|
HC INJECTION VITREOUS SUBSTITUTE
|
Facility
|
IP
|
$6,637.00
|
|
|
Service Code
|
CPT 67025
|
| Hospital Charge Code |
950510062
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,201.30 |
| Max. Negotiated Rate |
$4,977.75 |
| Rate for Payer: Adventist Health Commercial |
$1,327.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,559.62
|
| Rate for Payer: Cash Price |
$2,986.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,493.25
|
| Rate for Payer: Heritage Provider Network Senior |
$4,493.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,201.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,659.25
|
| Rate for Payer: Multiplan Commercial |
$4,977.75
|
|
|
HC INJECTION VITREOUS SUBSTITUTE
|
Facility
|
OP
|
$6,637.00
|
|
|
Service Code
|
CPT 67025
|
| Hospital Charge Code |
950510062
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$936.00 |
| Max. Negotiated Rate |
$4,977.75 |
| Rate for Payer: Adventist Health Commercial |
$1,327.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,559.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,367.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,202.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,911.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$2,986.65
|
| Rate for Payer: Cash Price |
$2,986.65
|
| Rate for Payer: Cash Price |
$2,986.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,314.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,367.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,202.79
|
| Rate for Payer: Dignity Health Senior |
$2,911.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,314.05
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,911.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,493.25
|
| Rate for Payer: Heritage Provider Network Senior |
$4,493.25
|
| Rate for Payer: Humana Medicare |
$2,911.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,911.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,199.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,201.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,435.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,659.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,668.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,668.65
|
| Rate for Payer: Multiplan Commercial |
$4,977.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,409.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,217.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,367.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,202.79
|
| Rate for Payer: Vantage Medical Group Senior |
$2,911.63
|
|
|
HC INJECT SINUS TRACT; THERAPEUTIC
|
Facility
|
OP
|
$3,026.00
|
|
|
Service Code
|
CPT 20500
|
| Hospital Charge Code |
909020500
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$164.94 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$605.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,078.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,858.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,095.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,905.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,879.15
|
| Rate for Payer: Blue Shield of California EPN |
$1,776.26
|
| Rate for Payer: Cash Price |
$1,361.70
|
| Rate for Payer: Cash Price |
$1,361.70
|
| Rate for Payer: Cash Price |
$1,361.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,966.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,858.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,095.98
|
| Rate for Payer: Dignity Health Senior |
$1,905.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,905.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,873.09
|
| Rate for Payer: Heritage Provider Network Senior |
$1,873.09
|
| Rate for Payer: Humana Medicare |
$1,905.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$164.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,905.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,620.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$547.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,248.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$756.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,400.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,400.85
|
| Rate for Payer: Multiplan Commercial |
$2,269.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,905.44
|
| Rate for Payer: TriValley Medical Group Senior |
$1,905.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,858.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,095.98
|
| Rate for Payer: Vantage Medical Group Senior |
$1,905.44
|
|
|
HC INJECT SINUS TRACT; THERAPEUTIC
|
Facility
|
IP
|
$3,026.00
|
|
|
Service Code
|
CPT 20500
|
| Hospital Charge Code |
909020500
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$547.71 |
| Max. Negotiated Rate |
$2,269.50 |
| Rate for Payer: Adventist Health Commercial |
$605.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,078.86
|
| Rate for Payer: Cash Price |
$1,361.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,048.60
|
| Rate for Payer: Heritage Provider Network Senior |
$2,048.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$547.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$756.50
|
| Rate for Payer: Multiplan Commercial |
$2,269.50
|
|
|
HC INJECT THER/PROP/DIAG SC/IM
|
Facility
|
OP
|
$380.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
910196372
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$29.25 |
| Max. Negotiated Rate |
$618.00 |
| Rate for Payer: Adventist Health Commercial |
$76.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$54.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$261.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$132.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$96.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$88.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$449.00
|
| 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 |
$171.00
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$247.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$132.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.82
|
| Rate for Payer: Dignity Health Senior |
