|
HC INFUSION INITIAL HOUR GT 16MIN
|
Facility
|
IP
|
$1,098.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
906820203
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$198.74 |
| Max. Negotiated Rate |
$823.50 |
| Rate for Payer: Adventist Health Commercial |
$219.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$754.33
|
| Rate for Payer: Cash Price |
$494.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$743.35
|
| Rate for Payer: Heritage Provider Network Senior |
$743.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$198.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$274.50
|
| Rate for Payer: Multiplan Commercial |
$823.50
|
|
|
HC INFUSION/THROMBOLYSIS,CEREBRAL
|
Facility
|
OP
|
$716.00
|
|
|
Service Code
|
CPT 37195
|
| Hospital Charge Code |
909081375
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$129.60 |
| Max. Negotiated Rate |
$12,620.00 |
| Rate for Payer: Adventist Health Commercial |
$143.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12,620.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$491.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$634.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$465.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$423.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,517.28
|
| Rate for Payer: Blue Shield of California EPN |
$3,022.94
|
| Rate for Payer: Cash Price |
$322.20
|
| Rate for Payer: Cash Price |
$322.20
|
| Rate for Payer: Cash Price |
$322.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$465.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$634.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$465.45
|
| Rate for Payer: Dignity Health Senior |
$423.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$423.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$443.20
|
| Rate for Payer: Heritage Provider Network Senior |
$520.46
|
| Rate for Payer: Humana Medicare |
$423.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$387.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$423.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$803.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$129.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$499.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$179.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$533.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$533.16
|
| Rate for Payer: Multiplan Commercial |
$537.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$465.45
|
| Rate for Payer: TriValley Medical Group Senior |
$465.45
|
| 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 Commercial/Exchange |
$634.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$465.45
|
| Rate for Payer: Vantage Medical Group Senior |
$423.14
|
|
|
HC INFUSION/THROMBOLYSIS,CEREBRAL
|
Facility
|
IP
|
$716.00
|
|
|
Service Code
|
CPT 37195
|
| Hospital Charge Code |
909081375
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$129.60 |
| Max. Negotiated Rate |
$537.00 |
| Rate for Payer: Adventist Health Commercial |
$143.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$491.89
|
| Rate for Payer: Cash Price |
$322.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$484.73
|
| Rate for Payer: Heritage Provider Network Senior |
$484.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$129.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$179.00
|
| Rate for Payer: Multiplan Commercial |
$537.00
|
|
|
HC INFUSION WIRE
|
Facility
|
IP
|
$504.00
|
|
| Hospital Charge Code |
909081247
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$91.22 |
| Max. Negotiated Rate |
$378.00 |
| Rate for Payer: Adventist Health Commercial |
$100.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$346.25
|
| Rate for Payer: Cash Price |
$226.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$341.21
|
| Rate for Payer: Heritage Provider Network Senior |
$341.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$126.00
|
| Rate for Payer: Multiplan Commercial |
$378.00
|
|
|
HC INFUSION WIRE
|
Facility
|
OP
|
$504.00
|
|
| Hospital Charge Code |
909081247
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$91.22 |
| Max. Negotiated Rate |
$428.40 |
| Rate for Payer: Adventist Health Commercial |
$100.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$269.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$346.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$428.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$277.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$378.00
|
| Rate for Payer: Blue Shield of California Commercial |
$312.98
|
| Rate for Payer: Blue Shield of California EPN |
$295.85
|
| Rate for Payer: Cash Price |
$226.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$327.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$428.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$428.40
|
| Rate for Payer: Dignity Health Senior |
$428.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$327.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$311.98
|
| Rate for Payer: Heritage Provider Network Senior |
$311.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$242.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$126.00
|
| Rate for Payer: Multiplan Commercial |
$378.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$428.40
|
| Rate for Payer: Vantage Medical Group Senior |
$428.40
|
|
|
HC INHALED NITRIC OXIDE PER HR
|
Facility
|
OP
|
$435.00
|
|
| Hospital Charge Code |
900800402
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.74 |
| Max. Negotiated Rate |
$369.75 |
| Rate for Payer: Adventist Health Commercial |
