|
HC CMV AB IGM
|
Facility
|
OP
|
$314.00
|
|
|
Service Code
|
CPT 86645
|
| Hospital Charge Code |
900910959
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$16.85 |
| Max. Negotiated Rate |
$235.50 |
| Rate for Payer: Vantage Medical Group Senior |
$16.85
|
| Rate for Payer: Adventist Health Commercial |
$62.80
|
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$194.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$153.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$153.16
|
| Rate for Payer: Blue Shield of California Commercial |
$135.59
|
| Rate for Payer: Blue Shield of California Commercial |
$135.59
|
| Rate for Payer: Blue Shield of California EPN |
$108.75
|
| Rate for Payer: Blue Shield of California EPN |
$108.75
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$78.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$204.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$185.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$70.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$74.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$194.37
|
| Rate for Payer: Heritage Provider Network Senior |
$74.28
|
| Rate for Payer: Heritage Provider Network Senior |
$194.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16.85
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$57.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$149.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$56.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22.58
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$235.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.85
|
| Rate for Payer: TriValley Medical Group Senior |
$16.85
|
| Rate for Payer: TriValley Medical Group Senior |
$16.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.54
|
| Rate for Payer: Vantage Medical Group Senior |
$16.85
|
|
|
HC CMV AB IGM
|
Facility
|
IP
|
$314.00
|
|
|
Service Code
|
CPT 86645
|
| Hospital Charge Code |
900910959
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$56.83 |
| Max. Negotiated Rate |
$235.50 |
| Rate for Payer: Adventist Health Commercial |
$62.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$202.22
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$212.58
|
| Rate for Payer: Heritage Provider Network Senior |
$212.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$56.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.50
|
| Rate for Payer: Multiplan Commercial |
$235.50
|
|
|
HC CMVABM
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
CPT 86645
|
| Hospital Charge Code |
900913700
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$153.16 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$153.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$153.16
|
| Rate for Payer: Blue Shield of California Commercial |
$135.59
|
| Rate for Payer: Blue Shield of California Commercial |
$135.59
|
| Rate for Payer: Blue Shield of California EPN |
$108.75
|
| Rate for Payer: Blue Shield of California EPN |
$108.75
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.03
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.38
|
| Rate for Payer: Heritage Provider Network Senior |
$10.52
|
| Rate for Payer: Heritage Provider Network Senior |
$12.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16.85
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$9.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22.58
|
| Rate for Payer: Multiplan Commercial |
$12.75
|
| Rate for Payer: Multiplan Commercial |
$15.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.85
|
| Rate for Payer: TriValley Medical Group Senior |
$16.85
|
| Rate for Payer: TriValley Medical Group Senior |
$16.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.54
|
| Rate for Payer: Vantage Medical Group Senior |
$16.85
|
| Rate for Payer: Vantage Medical Group Senior |
$16.85
|
|
|
HC CMVABM
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
CPT 86645
|
| Hospital Charge Code |
900913700
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.88
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.54
|
| Rate for Payer: Heritage Provider Network Senior |
$13.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$15.00
|
|
|
HC CMV ANTIBODY IGG
|
Facility
|
IP
|
$134.00
|
|
|
Service Code
|
CPT 86644
|
| Hospital Charge Code |
900913650
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$24.25 |
| Max. Negotiated Rate |
$100.50 |
| Rate for Payer: Adventist Health Commercial |
$26.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$86.30
|
| Rate for Payer: Cash Price |
$60.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$90.72
|
| Rate for Payer: Heritage Provider Network Senior |
$90.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$24.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.50
|
| Rate for Payer: Multiplan Commercial |
$100.50
|
|
|
HC CMV ANTIBODY IGG
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
CPT 86644
|
| Hospital Charge Code |
900913650
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$14.39 |
| Max. Negotiated Rate |
$136.22 |
| Rate for Payer: Adventist Health Commercial |
$19.60
|
| Rate for Payer: Adventist Health Commercial |
$26.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$60.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$136.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$136.22
|
| Rate for Payer: Blue Shield of California Commercial |
$115.83
|
| Rate for Payer: Blue Shield of California Commercial |
$115.83
|
| Rate for Payer: Blue Shield of California EPN |
$92.91
|
| Rate for Payer: Blue Shield of California EPN |
$92.91
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$60.30
|
| Rate for Payer: Cash Price |
$60.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$87.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$63.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$79.06