$88.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$247.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$88.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$235.22
|
| Rate for Payer: Heritage Provider Network Senior |
$235.22
|
| Rate for Payer: Humana Medicare |
$88.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$29.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$88.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$167.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$103.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$110.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$110.91
|
| Rate for Payer: Multiplan Commercial |
$285.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$96.82
|
| Rate for Payer: TriValley Medical Group Senior |
$88.02
|
| 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 |
$132.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.82
|
| Rate for Payer: Vantage Medical Group Senior |
$88.02
|
|
|
HC INJECT THER/PROP/DIAG SC/IM
|
Facility
|
IP
|
$380.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
910196372
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$68.78 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Adventist Health Commercial |
$76.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$261.06
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$257.26
|
| Rate for Payer: Heritage Provider Network Senior |
$257.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.00
|
| Rate for Payer: Multiplan Commercial |
$285.00
|
|
|
HC INJECT THER/PROP/DIAG SC/IM
|
Facility
|
OP
|
$380.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
910196372
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$54.53 |
| Max. Negotiated Rate |
$1,756.00 |
| Rate for Payer: Adventist Health Commercial |
$76.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$54.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$261.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$132.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$96.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$88.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,756.00
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$247.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$132.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.82
|
| Rate for Payer: Dignity Health Senior |
$88.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$247.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$88.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$257.26
|
| Rate for Payer: Heritage Provider Network Senior |
$257.26
|
| Rate for Payer: Humana Medicare |
$88.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$88.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$183.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$103.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$110.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$110.91
|
| Rate for Payer: Multiplan Commercial |
$285.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$137.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$126.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$132.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.82
|
| Rate for Payer: Vantage Medical Group Senior |
$88.02
|
|
|
HC INJECT THER/PROP/DIAG SC/IM
|
Facility
|
IP
|
$380.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
910196372
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$68.78 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Adventist Health Commercial |
$76.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$261.06
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$257.26
|
| Rate for Payer: Heritage Provider Network Senior |
$257.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.00
|
| Rate for Payer: Multiplan Commercial |
$285.00
|
|
|
HC INJECT TRIGGER POINT 1 OR 2
|
Facility
|
IP
|
$592.00
|
|
|
Service Code
|
CPT 20552
|
| Hospital Charge Code |
909000260
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$107.15 |
| Max. Negotiated Rate |
$444.00 |
| Rate for Payer: Adventist Health Commercial |
$118.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$406.70
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$400.78
|
| Rate for Payer: Heritage Provider Network Senior |
$400.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$148.00
|
| Rate for Payer: Multiplan Commercial |
$444.00
|
|
|
HC INJECT TRIGGER POINT 1 OR 2
|
Facility
|
OP
|
$592.00
|
|
|
Service Code
|
CPT 20552
|
| Hospital Charge Code |
909000260
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$81.88 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$118.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$406.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$555.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$370.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,086.22
|
| Rate for Payer: Blue Shield of California EPN |
$933.56
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$384.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$555.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$407.07
|
| Rate for Payer: Dignity Health Senior |
$370.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$370.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$366.45
|
| Rate for Payer: Heritage Provider Network Senior |
$455.17
|
| Rate for Payer: Humana Medicare |
$370.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$81.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$370.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$703.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$436.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$148.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$466.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$466.28
|
| Rate for Payer: Multiplan Commercial |
$444.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$407.07
|
| Rate for Payer: TriValley Medical Group Senior |
$407.07
|
| 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 |
$555.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Vantage Medical Group Senior |
$370.06
|
|
|
HC INJECT TRIGGER POINT 1 OR 2
|
Facility
|
OP
|