$87.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$232.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$298.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$369.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$239.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$326.25
|
| Rate for Payer: Blue Shield of California Commercial |
$270.14
|
| Rate for Payer: Blue Shield of California EPN |
$255.34
|
| Rate for Payer: Cash Price |
$195.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$282.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$369.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$369.75
|
| Rate for Payer: Dignity Health Senior |
$369.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$278.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$269.26
|
| Rate for Payer: Heritage Provider Network Senior |
$269.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$209.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$78.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.75
|
| Rate for Payer: Multiplan Commercial |
$326.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$174.00
|
| Rate for Payer: TriValley Medical Group Senior |
$174.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$369.75
|
| Rate for Payer: Vantage Medical Group Senior |
$369.75
|
|
|
HC INHALED NITRIC OXIDE PER HR
|
Facility
|
IP
|
$435.00
|
|
| Hospital Charge Code |
900800402
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.74 |
| Max. Negotiated Rate |
$326.25 |
| Rate for Payer: Adventist Health Commercial |
$87.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$298.84
|
| Rate for Payer: Cash Price |
$195.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$234.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$294.50
|
| Rate for Payer: Heritage Provider Network Senior |
$294.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$78.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.75
|
| Rate for Payer: Multiplan Commercial |
$326.25
|
|
|
HC INITIAL OP VISIT HIGH SEVERITY
|
Facility
|
OP
|
$1,027.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
908600106
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$129.01 |
| Max. Negotiated Rate |
$872.95 |
| Rate for Payer: Adventist Health Commercial |
$205.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$330.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$705.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$872.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$564.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$770.25
|
| Rate for Payer: Blue Shield of California Commercial |
$637.77
|
| Rate for Payer: Blue Shield of California EPN |
$602.85
|
| Rate for Payer: Cash Price |
$462.15
|
| Rate for Payer: Cash Price |
$462.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$872.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$872.95
|
| Rate for Payer: Dignity Health Senior |
$872.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$667.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$635.71
|
| Rate for Payer: Heritage Provider Network Senior |
$635.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$129.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$495.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$185.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$256.75
|
| Rate for Payer: Multiplan Commercial |
$770.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$513.50
|
| Rate for Payer: TriValley Medical Group Senior |
$513.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$872.95
|
| Rate for Payer: Vantage Medical Group Senior |
$872.95
|
|
|
HC INITIAL OP VISIT HIGH SEVERITY
|
Facility
|
IP
|
$1,027.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
908600106
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$185.89 |
| Max. Negotiated Rate |
$770.25 |
| Rate for Payer: Adventist Health Commercial |
$205.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$705.55
|
| Rate for Payer: Cash Price |
$462.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$695.28
|
| Rate for Payer: Heritage Provider Network Senior |
$695.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$185.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$256.75
|
| Rate for Payer: Multiplan Commercial |
$770.25
|
|
|
HC INITIAL OP VISIT HIGH SEVERITY
|
Facility
|
IP
|
$1,027.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
908600106
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$185.89 |
| Max. Negotiated Rate |
$770.25 |
| Rate for Payer: Adventist Health Commercial |
$205.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$705.55
|
| Rate for Payer: Cash Price |
$462.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$695.28
|
| Rate for Payer: Heritage Provider Network Senior |
$695.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$185.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$256.75
|
| Rate for Payer: Multiplan Commercial |
$770.25
|
|
|
HC INITIAL OP VISIT HIGH SEVERITY
|
Facility
|
OP
|
$1,027.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
908600106
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$165.16 |
| Max. Negotiated Rate |
$770.25 |
| Rate for Payer: Adventist Health Commercial |
$205.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$180.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$705.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$247.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$181.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$165.16
|
| Rate for Payer: Blue Shield of California Commercial |
$637.77
|
| Rate for Payer: Blue Shield of California EPN |
$602.85
|
| Rate for Payer: Cash Price |
$462.15
|
| Rate for Payer: Cash Price |
$462.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$247.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$181.68