|
| Rate for Payer: EPIC Health Plan Medicare |
$14.39
|
| Rate for Payer: EPIC Health Plan Medicare |
$14.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$82.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.66
|
| Rate for Payer: Heritage Provider Network Senior |
$82.95
|
| Rate for Payer: Heritage Provider Network Senior |
$60.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14.39
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$63.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$46.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$24.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$19.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$19.28
|
| Rate for Payer: Multiplan Commercial |
$100.50
|
| Rate for Payer: Multiplan Commercial |
$73.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.39
|
| Rate for Payer: TriValley Medical Group Senior |
$14.39
|
| Rate for Payer: TriValley Medical Group Senior |
$14.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.83
|
| Rate for Payer: Vantage Medical Group Senior |
$14.39
|
| Rate for Payer: Vantage Medical Group Senior |
$14.39
|
|
|
HC CMV ANTIBODY IGM
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
CPT 86645
|
| Hospital Charge Code |
900913651
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$16.85 |
| Max. Negotiated Rate |
$153.16 |
| Rate for Payer: Adventist Health Commercial |
$19.60
|
| Rate for Payer: Adventist Health Commercial |
$26.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$60.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$153.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$153.16
|
| Rate for Payer: Blue Shield of California Commercial |
$135.59
|
| Rate for Payer: Blue Shield of California Commercial |
$135.59
|
| Rate for Payer: Blue Shield of California EPN |
$108.75
|
| Rate for Payer: Blue Shield of California EPN |
$108.75
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$60.30
|
| Rate for Payer: Cash Price |
$60.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$87.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$63.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$79.06
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$82.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.66
|
| Rate for Payer: Heritage Provider Network Senior |
$82.95
|
| Rate for Payer: Heritage Provider Network Senior |
$60.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16.85
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$63.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$46.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$24.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22.58
|
| Rate for Payer: Multiplan Commercial |
$100.50
|
| Rate for Payer: Multiplan Commercial |
$73.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.85
|
| Rate for Payer: TriValley Medical Group Senior |
$16.85
|
| Rate for Payer: TriValley Medical Group Senior |
$16.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.54
|
| Rate for Payer: Vantage Medical Group Senior |
$16.85
|
| Rate for Payer: Vantage Medical Group Senior |
$16.85
|
|
|
HC CMV ANTIBODY IGM
|
Facility
|
IP
|
$134.00
|
|
|
Service Code
|
CPT 86645
|
| Hospital Charge Code |
900913651
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$24.25 |
| Max. Negotiated Rate |
$100.50 |
| Rate for Payer: Adventist Health Commercial |
$26.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$86.30
|
| Rate for Payer: Cash Price |
$60.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$90.72
|
| Rate for Payer: Heritage Provider Network Senior |
$90.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$24.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.50
|
| Rate for Payer: Multiplan Commercial |
$100.50
|
|
|
HC CMV DNA QUANT PCR TEST
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
CPT 87497
|
| Hospital Charge Code |
900913695
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$32.58 |
| Max. Negotiated Rate |
$344.74 |
| Rate for Payer: Adventist Health Commercial |
$36.00
|
| Rate for Payer: Adventist Health Commercial |
$30.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$92.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$111.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$64.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$64.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$42.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$42.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$245.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$245.65
|
| Rate for Payer: Blue Shield of California Commercial |
$344.74
|
| Rate for Payer: Blue Shield of California Commercial |
$344.74
|
| Rate for Payer: Blue Shield of California EPN |
$276.51
|
| Rate for Payer: Blue Shield of California EPN |
$276.51
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$97.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$117.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$64.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$64.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$42.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$42.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$117.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$42.84
|
| Rate for Payer: EPIC Health Plan Medicare |
$42.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$92.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$111.42
|
| Rate for Payer: Heritage Provider Network Senior |
$92.85
|
| Rate for Payer: Heritage Provider Network Senior |