$592.00
|
|
|
Service Code
|
CPT 20552
|
| Hospital Charge Code |
909000260
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$107.15 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$118.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$406.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$555.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$370.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$384.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$555.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$407.07
|
| Rate for Payer: Dignity Health Senior |
$370.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$370.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$400.78
|
| Rate for Payer: Heritage Provider Network Senior |
$400.78
|
| Rate for Payer: Humana Medicare |
$370.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$370.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$285.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$436.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$148.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$466.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$466.28
|
| Rate for Payer: Multiplan Commercial |
$444.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$214.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$197.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$555.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$407.07
|
| Rate for Payer: Vantage Medical Group Senior |
$370.06
|
|
|
HC INJECT TRIGGER POINT 1 OR 2
|
Facility
|
IP
|
$592.00
|
|
|
Service Code
|
CPT 20552
|
| Hospital Charge Code |
909000260
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$107.15 |
| Max. Negotiated Rate |
$444.00 |
| Rate for Payer: Adventist Health Commercial |
$118.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$406.70
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$400.78
|
| Rate for Payer: Heritage Provider Network Senior |
$400.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$148.00
|
| Rate for Payer: Multiplan Commercial |
$444.00
|
|
|
HC INJECT W/FLUOR, EVAL CV DEVICE
|
Facility
|
IP
|
$609.00
|
|
|
Service Code
|
CPT 36598
|
| Hospital Charge Code |
909081842
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$110.23 |
| Max. Negotiated Rate |
$456.75 |
| Rate for Payer: Adventist Health Commercial |
$121.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$418.38
|
| Rate for Payer: Cash Price |
$274.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$412.29
|
| Rate for Payer: Heritage Provider Network Senior |
$412.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$110.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$152.25
|
| Rate for Payer: Multiplan Commercial |
$456.75
|
|
|
HC INJECT W/FLUOR, EVAL CV DEVICE
|
Facility
|
OP
|
$609.00
|
|
|
Service Code
|
CPT 36598
|
| Hospital Charge Code |
909081842
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$110.23 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$121.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$418.38
|
| 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 |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,086.22
|
| Rate for Payer: Blue Shield of California EPN |
$933.56
|
| Rate for Payer: Cash Price |
$274.05
|
| Rate for Payer: Cash Price |
$274.05
|
| Rate for Payer: Cash Price |
$274.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$395.85
|
| 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 |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$267.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$376.97
|
| Rate for Payer: Heritage Provider Network Senior |
$329.39
|
| Rate for Payer: Humana Medicare |
$267.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$172.49
|
| 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 |
$110.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$316.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$152.25
|
| 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 |
$456.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$294.58
|
| Rate for Payer: TriValley Medical Group Senior |
$294.58
|
| 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 |
$401.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$294.58
|
| Rate for Payer: Vantage Medical Group Senior |
$267.80
|
|
|
HC INJ FORAMEN EPIDURAL ADD-ON
|
Facility
|
OP
|
$3,362.00
|
|
|
Service Code
|
CPT 64484
|
| Hospital Charge Code |
909081858
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$207.92 |
| Max. Negotiated Rate |
$3,517.28 |
| Rate for Payer: Adventist Health Commercial |
$672.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,309.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,857.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,849.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,521.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| 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 |
$1,512.90
|
| Rate for Payer: Cash Price |
$1,512.90
|
| Rate for Payer: Cash Price |
$1,512.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,185.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,857.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,857.70
|
| Rate for Payer: Dignity Health Senior |
$2,857.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,017.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,081.08
|
| Rate for Payer: Heritage Provider Network Senior |
$2,081.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$207.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,620.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$608.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$840.50
|
| Rate for Payer: Multiplan Commercial |
$2,521.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,040.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$874.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,857.70
|
| Rate for Payer: Vantage Medical Group Senior |
$2,857.70
|
|
|
HC INJ FORAMEN EPIDURAL ADD-ON
|
Facility
|
OP
|
$3,362.00
|
|
|
Service Code
|
CPT 64480
|
| Hospital Charge Code |
909081856
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$218.96 |
| Max. Negotiated Rate |
$3,517.28 |
