|
|
|
HC GUIDEWIRE SYNCHRO
|
Facility
|
IP
|
$2,901.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909000003
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$525.08 |
| Max. Negotiated Rate |
$2,175.75 |
| Rate for Payer: Adventist Health Commercial |
$580.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,992.99
|
| Rate for Payer: Cash Price |
$1,305.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,963.98
|
| Rate for Payer: Heritage Provider Network Senior |
$1,963.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$525.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$725.25
|
| Rate for Payer: Multiplan Commercial |
$2,175.75
|
|
|
HC GUIDEWIRE, TRANSEND
|
Facility
|
IP
|
$1,108.60
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909020096
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$200.66 |
| Max. Negotiated Rate |
$831.45 |
| Rate for Payer: Adventist Health Commercial |
$221.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$761.61
|
| Rate for Payer: Cash Price |
$498.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$750.52
|
| Rate for Payer: Heritage Provider Network Senior |
$750.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$200.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$277.15
|
| Rate for Payer: Multiplan Commercial |
$831.45
|
|
|
HC GUIDEWIRE, TRANSEND
|
Facility
|
OP
|
$1,108.60
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
909020096
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$157.10 |
| Max. Negotiated Rate |
$942.31 |
| Rate for Payer: Adventist Health Commercial |
$221.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$157.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$761.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$942.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$609.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$831.45
|
| Rate for Payer: Blue Shield of California Commercial |
$688.44
|
| Rate for Payer: Blue Shield of California EPN |
$650.75
|
| Rate for Payer: Cash Price |
$498.87
|
| Rate for Payer: Cash Price |
$498.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$720.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$942.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$942.31
|
| Rate for Payer: Dignity Health Senior |
$942.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$720.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$686.22
|
| Rate for Payer: Heritage Provider Network Senior |
$686.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$534.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$200.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$277.15
|
| Rate for Payer: Multiplan Commercial |
$831.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$942.31
|
| Rate for Payer: Vantage Medical Group Senior |
$942.31
|
|
|
HC HALO ADDITION MRI COMPATIBLE
|
Facility
|
OP
|
$2,933.00
|
|
|
Service Code
|
CPT L0859
|
| Hospital Charge Code |
905350860
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$586.60 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$586.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,407.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,014.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,493.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,613.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,199.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,821.39
|
| Rate for Payer: Blue Shield of California EPN |
$1,721.67
|
| Rate for Payer: Cash Price |
$1,319.85
|
| Rate for Payer: Cash Price |
$1,319.85
|
| Rate for Payer: Cash Price |
$1,319.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,349.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,493.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,493.05
|
| Rate for Payer: Dignity Health Senior |
$2,493.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,877.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,357.98
|
| Rate for Payer: Heritage Provider Network Senior |
$1,357.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,144.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,466.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,466.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,466.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$733.25
|
| Rate for Payer: Multiplan Commercial |
$2,199.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,069.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$979.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,493.05
|
| Rate for Payer: Vantage Medical Group Senior |
$2,493.05
|
|
|
HC HALO ADDITION MRI COMPATIBLE
|
Facility
|
IP
|
$2,933.00
|
|
|
Service Code
|
CPT L0859
|
| Hospital Charge Code |
905350860
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$586.60 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$586.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,407.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,014.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$1,319.85
|
| Rate for Payer: Cash Price |
$1,319.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,349.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,583.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,985.64
|
| Rate for Payer: Heritage Provider Network Senior |
$7,571.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,466.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,466.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,466.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$733.25
|
| Rate for Payer: Multiplan Commercial |
$2,199.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,069.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$979.92
|
|
|
HC HALO ADDITION MRI COMPATIBLE SYSTEM
|
Facility
|
IP
|
$2,210.00
|
|
|
Service Code
|
CPT L0859
|
| Hospital Charge Code |
905350859
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$442.00 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$442.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,060.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,518.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$994.50
|
| Rate for Payer: Cash Price |
$994.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,016.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,193.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,496.17
|
| Rate for Payer: Heritage Provider Network Senior |
$7,571.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,105.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,105.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,105.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$552.50
|
| Rate for Payer: Multiplan Commercial |
$1,657.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$805.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$738.36
|
|
|
HC HALO ADDITION MRI COMPATIBLE SYSTEM
|
Facility
|
OP
|
$2,210.00
|
|
|
Service Code
|
CPT L0859
|
| Hospital Charge Code |
905350859
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$442.00 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$442.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,060.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,518.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,878.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,215.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,657.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,372.41
|
| Rate for Payer: Blue Shield of California EPN |
$1,297.27
|
| Rate for Payer: Cash Price |
$994.50
|
| Rate for Payer: Cash Price |
$994.50
|
| Rate for Payer: Cash Price |
$994.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,016.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,878.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,878.50
|
| Rate for Payer: Dignity Health Senior |
$1,878.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,414.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,023.23
|
| Rate for Payer: Heritage Provider Network Senior |
$1,023.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,144.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,105.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,105.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,105.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$552.50
|
| Rate for Payer: Multiplan Commercial |
$1,657.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$805.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$738.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,878.50
|
| Rate for Payer: Vantage Medical Group Senior |
$1,878.50
|
|
|
HC HALO PROCEDURE, W/VEST
|
Facility
|
IP
|
$11,190.00
|
|
|
Service Code
|
CPT L0810
|
| Hospital Charge Code |
905350810
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$2,238.00 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$2,238.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5,371.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,687.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$5,035.50
|
| Rate for Payer: Cash Price |
$5,035.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,147.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,042.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,575.63
