|
HC DRES & OR DEB OF BURN INT/SUB SMALL
|
Facility
OP
|
$686.00
|
|
|
Service Code
|
CPT 16020
|
| Hospital Charge Code |
900501046
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$124.17 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$137.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$471.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: AlphaCare 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 |
$308.70
|
| Rate for Payer: Cash Price |
$308.70
|
| Rate for Payer: Cash Price |
$308.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$445.90
|
| 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 |
$464.42
|
| Rate for Payer: Heritage Provider Network Senior |
$464.42
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: IEHP Medi-Cal |
$936.00
|
| Rate for Payer: IEHP Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$330.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$124.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$295.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$171.50
|
| 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 |
$514.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$249.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$229.19
|
| 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
|
|
|
HC DRES & OR DEB OF BURN INT/SUB SMALL
|
Facility
IP
|
$686.00
|
|
|
Service Code
|
CPT 16020
|
| Hospital Charge Code |
900501046
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$124.17 |
| Max. Negotiated Rate |
$514.50 |
| Rate for Payer: Adventist Health Commercial |
$137.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$471.28
|
| Rate for Payer: Cash Price |
$308.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$464.42
|
| Rate for Payer: Heritage Provider Network Senior |
$464.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$124.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$171.50
|
| Rate for Payer: Multiplan Commercial |
$514.50
|
|
|
HC DRESSING CHANGE UNDER ANESTH
|
Facility
OP
|
$508.00
|
|
|
Service Code
|
CPT 15852
|
| Hospital Charge Code |
907201139
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$91.95 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$101.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$349.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$784.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$330.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$863.18
|
| Rate for Payer: Dignity Health Senior |
$784.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$784.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$343.92
|
| Rate for Payer: Heritage Provider Network Senior |
$343.92
|
| Rate for Payer: Humana Medicare |
$784.71
|
| Rate for Payer: IEHP Medi-Cal |
$936.00
|
| Rate for Payer: IEHP Medicare Advantage |
$784.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$244.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$925.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$127.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$988.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$988.73
|
| Rate for Payer: Multiplan Commercial |
$381.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$184.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$169.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: Vantage Medical Group Senior |
$784.71
|
|
|
HC DRESSING CHANGE UNDER ANESTH
|
Facility
IP
|
$508.00
|
|
|
Service Code
|
CPT 15852
|
| Hospital Charge Code |
907201139
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$91.95 |
| Max. Negotiated Rate |
$381.00 |
| Rate for Payer: Adventist Health Commercial |
$101.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$349.00
|
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$343.92
|
| Rate for Payer: Heritage Provider Network Senior |
$343.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$127.00
|
| Rate for Payer: Multiplan Commercial |
$381.00
|
|
|
HC DRIED BLOOD SPOT SCREEN DUKE
|
Facility
IP
|
$232.00
|
|
|
Service Code
|
CPT 84311
|
| Hospital Charge Code |
900914678
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$41.99 |
| Max. Negotiated Rate |
$174.00 |
| Rate for Payer: Adventist Health Commercial |
$46.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$159.38
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$157.06
|
| Rate for Payer: Heritage Provider Network Senior |
$157.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.00
|
| Rate for Payer: Multiplan Commercial |
$174.00
|
|
|
HC DRIED BLOOD SPOT SCREEN DUKE
|
Facility
OP
|
$232.00
|
|
|
Service Code
|
CPT 84311
|
| Hospital Charge Code |
900914678
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$174.00 |
| Rate for Payer: Adventist Health Commercial |
$46.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$20.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$159.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$58.55
|
| Rate for Payer: Blue Shield of California Commercial |
$54.61
|
| Rate for Payer: Blue Shield of California EPN |
$42.69
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$150.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.91
|
| Rate for Payer: Dignity Health Senior |
$8.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$150.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$143.61
|
| Rate for Payer: Heritage Provider Network Senior |
$143.61
|
| Rate for Payer: Humana Medicare |
$8.10
|
| Rate for Payer: IEHP Medi-Cal |
$10.11
|
| Rate for Payer: IEHP Medicare Advantage |
$8.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.99
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.21
|
| Rate for Payer: Multiplan Commercial |
$174.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.10
|
| Rate for Payer: TriValley Medical Group Senior |
$8.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.91
|
| Rate for Payer: Vantage Medical Group Senior |
$8.10
|
|
|
HC DRILL SKULL FOR IMPLANTATION
|
Facility
IP
|
$9,612.00
|
|
|
Service Code
|
CPT 61107
|
| Hospital Charge Code |
900501647
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,739.77 |
| Max. Negotiated Rate |
$7,209.00 |
| Rate for Payer: Adventist Health Commercial |
$1,922.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,603.44
|
| Rate for Payer: Cash Price |
$4,325.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,507.32
|
| Rate for Payer: Heritage Provider Network Senior |
$6,507.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,739.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,403.00
