|
HC DILAT XST TRC NEW ACCESS RCS
|
Facility
|
IP
|
$12,158.00
|
|
|
Service Code
|
CPT 50437
|
| Hospital Charge Code |
909050437
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,200.60 |
| Max. Negotiated Rate |
$9,118.50 |
| Rate for Payer: Adventist Health Commercial |
$2,431.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,829.75
|
| Rate for Payer: Cash Price |
$5,471.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$8,230.97
|
| Rate for Payer: Heritage Provider Network Senior |
$8,230.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,200.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,039.50
|
| Rate for Payer: Multiplan Commercial |
$9,118.50
|
|
|
HC DIRECT ADMIT OBS A/D SAME DT HIGH COMPLEX
|
Facility
|
OP
|
$827.00
|
|
|
Service Code
|
CPT G0379
|
| Hospital Charge Code |
902100072
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$67.70 |
| Max. Negotiated Rate |
$5,498.00 |
| Rate for Payer: Adventist Health Commercial |
$165.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$511.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,148.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$842.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$765.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,144.00
|
| Rate for Payer: Blue Shield of California Commercial |
$504.47
|
| Rate for Payer: Blue Shield of California EPN |
$403.58
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$537.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,148.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$842.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$765.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$765.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,860.00
|
| Rate for Payer: Heritage Provider Network Senior |
$67.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$765.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,498.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$880.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,026.37
|
| Rate for Payer: Multiplan Commercial |
$620.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$842.54
|
| Rate for Payer: TriValley Medical Group Senior |
$842.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,078.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,432.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,148.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$842.54
|
| Rate for Payer: Vantage Medical Group Senior |
$765.95
|
|
|
HC DIRECT ADMIT OBS A/D SAME DT HIGH COMPLEX
|
Facility
|
IP
|
$827.00
|
|
|
Service Code
|
CPT G0379
|
| Hospital Charge Code |
902100072
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$149.69 |
| Max. Negotiated Rate |
$620.25 |
| Rate for Payer: Adventist Health Commercial |
$165.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$532.59
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$559.88
|
| Rate for Payer: Heritage Provider Network Senior |
$559.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.75
|
| Rate for Payer: Multiplan Commercial |
$620.25
|
|
|
HC DIRECT ADMIT OBS A/D SAME DT LOW COMPLEX
|
Facility
|
OP
|
$827.00
|
|
|
Service Code
|
CPT 99234
|
| Hospital Charge Code |
902100070
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$67.70 |
| Max. Negotiated Rate |
$5,498.00 |
| Rate for Payer: Adventist Health Commercial |
$165.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$511.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$702.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$454.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$620.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,144.00
|
| Rate for Payer: Blue Shield of California Commercial |
$504.47
|
| Rate for Payer: Blue Shield of California EPN |
$403.58
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$537.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$702.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$702.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$702.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,860.00
|
| Rate for Payer: Heritage Provider Network Senior |
$67.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,498.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$578.90
|
| Rate for Payer: Multiplan Commercial |
$620.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$413.50
|
| Rate for Payer: TriValley Medical Group Senior |
$413.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,078.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,432.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$702.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$702.95
|
| Rate for Payer: Vantage Medical Group Senior |
$702.95
|
|
|
HC DIRECT ADMIT OBS A/D SAME DT LOW COMPLEX
|
Facility
|
IP
|
$827.00
|
|
|
Service Code
|
CPT 99234
|
| Hospital Charge Code |
902100070
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$149.69 |
| Max. Negotiated Rate |
$620.25 |
| Rate for Payer: Adventist Health Commercial |
$165.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$532.59
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$559.88
|
| Rate for Payer: Heritage Provider Network Senior |
$559.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.75
|
| Rate for Payer: Multiplan Commercial |
$620.25
|
|
|
HC DIRECT ADMIT OBS A/D SAME DT MOD COMPLEX
|
Facility
|
OP
|
$827.00
|
|
|
Service Code
|
CPT 99235
|
| Hospital Charge Code |
902100071
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$67.70 |
| Max. Negotiated Rate |
$5,498.00 |
| Rate for Payer: Adventist Health Commercial |
$165.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$511.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$702.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$454.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$620.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,144.00
|
| Rate for Payer: Blue Shield of California Commercial |
$504.47
|
| Rate for Payer: Blue Shield of California EPN |
