|
HC HSV 1,2 IGM
|
Facility
|
IP
|
$190.00
|
|
|
Service Code
|
CPT 86694
|
| Hospital Charge Code |
900913562
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$34.39 |
| Max. Negotiated Rate |
$142.50 |
| Rate for Payer: Adventist Health Commercial |
$38.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$130.53
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$128.63
|
| Rate for Payer: Heritage Provider Network Senior |
$128.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.50
|
| Rate for Payer: Multiplan Commercial |
$142.50
|
|
|
HC HSV 1,2 IGM
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT 86694
|
| Hospital Charge Code |
900913562
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$120.08 |
| Rate for Payer: Adventist Health Commercial |
$9.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$41.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21.58
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$120.08
|
| Rate for Payer: Blue Shield of California Commercial |
$112.41
|
| Rate for Payer: Blue Shield of California EPN |
$87.88
|
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.83
|
| Rate for Payer: Dignity Health Senior |
$14.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$14.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.86
|
| Rate for Payer: Heritage Provider Network Senior |
$27.86
|
| Rate for Payer: Humana Medicare |
$14.39
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$27.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$16.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.13
|
| Rate for Payer: Multiplan Commercial |
$33.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$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 Navigate/Select/Select+ |
$15.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.83
|
| Rate for Payer: Vantage Medical Group Senior |
$14.39
|
|
|
HC HSV 1&2 PCR
|
Facility
|
IP
|
$172.00
|
|
|
Service Code
|
CPT 87529
|
| Hospital Charge Code |
900912307
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$31.13 |
| Max. Negotiated Rate |
$129.00 |
| Rate for Payer: Adventist Health Commercial |
$34.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$118.16
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$116.44
|
| Rate for Payer: Heritage Provider Network Senior |
$116.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.00
|
| Rate for Payer: Multiplan Commercial |
$129.00
|
|
|
HC HSV 1&2 PCR
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 87529
|
| Hospital Charge Code |
900912307
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$18.10 |
| Max. Negotiated Rate |
$284.23 |
| Rate for Payer: Adventist Health Commercial |
$20.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$102.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$68.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$52.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$284.23
|
| Rate for Payer: Blue Shield of California Commercial |
$274.13
|
| Rate for Payer: Blue Shield of California EPN |
$214.30
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$65.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.60
|
| Rate for Payer: Dignity Health Senior |
$35.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$35.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$61.90
|
| Rate for Payer: Heritage Provider Network Senior |
$61.90
|
| Rate for Payer: Humana Medicare |
$35.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$38.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$66.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$41.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$44.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$44.21
|
| Rate for Payer: Multiplan Commercial |
$75.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$35.09
|
| Rate for Payer: TriValley Medical Group Senior |
$35.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$37.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$52.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Vantage Medical Group Senior |
$35.09
|
|
|
HC HSV 1 IGG
|
Facility
|
IP
|
$204.00
|
|
|
Service Code
|
CPT 86695
|
| Hospital Charge Code |
900913540
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$36.92 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Adventist Health Commercial |
$40.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$140.15
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$138.11
|
| Rate for Payer: Heritage Provider Network Senior |
$138.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.00
|
| Rate for Payer: Multiplan Commercial |
$153.00
|
|
|
HC HSV 1 IGG
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT 86695
|
| Hospital Charge Code |
900913540
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$110.39 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$38.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$110.39
|
| Rate for Payer: Blue Shield of California Commercial |
$103.02
|
| Rate for Payer: Blue Shield of California EPN |
$80.54
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.51
|
| Rate for Payer: Dignity Health Senior |
$13.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.95
|
| Rate for Payer: Heritage Provider Network Senior |
$30.95
|
| Rate for Payer: Humana Medicare |
$13.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$25.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.62
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.19
|
| Rate for Payer: TriValley Medical Group Senior |
$13.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.51
|
| Rate for Payer: Vantage Medical Group Senior |
$13.19
|
|
|
HC HSV 2 IGG
|
Facility
|
IP
|
$204.00
|
|
|
Service Code
|
CPT 86696
|
| Hospital Charge Code |
900913541
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$36.92 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Adventist Health Commercial |
$40.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$140.15
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$138.11
|
| Rate for Payer: Heritage Provider Network Senior |
$138.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.00
|
| Rate for Payer: Multiplan Commercial |
$153.00
|
|
|
HC HSV 2 IGG
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT 86696
|
| Hospital Charge Code |
900913541
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$161.90 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$56.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$161.90
|
| Rate for Payer: Blue Shield of California Commercial |
$151.21
|
| Rate for Payer: Blue Shield of California EPN |