|
| Rate for Payer: Multiplan Commercial |
$7,209.00
|
|
|
HC DRILL SKULL FOR IMPLANTATION
|
Facility
OP
|
$9,612.00
|
|
|
Service Code
|
CPT 61107
|
| Hospital Charge Code |
900501647
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$487.86 |
| Max. Negotiated Rate |
$12,620.00 |
| Rate for Payer: Adventist Health Commercial |
$1,922.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12,620.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,603.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8,170.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5,286.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,209.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| 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 |
$4,325.40
|
| Rate for Payer: Cash Price |
$4,325.40
|
| Rate for Payer: Cash Price |
$4,325.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6,247.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8,170.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,170.20
|
| Rate for Payer: Dignity Health Senior |
$8,170.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,767.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,949.83
|
| Rate for Payer: Heritage Provider Network Senior |
$5,949.83
|
| Rate for Payer: IEHP Medi-Cal |
$487.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,632.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,739.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,403.00
|
| Rate for Payer: Multiplan Commercial |
$7,209.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,374.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,841.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,170.20
|
| Rate for Payer: Vantage Medical Group Senior |
$8,170.20
|
|
|
HC DRSNG CAL AG MELGISORB+ 4X4"
|
Facility
OP
|
$15.76
|
|
|
Service Code
|
CPT A6196
|
| Hospital Charge Code |
901698367
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$13.40 |
| Rate for Payer: Adventist Health Commercial |
$3.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.83
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.82
|
| Rate for Payer: Blue Shield of California Commercial |
$9.79
|
| Rate for Payer: Blue Shield of California EPN |
$9.25
|
| Rate for Payer: Cash Price |
$7.09
|
| Rate for Payer: Cash Price |
$7.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.40
|
| Rate for Payer: Dignity Health Senior |
$13.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.76
|
| Rate for Payer: Heritage Provider Network Senior |
$9.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.94
|
| Rate for Payer: Multiplan Commercial |
$11.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.40
|
| Rate for Payer: Vantage Medical Group Senior |
$13.40
|
|
|
HC DRSNG CAL AG MELGISORB+ 4X4"
|
Facility
IP
|
$15.76
|
|
|
Service Code
|
CPT A6196
|
| Hospital Charge Code |
901698367
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$11.82 |
| Rate for Payer: Adventist Health Commercial |
$3.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.83
|
| Rate for Payer: Cash Price |
$7.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.67
|
| Rate for Payer: Heritage Provider Network Senior |
$10.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.94
|
| Rate for Payer: Multiplan Commercial |
$11.82
|
|
|
HC DRSNG KERECIS OMEGA 3 WOUND 1.75X1.75CM
|
Facility
IP
|
$826.00
|
|
|
Service Code
|
CPT Q4158
|
| Hospital Charge Code |
900102212
|
|
Hospital Revenue Code
|
636
|
| 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: Cigna of CA HMO/PPO |
$379.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$446.04
|
| 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
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$301.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$275.97
|
|
|
HC DRSNG KERECIS OMEGA 3 WOUND 1.75X1.75CM
|
Facility
OP
|
$826.00
|
|
|
Service Code
|
CPT Q4158
|
| Hospital Charge Code |
900102212
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$149.51 |
| Max. Negotiated Rate |
$702.10 |
| Rate for Payer: Adventist Health Commercial |
$165.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$413.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$567.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$702.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$454.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$619.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$328.20
|
| 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: Cigna of CA HMO/PPO |
$379.96
|
| 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 |
$528.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$382.44
|
| Rate for Payer: Heritage Provider Network Senior |
$382.44
|
| 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: United Healthcare All Other HMO/non HMO |
$301.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$275.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$702.10
|
| Rate for Payer: Vantage Medical Group Senior |
$702.10
|
|
|
HC DRSNG KERECIS OMEGA 3 WOUND 3 X 3.5CM
|
Facility
OP
|
$332.00
|
|
|
Service Code
|
CPT Q4158
|
| Hospital Charge Code |
900102213
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.09 |
| Max. Negotiated Rate |
$413.86 |
| Rate for Payer: Adventist Health Commercial |
$66.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$413.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$228.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$282.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$182.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$249.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$328.20
|
| Rate for Payer: Blue Shield of California Commercial |
$206.17
|
| Rate for Payer: Blue Shield of California EPN |
$194.88
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$152.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$282.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$282.20
|
| Rate for Payer: Dignity Health Senior |
$282.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$212.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$153.72
|
| Rate for Payer: Heritage Provider Network Senior |
$153.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$160.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.00
|
| Rate for Payer: Multiplan Commercial |
$249.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$121.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$110.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$282.20