$403.58
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$537.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$702.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$702.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$702.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,860.00
|
| Rate for Payer: Heritage Provider Network Senior |
$67.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,498.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$578.90
|
| Rate for Payer: Multiplan Commercial |
$620.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$413.50
|
| Rate for Payer: TriValley Medical Group Senior |
$413.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,078.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,432.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$702.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$702.95
|
| Rate for Payer: Vantage Medical Group Senior |
$702.95
|
|
|
HC DIRECT ADMIT OBS A/D SAME DT MOD COMPLEX
|
Facility
|
IP
|
$827.00
|
|
|
Service Code
|
CPT 99235
|
| Hospital Charge Code |
902100071
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$149.69 |
| Max. Negotiated Rate |
$620.25 |
| Rate for Payer: Adventist Health Commercial |
$165.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$532.59
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$559.88
|
| Rate for Payer: Heritage Provider Network Senior |
$559.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.75
|
| Rate for Payer: Multiplan Commercial |
$620.25
|
|
|
HC DIRECT ADMIT OBS HIGH COMPLEX
|
Facility
|
OP
|
$827.00
|
|
|
Service Code
|
CPT G0379
|
| Hospital Charge Code |
902100075
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$67.70 |
| Max. Negotiated Rate |
$5,498.00 |
| Rate for Payer: Adventist Health Commercial |
$165.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$511.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,148.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$842.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$765.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,144.00
|
| Rate for Payer: Blue Shield of California Commercial |
$504.47
|
| Rate for Payer: Blue Shield of California EPN |
$403.58
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$537.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,148.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$842.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$765.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$765.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,860.00
|
| Rate for Payer: Heritage Provider Network Senior |
$67.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$765.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,498.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$880.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,026.37
|
| Rate for Payer: Multiplan Commercial |
$620.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$842.54
|
| Rate for Payer: TriValley Medical Group Senior |
$842.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,078.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,432.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,148.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$842.54
|
| Rate for Payer: Vantage Medical Group Senior |
$765.95
|
|
|
HC DIRECT ADMIT OBS HIGH COMPLEX
|
Facility
|
IP
|
$827.00
|
|
|
Service Code
|
CPT G0379
|
| Hospital Charge Code |
902100075
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$149.69 |
| Max. Negotiated Rate |
$620.25 |
| Rate for Payer: Adventist Health Commercial |
$165.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$532.59
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$559.88
|
| Rate for Payer: Heritage Provider Network Senior |
$559.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.75
|
| Rate for Payer: Multiplan Commercial |
$620.25
|
|
|
HC DIRECT ADMIT OBS LOW COMPLEX
|
Facility
|
OP
|
$827.00
|
|
|
Service Code
|
CPT G0379
|
| Hospital Charge Code |
902100073
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$67.70 |
| Max. Negotiated Rate |
$5,498.00 |
| Rate for Payer: Adventist Health Commercial |
$165.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$511.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,148.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$842.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$765.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,144.00
|
| Rate for Payer: Blue Shield of California Commercial |
$504.47
|
| Rate for Payer: Blue Shield of California EPN |
$403.58
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$537.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,148.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$842.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$765.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$765.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,860.00
|
| Rate for Payer: Heritage Provider Network Senior |
$67.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$765.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,498.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$880.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,026.37
|
| Rate for Payer: Multiplan Commercial |
$620.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$842.54
|
| Rate for Payer: TriValley Medical Group Senior |
$842.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,078.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,432.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,148.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$842.54
|
| Rate for Payer: Vantage Medical Group Senior |
$765.95
|
|
|
HC DIRECT ADMIT OBS LOW COMPLEX
|
Facility
|
IP
|
$827.00
|
|
|
Service Code
|
CPT G0379
|
| Hospital Charge Code |
902100073
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$149.69 |
| Max. Negotiated Rate |
$620.25 |
| Rate for Payer: Adventist Health Commercial |