$118.21
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.28
|
| Rate for Payer: Dignity Health Senior |
$19.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$19.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.95
|
| Rate for Payer: Heritage Provider Network Senior |
$30.95
|
| Rate for Payer: Humana Medicare |
$19.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$26.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$36.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$24.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$24.38
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.35
|
| Rate for Payer: TriValley Medical Group Senior |
$19.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.28
|
| Rate for Payer: Vantage Medical Group Senior |
$19.35
|
|
|
HC HUMERUS
|
Facility
|
OP
|
$481.00
|
|
|
Service Code
|
CPT 73060
|
| Hospital Charge Code |
909001508
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$32.42 |
| Max. Negotiated Rate |
$360.75 |
| Rate for Payer: Adventist Health Commercial |
$96.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$45.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$330.45
|
| 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 |
$136.59
|
| Rate for Payer: Blue Shield of California Commercial |
$117.39
|
| Rate for Payer: Blue Shield of California EPN |
$66.75
|
| Rate for Payer: Cash Price |
$216.45
|
| Rate for Payer: Cash Price |
$216.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$312.65
|
| 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 |
$312.65
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$297.74
|
| Rate for Payer: Heritage Provider Network Senior |
$297.74
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$32.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$113.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$87.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$143.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$143.06
|
| Rate for Payer: Multiplan Commercial |
$360.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$113.54
|
| Rate for Payer: TriValley Medical Group Senior |
$113.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Vantage Medical Group Senior |
$113.54
|
|
|
HC HUMERUS
|
Facility
|
IP
|
$481.00
|
|
|
Service Code
|
CPT 73060
|
| Hospital Charge Code |
909001508
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$87.06 |
| Max. Negotiated Rate |
$360.75 |
| Rate for Payer: Adventist Health Commercial |
$96.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$330.45
|
| Rate for Payer: Cash Price |
$216.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$325.64
|
| Rate for Payer: Heritage Provider Network Senior |
$325.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$87.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.25
|
| Rate for Payer: Multiplan Commercial |
$360.75
|
|
|
HC HYDRATION INFUSION EA ADDL HR
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
910196361
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.20
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$73.12
|
| Rate for Payer: Heritage Provider Network Senior |
$73.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$81.00
|
|
|
HC HYDRATION INFUSION EA ADDL HR
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
910196361
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$618.00 |
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$36.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$89.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$65.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$59.35
|
| Rate for Payer: Blue Shield of California Commercial |
$618.00
|
| Rate for Payer: Blue Shield of California EPN |
$530.00
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$70.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$65.28
|
| Rate for Payer: Dignity Health Senior |
$59.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$70.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$59.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$66.85
|
| Rate for Payer: Heritage Provider Network Senior |
$66.85
|
| Rate for Payer: Humana Medicare |
$59.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$59.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$112.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.55
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$70.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$74.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$74.78
|
| Rate for Payer: Multiplan Commercial |
$81.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$65.28
|
| Rate for Payer: TriValley Medical Group Senior |
$59.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$596.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$501.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$65.28
|
| Rate for Payer: Vantage Medical Group Senior |
$59.35
|
|
|
HC HYDRATION INFUSION EA ADDL HR
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
910196361
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$1,756.00 |
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$36.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$89.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$65.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$59.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,756.00
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$70.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$65.28
|
| Rate for Payer: Dignity Health Senior |
$59.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$70.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$59.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$73.12
|
| Rate for Payer: Heritage Provider Network Senior |
$73.12
|
| Rate for Payer: Humana Medicare |
$59.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$59.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$52.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.55
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$70.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$74.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$74.78
|
| Rate for Payer: Multiplan Commercial |
$81.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$65.28
|
| Rate for Payer: Vantage Medical Group Senior |
$59.35
|
|
|
HC HYDRATION INFUSION EA ADDL HR
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
910196361
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.20
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$73.12
|
| Rate for Payer: Heritage Provider Network Senior |