|
| Rate for Payer: Dignity Health Senior |
$165.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$667.55
|
| Rate for Payer: EPIC Health Plan Medicare |
$165.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$635.71
|
| Rate for Payer: Heritage Provider Network Senior |
$635.71
|
| Rate for Payer: Humana Medicare |
$165.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$165.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$313.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$185.89
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$194.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$256.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$208.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$208.10
|
| Rate for Payer: Multiplan Commercial |
$770.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$513.50
|
| Rate for Payer: TriValley Medical Group Senior |
$513.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$247.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$181.68
|
| Rate for Payer: Vantage Medical Group Senior |
$165.16
|
|
|
HC INITIAL OP VISIT LOW TO MOD
|
Facility
|
IP
|
$366.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
908600103
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.25 |
| Max. Negotiated Rate |
$274.50 |
| Rate for Payer: Adventist Health Commercial |
$73.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$251.44
|
| Rate for Payer: Cash Price |
$164.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$247.78
|
| Rate for Payer: Heritage Provider Network Senior |
$247.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.50
|
| Rate for Payer: Multiplan Commercial |
$274.50
|
|
|
HC INITIAL OP VISIT LOW TO MOD
|
Facility
|
IP
|
$366.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
908600103
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.25 |
| Max. Negotiated Rate |
$274.50 |
| Rate for Payer: Adventist Health Commercial |
$73.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$251.44
|
| Rate for Payer: Cash Price |
$164.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$247.78
|
| Rate for Payer: Heritage Provider Network Senior |
$247.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.50
|
| Rate for Payer: Multiplan Commercial |
$274.50
|
|
|
HC INITIAL OP VISIT LOW TO MOD
|
Facility
|
OP
|
$366.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
908600103
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.51 |
| Max. Negotiated Rate |
$311.10 |
| Rate for Payer: Adventist Health Commercial |
$73.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$99.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$251.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$311.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$201.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$274.50
|
| Rate for Payer: Blue Shield of California Commercial |
$227.29
|
| Rate for Payer: Blue Shield of California EPN |
$214.84
|
| Rate for Payer: Cash Price |
$164.70
|
| Rate for Payer: Cash Price |
$164.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$311.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$311.10
|
| Rate for Payer: Dignity Health Senior |
$311.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$237.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$226.55
|
| Rate for Payer: Heritage Provider Network Senior |
$226.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$53.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$176.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.50
|
| Rate for Payer: Multiplan Commercial |
$274.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$183.00
|
| Rate for Payer: TriValley Medical Group Senior |
$183.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$311.10
|
| Rate for Payer: Vantage Medical Group Senior |
$311.10
|
|
|
HC INITIAL OP VISIT LOW TO MOD
|
Facility
|
OP
|
$366.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
908600103
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.25 |
| Max. Negotiated Rate |
$313.80 |
| Rate for Payer: Adventist Health Commercial |
$73.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$180.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$251.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$247.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$181.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$165.16
|
| Rate for Payer: Blue Shield of California Commercial |
$227.29
|
| Rate for Payer: Blue Shield of California EPN |
$214.84
|
| Rate for Payer: Cash Price |
$164.70
|
| Rate for Payer: Cash Price |
$164.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$247.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$181.68
|
| Rate for Payer: Dignity Health Senior |
$165.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$237.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$165.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$226.55
|
| Rate for Payer: Heritage Provider Network Senior |
$226.55
|
| Rate for Payer: Humana Medicare |
$165.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$165.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$313.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$194.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$208.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$208.10
|
| Rate for Payer: Multiplan Commercial |
$274.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$183.00
|
| Rate for Payer: TriValley Medical Group Senior |
$183.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$247.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$181.68
|
| Rate for Payer: Vantage Medical Group Senior |
$165.16
|
|
|
HC INITIAL OP VISIT MODERATE