$165.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$532.59
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$559.88
|
| Rate for Payer: Heritage Provider Network Senior |
$559.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.75
|
| Rate for Payer: Multiplan Commercial |
$620.25
|
|
|
HC DIRECT ADMIT OBS MOD COMPLEX
|
Facility
|
IP
|
$827.00
|
|
|
Service Code
|
CPT G0379
|
| Hospital Charge Code |
902100074
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$149.69 |
| Max. Negotiated Rate |
$620.25 |
| Rate for Payer: Adventist Health Commercial |
$165.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$532.59
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$559.88
|
| Rate for Payer: Heritage Provider Network Senior |
$559.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.75
|
| Rate for Payer: Multiplan Commercial |
$620.25
|
|
|
HC DIRECT ADMIT OBS MOD COMPLEX
|
Facility
|
OP
|
$827.00
|
|
|
Service Code
|
CPT G0379
|
| Hospital Charge Code |
902100074
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$67.70 |
| Max. Negotiated Rate |
$5,498.00 |
| Rate for Payer: Adventist Health Commercial |
$165.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$511.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,148.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$842.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$765.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,144.00
|
| Rate for Payer: Blue Shield of California Commercial |
$504.47
|
| Rate for Payer: Blue Shield of California EPN |
$403.58
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$537.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,148.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$842.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$765.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$765.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,860.00
|
| Rate for Payer: Heritage Provider Network Senior |
$67.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$765.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,498.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$880.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,026.37
|
| Rate for Payer: Multiplan Commercial |
$620.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$842.54
|
| Rate for Payer: TriValley Medical Group Senior |
$842.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,078.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,432.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,148.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$842.54
|
| Rate for Payer: Vantage Medical Group Senior |
$765.95
|
|
|
HC DISCOGRAM C SPINE
|
Facility
|
IP
|
$5,935.00
|
|
|
Service Code
|
CPT 72285
|
| Hospital Charge Code |
909001360
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,074.23 |
| Max. Negotiated Rate |
$4,451.25 |
| Rate for Payer: Adventist Health Commercial |
$1,187.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,822.14
|
| Rate for Payer: Cash Price |
$2,670.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,017.99
|
| Rate for Payer: Heritage Provider Network Senior |
$4,017.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,074.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,483.75
|
| Rate for Payer: Multiplan Commercial |
$4,451.25
|
|
|
HC DISCOGRAM C SPINE
|
Facility
|
OP
|
$5,935.00
|
|
|
Service Code
|
CPT 72285
|
| Hospital Charge Code |
909001360
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,074.23 |
| Max. Negotiated Rate |
$4,451.25 |
| Rate for Payer: Adventist Health Commercial |
$1,187.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,667.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,767.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,762.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,511.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,264.95
|
| Rate for Payer: Blue Shield of California Commercial |
$1,760.93
|
| Rate for Payer: Blue Shield of California EPN |
$1,416.08
|
| Rate for Payer: Cash Price |
$2,670.75
|
| Rate for Payer: Cash Price |
$2,670.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,857.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,767.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,762.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,511.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,501.65
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,511.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,673.76
|
| Rate for Payer: Heritage Provider Network Senior |
$3,673.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,511.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,830.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,074.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,888.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,483.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,365.45
|
| Rate for Payer: Multiplan Commercial |
$4,451.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,511.53
|
| Rate for Payer: TriValley Medical Group Senior |
$2,511.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,558.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,558.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,767.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,762.68
|
| Rate for Payer: Vantage Medical Group Senior |
$2,511.53
|
|
|
HC DISCOGRAM LUMBAR SPINE
|
Facility
|
OP
|
$5,935.00
|
|
|
Service Code
|
CPT 72295
|
| Hospital Charge Code |
909001361
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,074.23 |
| Max. Negotiated Rate |
$4,451.25 |
| Rate for Payer: Adventist Health Commercial |
$1,187.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,667.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,767.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,762.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,511.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,121.12
|
| Rate for Payer: Blue Shield of California Commercial |