| Rate for Payer: Adventist Health Commercial |
$672.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,309.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,857.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,849.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,521.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| 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 |
$1,512.90
|
| Rate for Payer: Cash Price |
$1,512.90
|
| Rate for Payer: Cash Price |
$1,512.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,185.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,857.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,857.70
|
| Rate for Payer: Dignity Health Senior |
$2,857.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,017.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,081.08
|
| Rate for Payer: Heritage Provider Network Senior |
$2,081.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$218.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,620.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$608.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$840.50
|
| Rate for Payer: Multiplan Commercial |
$2,521.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,040.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$874.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,857.70
|
| Rate for Payer: Vantage Medical Group Senior |
$2,857.70
|
|
|
HC INJ FORAMEN EPIDURAL ADD-ON
|
Facility
|
IP
|
$3,362.00
|
|
|
Service Code
|
CPT 64484
|
| Hospital Charge Code |
909081858
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$608.52 |
| Max. Negotiated Rate |
$2,521.50 |
| Rate for Payer: Adventist Health Commercial |
$672.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,309.69
|
| Rate for Payer: Cash Price |
$1,512.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,276.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2,276.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$608.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$840.50
|
| Rate for Payer: Multiplan Commercial |
$2,521.50
|
|
|
HC INJ FORAMEN EPIDURAL ADD-ON
|
Facility
|
IP
|
$3,362.00
|
|
|
Service Code
|
CPT 64480
|
| Hospital Charge Code |
909081856
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$608.52 |
| Max. Negotiated Rate |
$2,521.50 |
| Rate for Payer: Adventist Health Commercial |
$672.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,309.69
|
| Rate for Payer: Cash Price |
$1,512.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,276.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2,276.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$608.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$840.50
|
| Rate for Payer: Multiplan Commercial |
$2,521.50
|
|
|
HC INJ FORAMEN EPIDURAL C/T
|
Facility
|
OP
|
$3,362.00
|
|
|
Service Code
|
CPT 64479
|
| Hospital Charge Code |
909081855
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$241.02 |
| Max. Negotiated Rate |
$3,517.28 |
| Rate for Payer: Adventist Health Commercial |
$672.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,309.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,138.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| 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 |
$1,512.90
|
| Rate for Payer: Cash Price |
$1,512.90
|
| Rate for Payer: Cash Price |
$1,512.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,185.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,252.71
|
| Rate for Payer: Dignity Health Senior |
$1,138.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,017.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,138.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,081.08
|
| Rate for Payer: Heritage Provider Network Senior |
$1,400.76
|
| Rate for Payer: Humana Medicare |
$1,138.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$241.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,138.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,163.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$608.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,343.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$840.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,434.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,434.93
|
| Rate for Payer: Multiplan Commercial |
$2,521.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,252.71
|
| Rate for Payer: TriValley Medical Group Senior |
$1,252.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,600.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,188.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1,138.83
|
|
|
HC INJ FORAMEN EPIDURAL C/T
|
Facility
|
IP
|
$3,362.00
|
|
|
Service Code
|
CPT 64479
|
| Hospital Charge Code |
909081855
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$608.52 |
| Max. Negotiated Rate |
$2,521.50 |
| Rate for Payer: Adventist Health Commercial |
$672.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,309.69
|
| Rate for Payer: Cash Price |
$1,512.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,276.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2,276.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$608.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$840.50
|
| Rate for Payer: Multiplan Commercial |
$2,521.50
|
|
|
HC INJ FORAMEN EPIDURAL L/S
|
Facility
|
OP
|
$5,043.00
|
|
|
Service Code
|
CPT 64483
|
| Hospital Charge Code |
909081857
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$223.61 |
| Max. Negotiated Rate |
$3,782.25 |
| Rate for Payer: Adventist Health Commercial |
$1,008.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,464.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,138.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| 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 |
$2,269.35
|
| Rate for Payer: Cash Price |
$2,269.35
|
| Rate for Payer: Cash Price |
$2,269.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,277.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,252.71
|
| Rate for Payer: Dignity Health Senior |
$1,138.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,025.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,138.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,121.62