$73.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$81.00
|
|
|
HC HYDRATION INFUSION INITIAL 31-90MIN
|
Facility
|
OP
|
$639.00
|
|
|
Service Code
|
CPT 96360
|
| Hospital Charge Code |
910196360
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$80.03 |
| Max. Negotiated Rate |
$618.00 |
| Rate for Payer: Adventist Health Commercial |
$127.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$135.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$438.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$401.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$294.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$267.80
|
| Rate for Payer: Blue Shield of California Commercial |
$618.00
|
| Rate for Payer: Blue Shield of California EPN |
$530.00
|
| Rate for Payer: Cash Price |
$287.55
|
| Rate for Payer: Cash Price |
$287.55
|
| Rate for Payer: Cash Price |
$287.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$415.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$401.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$294.58
|
| Rate for Payer: Dignity Health Senior |
$267.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$415.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$267.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$395.54
|
| Rate for Payer: Heritage Provider Network Senior |
$395.54
|
| Rate for Payer: Humana Medicare |
$267.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$80.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$267.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$508.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$115.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$316.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$159.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$337.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$337.43
|
| Rate for Payer: Multiplan Commercial |
$479.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$294.58
|
| Rate for Payer: TriValley Medical Group Senior |
$267.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$596.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$501.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$401.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$294.58
|
| Rate for Payer: Vantage Medical Group Senior |
$267.80
|
|
|
HC HYDRATION INFUSION INITIAL 31-90MIN
|
Facility
|
IP
|
$639.00
|
|
|
Service Code
|
CPT 96360
|
| Hospital Charge Code |
910196360
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$115.66 |
| Max. Negotiated Rate |
$479.25 |
| Rate for Payer: Adventist Health Commercial |
$127.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$438.99
|
| Rate for Payer: Cash Price |
$287.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$432.60
|
| Rate for Payer: Heritage Provider Network Senior |
$432.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$115.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$159.75
|
| Rate for Payer: Multiplan Commercial |
$479.25
|
|
|
HC HYDRATION INFUSION INITIAL 31-90MIN
|
Facility
|
IP
|
$639.00
|
|
|
Service Code
|
CPT 96360
|
| Hospital Charge Code |
910196360
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$115.66 |
| Max. Negotiated Rate |
$479.25 |
| Rate for Payer: Adventist Health Commercial |
$127.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$438.99
|
| Rate for Payer: Cash Price |
$287.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$432.60
|
| Rate for Payer: Heritage Provider Network Senior |
$432.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$115.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$159.75
|
| Rate for Payer: Multiplan Commercial |
$479.25
|
|
|
HC HYDRATION INFUSION INITIAL 31-90MIN
|
Facility
|
OP
|
$639.00
|
|
|
Service Code
|
CPT 96360
|
| Hospital Charge Code |
910196360
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$115.66 |
| Max. Negotiated Rate |
$1,756.00 |
| Rate for Payer: Adventist Health Commercial |
$127.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$135.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$438.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$401.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$294.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$267.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,756.00
|
| Rate for Payer: Cash Price |
$287.55
|
| Rate for Payer: Cash Price |
$287.55
|
| Rate for Payer: Cash Price |
$287.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$415.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$401.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$294.58
|
| Rate for Payer: Dignity Health Senior |
$267.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$415.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$267.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$432.60
|
| Rate for Payer: Heritage Provider Network Senior |
$432.60
|
| Rate for Payer: Humana Medicare |
$267.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$267.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$308.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$115.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$316.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$159.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$337.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$337.43
|
| Rate for Payer: Multiplan Commercial |
$479.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$232.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$213.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$401.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$294.58
|
| Rate for Payer: Vantage Medical Group Senior |
$267.80
|
|
|
HC HYDROCOIL
|
Facility
|
OP
|
$3,744.00
|
|
| Hospital Charge Code |
909020028
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$748.80 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$748.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,797.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,572.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,182.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,059.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,808.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,325.02
|
| Rate for Payer: Blue Shield of California EPN |
$2,197.73
|
| Rate for Payer: Cash Price |
$1,684.80
|
| Rate for Payer: Cash Price |
$1,684.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,722.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,182.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,182.40
|
| Rate for Payer: Dignity Health Senior |