$1,649.52
|
| Rate for Payer: Blue Shield of California EPN |
$1,326.49
|
| Rate for Payer: Cash Price |
$2,670.75
|
| Rate for Payer: Cash Price |
$2,670.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,857.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,767.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,762.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,511.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,501.65
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,511.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,673.76
|
| Rate for Payer: Heritage Provider Network Senior |
$3,673.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,511.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,830.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,074.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,888.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,483.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,365.45
|
| Rate for Payer: Multiplan Commercial |
$4,451.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,511.53
|
| Rate for Payer: TriValley Medical Group Senior |
$2,511.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,558.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,558.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,767.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,762.68
|
| Rate for Payer: Vantage Medical Group Senior |
$2,511.53
|
|
|
HC DISCOGRAM LUMBAR SPINE
|
Facility
|
IP
|
$5,935.00
|
|
|
Service Code
|
CPT 72295
|
| Hospital Charge Code |
909001361
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,074.23 |
| Max. Negotiated Rate |
$4,451.25 |
| Rate for Payer: Adventist Health Commercial |
$1,187.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,822.14
|
| Rate for Payer: Cash Price |
$2,670.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,017.99
|
| Rate for Payer: Heritage Provider Network Senior |
$4,017.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,074.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,483.75
|
| Rate for Payer: Multiplan Commercial |
$4,451.25
|
|
|
HC DISK ASPIRATION
|
Facility
|
OP
|
$21,320.00
|
|
|
Service Code
|
CPT 62287
|
| Hospital Charge Code |
909000258
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,511.53 |
| Max. Negotiated Rate |
$15,990.00 |
| Rate for Payer: Adventist Health Commercial |
$4,264.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13,175.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,767.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,762.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,511.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,245.00
|
| Rate for Payer: Blue Shield of California Commercial |
$14,574.13
|
| Rate for Payer: Blue Shield of California EPN |
$11,673.59
|
| Rate for Payer: Cash Price |
$9,594.00
|
| Rate for Payer: Cash Price |
$9,594.00
|
| Rate for Payer: Cash Price |
$9,594.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13,858.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,767.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,762.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,511.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,792.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,511.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$13,197.08
|
| Rate for Payer: Heritage Provider Network Senior |
$3,089.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,511.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4,771.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3,858.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,888.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,330.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,365.45
|
| Rate for Payer: Multiplan Commercial |
$15,990.00
|
| Rate for Payer: Multiplan WC |
$3,953.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,762.68
|
| Rate for Payer: TriValley Medical Group Senior |
$2,762.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,001.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,445.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,767.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,762.68
|
| Rate for Payer: Vantage Medical Group Senior |
$2,511.53
|
|
|
HC DISK ASPIRATION
|
Facility
|
IP
|
$21,320.00
|
|
|
Service Code
|
CPT 62287
|
| Hospital Charge Code |
909000258
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$3,858.92 |
| Max. Negotiated Rate |
$15,990.00 |
| Rate for Payer: Adventist Health Commercial |
$4,264.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13,730.08
|
| Rate for Payer: Cash Price |
$9,594.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$14,433.64
|
| Rate for Payer: Heritage Provider Network Senior |
$14,433.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3,858.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,330.00
|
| Rate for Payer: Multiplan Commercial |
$15,990.00
|
|
|
HC DISSOLVE CLOT HEART VESSEL
|
Facility
|
OP
|
$525.00
|
|
|
Service Code
|
CPT 92977
|
| Hospital Charge Code |
906811128
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$95.03 |
| Max. Negotiated Rate |
$8,962.13 |
| Rate for Payer: Adventist Health Commercial |
$105.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$324.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$446.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$288.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$393.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,245.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,340.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$446.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$446.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$446.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$309.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$324.98
|
| Rate for Payer: Heritage Provider Network Senior |
$324.98