$111.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$42.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$42.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$71.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$85.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$27.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$32.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$49.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$49.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$57.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$57.41
|
| Rate for Payer: Multiplan Commercial |
$112.50
|
| Rate for Payer: Multiplan Commercial |
$135.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$42.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$42.84
|
| Rate for Payer: TriValley Medical Group Senior |
$42.84
|
| Rate for Payer: TriValley Medical Group Senior |
$42.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$46.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$46.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$46.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$46.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$64.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$64.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.12
|
| Rate for Payer: Vantage Medical Group Senior |
$42.84
|
| Rate for Payer: Vantage Medical Group Senior |
$42.84
|
|
|
HC CMV DNA QUANT PCR TEST
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
CPT 87497
|
| Hospital Charge Code |
900913695
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$32.58 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Adventist Health Commercial |
$36.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$115.92
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$121.86
|
| Rate for Payer: Heritage Provider Network Senior |
$121.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$32.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.00
|
| Rate for Payer: Multiplan Commercial |
$135.00
|
|
|
HC CNTR BRACCO ISOVUE 370 50ML
|
Facility
|
IP
|
$3.78
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
906812530
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Adventist Health Commercial |
$0.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.43
|
| Rate for Payer: Cash Price |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.56
|
| Rate for Payer: Heritage Provider Network Senior |
$2.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$2.83
|
|
|
HC CNTR BRACCO ISOVUE 370 50ML
|
Facility
|
OP
|
$3.78
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
906812530
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$3.21 |
| Rate for Payer: Adventist Health Commercial |
$0.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$2.31
|
| Rate for Payer: Blue Shield of California EPN |
$1.84
|
| Rate for Payer: Cash Price |
$1.70
|
| Rate for Payer: Cash Price |
$1.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.34
|
| Rate for Payer: Heritage Provider Network Senior |
$2.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.65
|
| Rate for Payer: Multiplan Commercial |
$2.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.51
|
| Rate for Payer: TriValley Medical Group Senior |
$1.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.21
|
| Rate for Payer: Vantage Medical Group Senior |
$3.21
|
|
|
HC CNTRL NASAL HEMORRHAGE COMPLEX
|
Facility
|
IP
|
$657.00
|
|
|
Service Code
|
CPT 30903
|
| Hospital Charge Code |
900501115
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$118.92 |
| Max. Negotiated Rate |
$492.75 |
| Rate for Payer: Adventist Health Commercial |
$131.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$423.11
|
| Rate for Payer: Cash Price |
$295.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$444.79
|
| Rate for Payer: Heritage Provider Network Senior |
$444.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$118.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$164.25
|
| Rate for Payer: Multiplan Commercial |
$492.75
|
|
|
HC CNTRL NASAL HEMORRHAGE COMPLEX
|
Facility
|
OP
|
$657.00
|
|
|
Service Code
|
CPT 30903
|
| Hospital Charge Code |
900501115
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$118.92 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$131.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$406.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$256.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$188.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$171.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$312.07
|
| Rate for Payer: Blue Shield of California EPN |
$248.35
|
| Rate for Payer: Cash Price |
$295.65
|
| Rate for Payer: Cash Price |
$295.65
|
| Rate for Payer: Cash Price |
$295.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$427.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$256.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$188.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$171.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$171.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$444.79
|
| Rate for Payer: Heritage Provider Network Senior |
$444.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$171.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$313.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$118.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$196.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$164.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$229.30
|
| Rate for Payer: Multiplan Commercial |
$492.75
|
| Rate for Payer: Multiplan WC |
$260.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$394.20
|
| Rate for Payer: TriValley Medical Group Senior |
$394.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$256.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$188.23
|
| Rate for Payer: Vantage Medical Group Senior |
$171.12
|
|
|
HC CNTRL NASAL HEMORRHAGE SIMPLE
|
Facility
|
IP
|
$545.00
|
|
|
Service Code
|
CPT 30901
|
| Hospital Charge Code |
900501114