$3,182.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,396.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,733.47
|
| Rate for Payer: Heritage Provider Network Senior |
$1,733.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,872.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,872.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,872.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$936.00
|
| Rate for Payer: Multiplan Commercial |
$2,808.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,365.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,250.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,182.40
|
| Rate for Payer: Vantage Medical Group Senior |
$3,182.40
|
|
|
HC HYDROCOIL
|
Facility
|
IP
|
$3,744.00
|
|
| Hospital Charge Code |
909020028
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$748.80 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$748.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,797.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,572.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$1,684.80
|
| Rate for Payer: Cash Price |
$1,684.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,722.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,021.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,534.69
|
| Rate for Payer: Heritage Provider Network Senior |
$2,534.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,872.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,872.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,872.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$936.00
|
| Rate for Payer: Multiplan Commercial |
$2,808.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,365.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,250.87
|
|
|
HC HYDROCOIL DETACHMENT CONTROLLE
|
Facility
|
IP
|
$828.00
|
|
| Hospital Charge Code |
909020029
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.87 |
| Max. Negotiated Rate |
$621.00 |
| Rate for Payer: Adventist Health Commercial |
$165.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$568.84
|
| Rate for Payer: Cash Price |
$372.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$560.56
|
| Rate for Payer: Heritage Provider Network Senior |
$560.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$149.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$207.00
|
| Rate for Payer: Multiplan Commercial |
$621.00
|
|
|
HC HYDROCOIL DETACHMENT CONTROLLE
|
Facility
|
OP
|
$828.00
|
|
| Hospital Charge Code |
909020029
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.87 |
| Max. Negotiated Rate |
$703.80 |
| Rate for Payer: Adventist Health Commercial |
$165.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$442.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$568.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$703.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$455.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$621.00
|
| Rate for Payer: Blue Shield of California Commercial |
$514.19
|
| Rate for Payer: Blue Shield of California EPN |
$486.04
|
| Rate for Payer: Cash Price |
$372.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$538.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$703.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$703.80
|
| Rate for Payer: Dignity Health Senior |
$703.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$538.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$512.53
|
| Rate for Payer: Heritage Provider Network Senior |
$512.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$399.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$149.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$207.00
|
| Rate for Payer: Multiplan Commercial |
$621.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$703.80
|
| Rate for Payer: Vantage Medical Group Senior |
$703.80
|
|
|
HC HYSTEROSALPINGOGRAM
|
Facility
|
IP
|
$561.00
|
|
|
Service Code
|
CPT 58340
|
| Hospital Charge Code |
909000176
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$101.54 |
| Max. Negotiated Rate |
$420.75 |
| Rate for Payer: Adventist Health Commercial |
$112.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$385.41
|
| Rate for Payer: Cash Price |
$252.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$379.80
|
| Rate for Payer: Heritage Provider Network Senior |
$379.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$101.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$140.25
|
| Rate for Payer: Multiplan Commercial |
$420.75
|
|
|
HC HYSTEROSALPINGOGRAM
|
Facility
|
OP
|
$561.00
|
|
|
Service Code
|
CPT 58340
|
| Hospital Charge Code |
909000176
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$101.54 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$112.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$385.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$476.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$308.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$420.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| 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 |
$252.45
|
| Rate for Payer: Cash Price |
$252.45
|
| Rate for Payer: Cash Price |
$252.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$364.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$476.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$476.85
|
| Rate for Payer: Dignity Health Senior |
$476.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$347.26
|
| Rate for Payer: Heritage Provider Network Senior |
$347.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$289.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$270.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$101.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$140.25
|
| Rate for Payer: Multiplan Commercial |
$420.75
|
| 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 |
$476.85
|
| Rate for Payer: Vantage Medical Group Senior |
$476.85
|
|
|
HC HYSTEROSALPINGOGRAM EXAM
|
Facility
|
IP
|
$1,792.00
|
|
|
Service Code
|
CPT 74740
|
| Hospital Charge Code |
909001930
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$324.35 |
| Max. Negotiated Rate |
$1,344.00 |
| Rate for Payer: Adventist Health Commercial |
$358.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,231.10
|
| Rate for Payer: Cash Price |
$806.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,213.18
|
| Rate for Payer: Heritage Provider Network Senior |
$1,213.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$324.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$448.00
|
| Rate for Payer: Multiplan Commercial |
$1,344.00
|
|