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$250.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$95.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$367.50
|
| Rate for Payer: Multiplan Commercial |
$393.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,093.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$446.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$446.25
|
| Rate for Payer: Vantage Medical Group Senior |
$446.25
|
|
|
HC DISSOLVE CLOT HEART VESSEL
|
Facility
|
OP
|
$525.00
|
|
|
Service Code
|
CPT 92977
|
| Hospital Charge Code |
906811128
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$95.03 |
| Max. Negotiated Rate |
$6,245.00 |
| Rate for Payer: Adventist Health Commercial |
$105.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$324.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$446.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$288.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$393.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,245.00
|
| Rate for Payer: Blue Shield of California Commercial |
$249.38
|
| Rate for Payer: Blue Shield of California EPN |
$198.45
|
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$341.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$446.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$446.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$446.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$341.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$355.43
|
| Rate for Payer: Heritage Provider Network Senior |
$355.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$250.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$95.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$367.50
|
| Rate for Payer: Multiplan Commercial |
$393.75
|
| Rate for Payer: Multiplan WC |
$671.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$315.00
|
| Rate for Payer: TriValley Medical Group Senior |
$315.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$446.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$446.25
|
| Rate for Payer: Vantage Medical Group Senior |
$446.25
|
|
|
HC DISSOLVE CLOT HEART VESSEL
|
Facility
|
IP
|
$525.00
|
|
|
Service Code
|
CPT 92977
|
| Hospital Charge Code |
906811128
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$95.03 |
| Max. Negotiated Rate |
$393.75 |
| Rate for Payer: Adventist Health Commercial |
$105.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$338.10
|
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$355.43
|
| Rate for Payer: Heritage Provider Network Senior |
$355.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$95.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.25
|
| Rate for Payer: Multiplan Commercial |
$393.75
|
|
|
HC DISSOLVE CLOT HEART VESSEL
|
Facility
|
IP
|
$525.00
|
|
|
Service Code
|
CPT 92977
|
| Hospital Charge Code |
906811128
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$95.03 |
| Max. Negotiated Rate |
$5,478.00 |
| Rate for Payer: Adventist Health Commercial |
$105.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$338.10
|
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,478.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,982.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$95.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.25
|
| Rate for Payer: Multiplan Commercial |
$393.75
|
|
|
HC DISTRTN NEUROLTC AGT GNCLR NRV
|
Facility
|
IP
|
$5,232.00
|
|
|
Service Code
|
CPT 64624
|
| Hospital Charge Code |
909004624
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$946.99 |
| Max. Negotiated Rate |
$3,924.00 |
| Rate for Payer: Adventist Health Commercial |
$1,046.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,369.41
|
| Rate for Payer: Cash Price |
$2,354.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,542.06
|
| Rate for Payer: Heritage Provider Network Senior |
$3,542.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$946.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,308.00
|
| Rate for Payer: Multiplan Commercial |
$3,924.00
|
|
|
HC DISTRTN NEUROLTC AGT GNCLR NRV
|
Facility
|
OP
|
$5,232.00
|
|
|
Service Code
|
CPT 64624
|
| Hospital Charge Code |
909004624
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$946.99 |
| Max. Negotiated Rate |
$8,962.13 |
| Rate for Payer: Adventist Health Commercial |
$1,046.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,233.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,767.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,762.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,511.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$2,354.40
|
| Rate for Payer: Cash Price |
$2,354.40
|
| Rate for Payer: Cash Price |
$2,354.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,400.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,767.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,762.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,511.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,139.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,511.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,238.61
|
| Rate for Payer: Heritage Provider Network Senior |
$3,089.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,511.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4,771.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$946.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,888.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,308.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,365.45
|
| Rate for Payer: Multiplan Commercial |
$3,924.00
|
| Rate for Payer: Multiplan WC |
$3,953.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,762.68
|
| Rate for Payer: TriValley Medical Group Senior |
$2,762.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,454.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,273.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,767.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,762.68
|
| Rate for Payer: Vantage Medical Group Senior |
$2,511.53
|
|