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$98.64 |
| Max. Negotiated Rate |
$408.75 |
| Rate for Payer: Adventist Health Commercial |
$109.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$350.98
|
| Rate for Payer: Cash Price |
$245.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$368.96
|
| Rate for Payer: Heritage Provider Network Senior |
$368.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$98.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$136.25
|
| Rate for Payer: Multiplan Commercial |
$408.75
|
|
|
HC CNTRL NASAL HEMORRHAGE SIMPLE
|
Facility
|
OP
|
$545.00
|
|
|
Service Code
|
CPT 30901
|
| Hospital Charge Code |
900501114
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$98.64 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$109.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$336.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$256.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$188.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$171.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$258.88
|
| Rate for Payer: Blue Shield of California EPN |
$206.01
|
| Rate for Payer: Cash Price |
$245.25
|
| Rate for Payer: Cash Price |
$245.25
|
| Rate for Payer: Cash Price |
$245.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$354.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$256.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$188.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$171.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$171.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$368.96
|
| Rate for Payer: Heritage Provider Network Senior |
$368.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$171.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$259.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$98.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$196.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$136.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$229.30
|
| Rate for Payer: Multiplan Commercial |
$408.75
|
| Rate for Payer: Multiplan WC |
$260.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$327.00
|
| Rate for Payer: TriValley Medical Group Senior |
$327.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$256.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$188.23
|
| Rate for Payer: Vantage Medical Group Senior |
$171.12
|
|
|
HC CNTRL NASAL HEM POSTERIOR
|
Facility
|
IP
|
$568.00
|
|
|
Service Code
|
CPT 30905
|
| Hospital Charge Code |
900501116
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$102.81 |
| Max. Negotiated Rate |
$426.00 |
| Rate for Payer: Adventist Health Commercial |
$113.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$365.79
|
| Rate for Payer: Cash Price |
$255.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$384.54
|
| Rate for Payer: Heritage Provider Network Senior |
$384.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$102.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$142.00
|
| Rate for Payer: Multiplan Commercial |
$426.00
|
|
|
HC CNTRL NASAL HEM POSTERIOR
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
CPT 30905
|
| Hospital Charge Code |
900501116
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$102.81 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$113.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$351.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$256.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$188.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$171.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$269.80
|
| Rate for Payer: Blue Shield of California EPN |
$214.70
|
| Rate for Payer: Cash Price |
$255.60
|
| Rate for Payer: Cash Price |
$255.60
|
| Rate for Payer: Cash Price |
$255.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$369.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$256.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$188.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$171.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$171.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$384.54
|
| Rate for Payer: Heritage Provider Network Senior |
$384.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$171.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$270.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$102.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$196.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$142.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$229.30
|
| Rate for Payer: Multiplan Commercial |
$426.00
|
| Rate for Payer: Multiplan WC |
$260.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$340.80
|
| Rate for Payer: TriValley Medical Group Senior |
$340.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$256.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$188.23
|
| Rate for Payer: Vantage Medical Group Senior |
$171.12
|
|
|
HC CNTRL NASAL HEM POST SUBSQ
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
CPT 30906
|
| Hospital Charge Code |
900501117
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$102.81 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$113.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$351.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$456.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$335.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$304.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$269.80
|
| Rate for Payer: Blue Shield of California EPN |
$214.70
|
| Rate for Payer: Cash Price |
$255.60
|
| Rate for Payer: Cash Price |
$255.60
|
| Rate for Payer: Cash Price |
$255.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$369.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$456.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$335.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$304.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$304.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$384.54