|
Facility
|
IP
|
$539.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
908600104
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$97.56 |
| Max. Negotiated Rate |
$404.25 |
| Rate for Payer: Adventist Health Commercial |
$107.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$370.29
|
| Rate for Payer: Cash Price |
$242.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$364.90
|
| Rate for Payer: Heritage Provider Network Senior |
$364.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.75
|
| Rate for Payer: Multiplan Commercial |
$404.25
|
|
|
HC INITIAL OP VISIT MODERATE
|
Facility
|
OP
|
$539.00
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
908600104
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$89.23 |
| Max. Negotiated Rate |
$458.15 |
| Rate for Payer: Adventist Health Commercial |
$107.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$151.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$370.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$458.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$296.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$404.25
|
| Rate for Payer: Blue Shield of California Commercial |
$334.72
|
| Rate for Payer: Blue Shield of California EPN |
$316.39
|
| Rate for Payer: Cash Price |
$242.55
|
| Rate for Payer: Cash Price |
$242.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$458.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$458.15
|
| Rate for Payer: Dignity Health Senior |
$458.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$350.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$333.64
|
| Rate for Payer: Heritage Provider Network Senior |
$333.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$89.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$259.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.75
|
| Rate for Payer: Multiplan Commercial |
$404.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$269.50
|
| Rate for Payer: TriValley Medical Group Senior |
$269.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$458.15
|
| Rate for Payer: Vantage Medical Group Senior |
$458.15
|
|
|
HC INITIAL OP VISIT MODERATE
|
Facility
|
OP
|
$539.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
908600104
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$97.56 |
| Max. Negotiated Rate |
$404.25 |
| Rate for Payer: Adventist Health Commercial |
$107.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$180.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$370.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$247.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$181.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$165.16
|
| Rate for Payer: Blue Shield of California Commercial |
$334.72
|
| Rate for Payer: Blue Shield of California EPN |
$316.39
|
| Rate for Payer: Cash Price |
$242.55
|
| Rate for Payer: Cash Price |
$242.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$247.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$181.68
|
| Rate for Payer: Dignity Health Senior |
$165.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$350.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$165.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$333.64
|
| Rate for Payer: Heritage Provider Network Senior |
$333.64
|
| Rate for Payer: Humana Medicare |
$165.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$165.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$313.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$194.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$208.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$208.10
|
| Rate for Payer: Multiplan Commercial |
$404.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$269.50
|
| Rate for Payer: TriValley Medical Group Senior |
$269.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$247.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$181.68
|
| Rate for Payer: Vantage Medical Group Senior |
$165.16
|
|
|
HC INITIAL OP VISIT MODERATE
|
Facility
|
IP
|
$539.00
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
908600104
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$97.56 |
| Max. Negotiated Rate |
$404.25 |
| Rate for Payer: Adventist Health Commercial |
$107.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$370.29
|
| Rate for Payer: Cash Price |
$242.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$364.90
|
| Rate for Payer: Heritage Provider Network Senior |
$364.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.75
|
| Rate for Payer: Multiplan Commercial |
$404.25
|
|
|
HC INITIAL OP VISIT MOD TO HIGH
|
Facility
|
IP
|
$826.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
908600105
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$149.51 |
| Max. Negotiated Rate |
$619.50 |
| Rate for Payer: Adventist Health Commercial |
$165.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$567.46
|
| Rate for Payer: Cash Price |
$371.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$559.20
|
| Rate for Payer: Heritage Provider Network Senior |
$559.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$149.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.50
|
| Rate for Payer: Multiplan Commercial |
$619.50
|
|
|
HC INITIAL OP VISIT MOD TO HIGH
|
Facility
|
IP
|
$826.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
908600105
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$149.51 |
| Max. Negotiated Rate |
$619.50 |
| Rate for Payer: Adventist Health Commercial |
$165.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$567.46
|
| Rate for Payer: Cash Price |
$371.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$559.20
|
| Rate for Payer: Heritage Provider Network Senior |