|
| Rate for Payer: Vantage Medical Group Senior |
$282.20
|
|
|
HC DRSNG KERECIS OMEGA 3 WOUND 3 X 3.5CM
|
Facility
IP
|
$332.00
|
|
|
Service Code
|
CPT Q4158
|
| Hospital Charge Code |
900102213
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.09 |
| Max. Negotiated Rate |
$249.00 |
| Rate for Payer: Adventist Health Commercial |
$66.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$228.08
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$152.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$179.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$224.76
|
| Rate for Payer: Heritage Provider Network Senior |
$224.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.00
|
| Rate for Payer: Multiplan Commercial |
$249.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$121.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$110.92
|
|
|
HC DRSNG KERECIS OMEGA 3 WOUND 3 X 7CM
|
Facility
IP
|
$213.00
|
|
|
Service Code
|
CPT Q4158
|
| Hospital Charge Code |
900102214
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.55 |
| Max. Negotiated Rate |
$159.75 |
| Rate for Payer: Adventist Health Commercial |
$42.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$146.33
|
| Rate for Payer: Cash Price |
$95.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$97.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$115.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$144.20
|
| Rate for Payer: Heritage Provider Network Senior |
$144.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.25
|
| Rate for Payer: Multiplan Commercial |
$159.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$77.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.16
|
|
|
HC DRSNG KERECIS OMEGA 3 WOUND 3 X 7CM
|
Facility
OP
|
$213.00
|
|
|
Service Code
|
CPT Q4158
|
| Hospital Charge Code |
900102214
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.55 |
| Max. Negotiated Rate |
$413.86 |
| Rate for Payer: Adventist Health Commercial |
$42.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$413.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$146.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$181.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$117.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$159.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$328.20
|
| Rate for Payer: Blue Shield of California Commercial |
$132.27
|
| Rate for Payer: Blue Shield of California EPN |
$125.03
|
| Rate for Payer: Cash Price |
$95.85
|
| Rate for Payer: Cash Price |
$95.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$97.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$181.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$181.05
|
| Rate for Payer: Dignity Health Senior |
$181.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$136.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$98.62
|
| Rate for Payer: Heritage Provider Network Senior |
$98.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$102.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.25
|
| Rate for Payer: Multiplan Commercial |
$159.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$77.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$181.05
|
| Rate for Payer: Vantage Medical Group Senior |
$181.05
|
|
|
HC DRSNG OPTIFOAM AG 4X4" NO BRDR
|
Facility
IP
|
$50.08
|
|
|
Service Code
|
CPT A6209
|
| Hospital Charge Code |
901698381
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.06 |
| Max. Negotiated Rate |
$37.56 |
| Rate for Payer: Adventist Health Commercial |
$10.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.40
|
| Rate for Payer: Cash Price |
$22.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.90
|
| Rate for Payer: Heritage Provider Network Senior |
$33.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.52
|
| Rate for Payer: Multiplan Commercial |
$37.56
|
|
|
HC DRSNG OPTIFOAM AG 4X4" NO BRDR
|
Facility
OP
|
$50.08
|
|
|
Service Code
|
CPT A6209
|
| Hospital Charge Code |
901698381
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.78 |
| Max. Negotiated Rate |
$42.57 |
| Rate for Payer: Adventist Health Commercial |
$10.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$42.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$27.54
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$37.56
|
| Rate for Payer: Blue Shield of California Commercial |
$31.10
|
| Rate for Payer: Blue Shield of California EPN |
$29.40
|
| Rate for Payer: Cash Price |
$22.54
|
| Rate for Payer: Cash Price |
$22.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.57
|
| Rate for Payer: Dignity Health Senior |
$42.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.00
|
| Rate for Payer: Heritage Provider Network Senior |
$31.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$24.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.52
|
| Rate for Payer: Multiplan Commercial |
$37.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.57
|
| Rate for Payer: Vantage Medical Group Senior |
$42.57
|
|
|
HC DRSNG OPTIFOAM SA 6X6" BRDR
|
Facility
IP
|
$36.43
|
|
|
Service Code
|
CPT A6213
|
| Hospital Charge Code |
901698382
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.59 |
| Max. Negotiated Rate |
$27.32 |
| Rate for Payer: Adventist Health Commercial |
$7.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.03
|
| Rate for Payer: Cash Price |
$16.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.66
|
| Rate for Payer: Heritage Provider Network Senior |
$24.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.11
|
| Rate for Payer: Multiplan Commercial |
$27.32
|
|
|
HC DRSNG OPTIFOAM SA 6X6" BRDR
|
Facility
OP
|
$36.43
|
|
|
Service Code
|
CPT A6213
|
| Hospital Charge Code |
901698382
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.59 |
| Max. Negotiated Rate |
$30.97 |
| Rate for Payer: Adventist Health Commercial |
$7.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$30.97
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$27.32
|
| Rate for Payer: Blue Shield of California Commercial |
$22.62
|
| Rate for Payer: Blue Shield of California EPN |
$21.38
|
| Rate for Payer: Cash Price |
$16.39
|
| Rate for Payer: Cash Price |
$16.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.97
|
| Rate for Payer: Dignity Health Senior |
$30.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.55
|
| Rate for Payer: Heritage Provider Network Senior |