|
| Rate for Payer: Heritage Provider Network Senior |
$384.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$304.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$270.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$102.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$350.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$142.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$408.20
|
| Rate for Payer: Multiplan Commercial |
$426.00
|
| Rate for Payer: Multiplan WC |
$470.13
|
| Rate for Payer: TriValley Medical Group Commercial |
$340.80
|
| Rate for Payer: TriValley Medical Group Senior |
$340.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$456.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$335.09
|
| Rate for Payer: Vantage Medical Group Senior |
$304.63
|
|
|
HC CNTRL NASAL HEM POST SUBSQ
|
Facility
|
IP
|
$568.00
|
|
|
Service Code
|
CPT 30906
|
| Hospital Charge Code |
900501117
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$102.81 |
| Max. Negotiated Rate |
$426.00 |
| Rate for Payer: Adventist Health Commercial |
$113.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$365.79
|
| Rate for Payer: Cash Price |
$255.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$384.54
|
| Rate for Payer: Heritage Provider Network Senior |
$384.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$102.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$142.00
|
| Rate for Payer: Multiplan Commercial |
$426.00
|
|
|
HC CNTRL ORO HEM W SURG INTRV
|
Facility
|
OP
|
$10,844.00
|
|
|
Service Code
|
CPT 42962
|
| Hospital Charge Code |
900542962
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,962.76 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$2,168.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,701.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,396.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,690.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,264.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,158.00
|
| Rate for Payer: Blue Shield of California Commercial |
$5,150.90
|
| Rate for Payer: Blue Shield of California EPN |
$4,099.03
|
| Rate for Payer: Cash Price |
$4,879.80
|
| Rate for Payer: Cash Price |
$4,879.80
|
| Rate for Payer: Cash Price |
$4,879.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,048.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,396.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,690.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,264.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,264.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,341.39
|
| Rate for Payer: Heritage Provider Network Senior |
$7,341.39
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,264.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,172.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,962.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,903.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,711.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,714.07
|
| Rate for Payer: Multiplan Commercial |
$8,133.00
|
| Rate for Payer: Multiplan WC |
$6,565.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$6,506.40
|
| Rate for Payer: TriValley Medical Group Senior |
$6,506.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,396.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,690.65
|
| Rate for Payer: Vantage Medical Group Senior |
$4,264.23
|
|
|
HC CNTRL ORO HEM W SURG INTRV
|
Facility
|
IP
|
$10,844.00
|
|
|
Service Code
|
CPT 42962
|
| Hospital Charge Code |
900542962
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,962.76 |
| Max. Negotiated Rate |
$8,133.00 |
| Rate for Payer: Adventist Health Commercial |
$2,168.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,983.54
|
| Rate for Payer: Cash Price |
$4,879.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,341.39
|
| Rate for Payer: Heritage Provider Network Senior |
$7,341.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,962.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,711.00
|
| Rate for Payer: Multiplan Commercial |
$8,133.00
|
|
|
HC CNTR VISIPAQUE 320 50ML PER ML
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
906812679
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.86
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.06
|
| Rate for Payer: Heritage Provider Network Senior |
$4.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
|
|
HC CNTR VISIPAQUE 320 50ML PER ML
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
906812679
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$3.66
|
| Rate for Payer: Blue Shield of California EPN |
$2.93
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.71
|
| Rate for Payer: Heritage Provider Network Senior |
$3.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.20
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.40
|
| Rate for Payer: TriValley Medical Group Senior |
$2.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
HC CNVRT NEHPU TO NEPH CATH PERCU
|
Facility
|
IP
|
$1,359.00
|
|
|
Service Code
|
CPT 50434
|
| Hospital Charge Code |
909050434
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$245.98 |
| Max. Negotiated Rate |
$1,019.25 |
| Rate for Payer: Adventist Health Commercial |
$271.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$875.20
|
| Rate for Payer: Cash Price |
$611.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$920.04
|
| Rate for Payer: Heritage Provider Network Senior |
$920.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$245.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$339.75
|
| Rate for Payer: Multiplan Commercial |
$1,019.25
|
|