|
| Rate for Payer: Heritage Provider Network Senior |
$1,400.76
|
| Rate for Payer: Humana Medicare |
$1,138.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$223.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,138.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,163.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$912.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,343.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,260.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,434.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,434.93
|
| Rate for Payer: Multiplan Commercial |
$3,782.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,252.71
|
| Rate for Payer: TriValley Medical Group Senior |
$1,252.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,600.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,188.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1,138.83
|
|
|
HC INJ FORAMEN EPIDURAL L/S
|
Facility
|
IP
|
$5,043.00
|
|
|
Service Code
|
CPT 64483
|
| Hospital Charge Code |
909081857
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$912.78 |
| Max. Negotiated Rate |
$3,782.25 |
| Rate for Payer: Adventist Health Commercial |
$1,008.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,464.54
|
| Rate for Payer: Cash Price |
$2,269.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,414.11
|
| Rate for Payer: Heritage Provider Network Senior |
$3,414.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$912.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,260.75
|
| Rate for Payer: Multiplan Commercial |
$3,782.25
|
|
|
HC INJ INTER CRV/THRC WGUID
|
Facility
|
OP
|
$2,632.00
|
|
|
Service Code
|
CPT 62321
|
| Hospital Charge Code |
907262321
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$348.47 |
| Max. Negotiated Rate |
$3,517.28 |
| Rate for Payer: Adventist Health Commercial |
$526.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,808.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$864.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| 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 |
$1,184.40
|
| Rate for Payer: Cash Price |
$1,184.40
|
| Rate for Payer: Cash Price |
$1,184.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,710.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$950.44
|
| Rate for Payer: Dignity Health Senior |
$864.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,579.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$864.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,629.21
|
| Rate for Payer: Heritage Provider Network Senior |
$1,062.77
|
| Rate for Payer: Humana Medicare |
$864.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$348.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$864.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,641.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$476.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,019.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$658.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,088.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,088.69
|
| Rate for Payer: Multiplan Commercial |
$1,974.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$950.44
|
| Rate for Payer: TriValley Medical Group Senior |
$950.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,600.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,188.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Vantage Medical Group Senior |
$864.04
|
|
|
HC INJ INTER CRV/THRC WGUID
|
Facility
|
IP
|
$2,632.00
|
|
|
Service Code
|
CPT 62321
|
| Hospital Charge Code |
907262321
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$476.39 |
| Max. Negotiated Rate |
$1,974.00 |
| Rate for Payer: Adventist Health Commercial |
$526.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,808.18
|
| Rate for Payer: Cash Price |
$1,184.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,781.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1,781.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$476.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$658.00
|
| Rate for Payer: Multiplan Commercial |
$1,974.00
|
|
|
HC INJ INTER CRV/THRC WO GUID
|
Facility
|
OP
|
$1,878.00
|
|
|
Service Code
|
CPT 62320
|
| Hospital Charge Code |
907262320
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$230.57 |
| Max. Negotiated Rate |
$3,517.28 |
| Rate for Payer: Adventist Health Commercial |
$375.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,290.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$864.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| 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 |
$845.10
|
| Rate for Payer: Cash Price |
$845.10
|
| Rate for Payer: Cash Price |
$845.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,220.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$950.44
|
| Rate for Payer: Dignity Health Senior |
$864.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,126.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$864.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,162.48
|
| Rate for Payer: Heritage Provider Network Senior |
$1,062.77
|
| Rate for Payer: Humana Medicare |
$864.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$230.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$864.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,641.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$339.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,019.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$469.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,088.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,088.69
|
| Rate for Payer: Multiplan Commercial |
$1,408.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$950.44
|
| Rate for Payer: TriValley Medical Group Senior |
$950.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,600.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,188.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,296.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$950.44
|
| Rate for Payer: Vantage Medical Group Senior |
$864.04
|
|