$559.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$149.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.50
|
| Rate for Payer: Multiplan Commercial |
$619.50
|
|
|
HC INITIAL OP VISIT MOD TO HIGH
|
Facility
|
OP
|
$826.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
908600105
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$107.48 |
| Max. Negotiated Rate |
$702.10 |
| Rate for Payer: Adventist Health Commercial |
$165.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$256.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$567.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$702.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$454.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$619.50
|
| Rate for Payer: Blue Shield of California Commercial |
$512.95
|
| Rate for Payer: Blue Shield of California EPN |
$484.86
|
| Rate for Payer: Cash Price |
$371.70
|
| Rate for Payer: Cash Price |
$371.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$702.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$702.10
|
| Rate for Payer: Dignity Health Senior |
$702.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$536.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$511.29
|
| Rate for Payer: Heritage Provider Network Senior |
$511.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$107.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$398.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$149.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.50
|
| Rate for Payer: Multiplan Commercial |
$619.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$413.00
|
| Rate for Payer: TriValley Medical Group Senior |
$413.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$702.10
|
| Rate for Payer: Vantage Medical Group Senior |
$702.10
|
|
|
HC INITIAL OP VISIT MOD TO HIGH
|
Facility
|
OP
|
$826.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
908600105
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$149.51 |
| Max. Negotiated Rate |
$619.50 |
| Rate for Payer: Adventist Health Commercial |
$165.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$180.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$567.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$247.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$181.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$165.16
|
| Rate for Payer: Blue Shield of California Commercial |
$512.95
|
| Rate for Payer: Blue Shield of California EPN |
$484.86
|
| Rate for Payer: Cash Price |
$371.70
|
| Rate for Payer: Cash Price |
$371.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$247.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$181.68
|
| Rate for Payer: Dignity Health Senior |
$165.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$536.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$165.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$511.29
|
| Rate for Payer: Heritage Provider Network Senior |
$511.29
|
| Rate for Payer: Humana Medicare |
$165.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$165.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$313.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$149.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$194.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$208.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$208.10
|
| Rate for Payer: Multiplan Commercial |
$619.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$413.00
|
| Rate for Payer: TriValley Medical Group Senior |
$413.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$247.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$181.68
|
| Rate for Payer: Vantage Medical Group Senior |
$165.16
|
|
|
HC INIT TREATMENT 1ST DEG BURN
|
Facility
|
IP
|
$645.00
|
|
|
Service Code
|
CPT 16000
|
| Hospital Charge Code |
900501044
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$116.74 |
| Max. Negotiated Rate |
$483.75 |
| Rate for Payer: Adventist Health Commercial |
$129.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$443.12
|
| Rate for Payer: Cash Price |
$290.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$436.66
|
| Rate for Payer: Heritage Provider Network Senior |
$436.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$116.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$161.25
|
| Rate for Payer: Multiplan Commercial |
$483.75
|
|
|
HC INIT TREATMENT 1ST DEG BURN
|
Facility
|
OP
|
$645.00
|
|
|
Service Code
|
CPT 16000
|
| Hospital Charge Code |
900501044
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$91.65 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$129.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$91.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$443.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$290.25
|
| Rate for Payer: Cash Price |
$290.25
|
| Rate for Payer: Cash Price |
$290.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$419.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: Dignity Health Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$250.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$436.66
|
| Rate for Payer: Heritage Provider Network Senior |
$436.66
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$310.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$116.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$295.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$161.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.18
|
| Rate for Payer: Multiplan Commercial |
$483.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$234.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$215.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Vantage Medical Group Senior |
$250.14
|
|