|
| Rate for Payer: Heritage Provider Network Senior |
$7,571.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,595.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,595.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,595.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,797.50
|
| Rate for Payer: Multiplan Commercial |
$8,392.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,079.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,738.58
|
|
|
HC HALO PROCEDURE, W/VEST
|
Facility
|
OP
|
$11,190.00
|
|
|
Service Code
|
CPT L0810
|
| Hospital Charge Code |
905350810
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$2,238.00 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$2,238.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5,371.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,687.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9,511.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6,154.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,392.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$6,948.99
|
| Rate for Payer: Blue Shield of California EPN |
$6,568.53
|
| Rate for Payer: Cash Price |
$5,035.50
|
| Rate for Payer: Cash Price |
$5,035.50
|
| Rate for Payer: Cash Price |
$5,035.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,147.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,511.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,511.50
|
| Rate for Payer: Dignity Health Senior |
$9,511.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,161.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,180.97
|
| Rate for Payer: Heritage Provider Network Senior |
$5,180.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2,903.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,595.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,595.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,595.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,797.50
|
| Rate for Payer: Multiplan Commercial |
$8,392.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,079.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,738.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,511.50
|
| Rate for Payer: Vantage Medical Group Senior |
$9,511.50
|
|
|
HC HALO REPL LINER/INTERFACE
|
Facility
|
IP
|
$339.00
|
|
|
Service Code
|
CPT L0861
|
| Hospital Charge Code |
905350861
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$67.80 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$67.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$162.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$232.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$152.55
|
| Rate for Payer: Cash Price |
$152.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$155.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$183.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$229.50
|
| Rate for Payer: Heritage Provider Network Senior |
$7,571.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$169.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$169.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$169.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.75
|
| Rate for Payer: Multiplan Commercial |
$254.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$123.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$113.26
|
|
|
HC HALO REPL LINER/INTERFACE
|
Facility
|
OP
|
$339.00
|
|
|
Service Code
|
CPT L0861
|
| Hospital Charge Code |
905350861
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$67.80 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$67.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$162.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$232.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$288.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$186.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$254.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$210.52
|
| Rate for Payer: Blue Shield of California EPN |
$198.99
|
| Rate for Payer: Cash Price |
$152.55
|
| Rate for Payer: Cash Price |
$152.55
|
| Rate for Payer: Cash Price |
$152.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$155.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$288.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$288.15
|
| Rate for Payer: Dignity Health Senior |
$288.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$216.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$156.96
|
| Rate for Payer: Heritage Provider Network Senior |
$156.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$211.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$169.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$169.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$169.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.75
|
| Rate for Payer: Multiplan Commercial |
$254.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$123.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$113.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$288.15
|
| Rate for Payer: Vantage Medical Group Senior |
$288.15
|
|
|
HC HALO/TONGS REMOVAL
|
Facility
|
IP
|
$436.00
|
|
|
Service Code
|
CPT 20665
|
| Hospital Charge Code |
900501562
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$78.92 |
| Max. Negotiated Rate |
$327.00 |
| Rate for Payer: Adventist Health Commercial |
$87.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$299.53
|
| Rate for Payer: Cash Price |
$196.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$295.17
|
| Rate for Payer: Heritage Provider Network Senior |
$295.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$78.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.00
|
| Rate for Payer: Multiplan Commercial |
$327.00
|
|
|
HC HALO/TONGS REMOVAL
|
Facility
|
OP
|
$436.00
|
|
|
Service Code
|
CPT 20665
|
| Hospital Charge Code |
900501562
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$78.92 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$87.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$299.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$746.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$547.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$497.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$196.20
|
| Rate for Payer: Cash Price |
$196.20
|
| Rate for Payer: Cash Price |
$196.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$283.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$746.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$547.60
|
| Rate for Payer: Dignity Health Senior |
$497.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$497.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$295.17
|
| Rate for Payer: Heritage Provider Network Senior |
$295.17
|
| Rate for Payer: Humana Medicare |
$497.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$497.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$210.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$78.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$587.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$627.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$627.25
|
| Rate for Payer: Multiplan Commercial |
$327.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$158.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$145.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$746.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$547.60
|
| Rate for Payer: Vantage Medical Group Senior |
$497.82
|
|
|
HC HAND COMPLETE MIN 3 VIEWS
|
Facility
|
OP
|
$575.00
|
|
|
Service Code
|
CPT 73130
|
| Hospital Charge Code |
909001520
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$39.22 |
| Max. Negotiated Rate |
$431.25 |
| Rate for Payer: Adventist Health Commercial |
$115.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$52.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$395.02
|
| 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 |
$258.75
|
| Rate for Payer: Cash Price |
$258.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$373.75
|
| 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 |
$373.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$355.92
|
| Rate for Payer: Heritage Provider Network Senior |
$355.92
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$39.22
|
| 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 |
$104.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$143.75
|
| 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 |
$431.25
|
| 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 HAND COMPLETE MIN 3 VIEWS
|
Facility
|
IP
|
$575.00
|
|
|
Service Code
|
CPT 73130
|
| Hospital Charge Code |
909001520
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$104.08 |
| Max. Negotiated Rate |
$431.25 |
| Rate for Payer: Adventist Health Commercial |
$115.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$395.02
|
| Rate for Payer: Cash Price |
$258.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$389.28
|
| Rate for Payer: Heritage Provider Network Senior |
$389.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$104.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$143.75
|
| Rate for Payer: Multiplan Commercial |
$431.25
|
|