$22.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.11
|
| Rate for Payer: Multiplan Commercial |
$27.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.97
|
| Rate for Payer: Vantage Medical Group Senior |
$30.97
|
|
|
HC DRUGS ABUSE SCREEN,URINE(7)COC
|
Facility
IP
|
$851.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900912159
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$154.03 |
| Max. Negotiated Rate |
$638.25 |
| Rate for Payer: Adventist Health Commercial |
$170.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$584.64
|
| Rate for Payer: Cash Price |
$382.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$576.13
|
| Rate for Payer: Heritage Provider Network Senior |
$576.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$154.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$212.75
|
| Rate for Payer: Multiplan Commercial |
$638.25
|
|
|
HC DRUGS ABUSE SCREEN,URINE(7)COC
|
Facility
OP
|
$105.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900912159
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.00 |
| Max. Negotiated Rate |
$515.78 |
| Rate for Payer: Adventist Health Commercial |
$21.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$165.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$62.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$515.78
|
| Rate for Payer: Blue Shield of California Commercial |
$446.14
|
| Rate for Payer: Blue Shield of California EPN |
$348.77
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$68.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$93.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.35
|
| Rate for Payer: Dignity Health Senior |
$62.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$62.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.00
|
| Rate for Payer: Heritage Provider Network Senior |
$65.00
|
| Rate for Payer: Humana Medicare |
$62.14
|
| Rate for Payer: IEHP Medi-Cal |
$67.86
|
| Rate for Payer: IEHP Medicare Advantage |
$62.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$118.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$73.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$78.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78.30
|
| Rate for Payer: Multiplan Commercial |
$78.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$62.14
|
| Rate for Payer: TriValley Medical Group Senior |
$62.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$67.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$67.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: Vantage Medical Group Senior |
$62.14
|
|
|
HC DRUG SCREEN AMPHETAMINES
|
Facility
OP
|
$105.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900911077
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.00 |
| Max. Negotiated Rate |
$515.78 |
| Rate for Payer: Adventist Health Commercial |
$21.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$165.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$62.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$515.78
|
| Rate for Payer: Blue Shield of California Commercial |
$446.14
|
| Rate for Payer: Blue Shield of California EPN |
$348.77
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$68.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$93.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.35
|
| Rate for Payer: Dignity Health Senior |
$62.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$62.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.00
|
| Rate for Payer: Heritage Provider Network Senior |
$65.00
|
| Rate for Payer: Humana Medicare |
$62.14
|
| Rate for Payer: IEHP Medi-Cal |
$67.86
|
| Rate for Payer: IEHP Medicare Advantage |
$62.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$118.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$73.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$78.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78.30
|
| Rate for Payer: Multiplan Commercial |
$78.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$62.14
|
| Rate for Payer: TriValley Medical Group Senior |
$62.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$67.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$67.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: Vantage Medical Group Senior |
$62.14
|
|
|
HC DRUG SCREEN AMPHETAMINES
|
Facility
IP
|
$121.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900911077
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$90.75 |
| Rate for Payer: Adventist Health Commercial |
$24.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$83.13
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.92
|
| Rate for Payer: Heritage Provider Network Senior |
$81.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.25
|
| Rate for Payer: Multiplan Commercial |
$90.75
|
|
|
HC DRUG SCREEN BARBITUATES
|
Facility
OP
|
$105.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900910325
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.00 |
| Max. Negotiated Rate |
$515.78 |
| Rate for Payer: Adventist Health Commercial |
$21.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$165.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$62.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$515.78
|
| Rate for Payer: Blue Shield of California Commercial |
$446.14
|
| Rate for Payer: Blue Shield of California EPN |
$348.77
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$68.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$93.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.35
|
| Rate for Payer: Dignity Health Senior |
$62.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$62.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.00
|
| Rate for Payer: Heritage Provider Network Senior |
$65.00
|
| Rate for Payer: Humana Medicare |
$62.14
|
| Rate for Payer: IEHP Medi-Cal |
$67.86
|
| Rate for Payer: IEHP Medicare Advantage |
$62.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$118.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$73.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$78.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78.30
|
| Rate for Payer: Multiplan Commercial |
$78.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$62.14
|
| Rate for Payer: TriValley Medical Group Senior |
$62.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$67.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$67.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: Vantage Medical Group Senior |
$62.14
|
|
