|
HC FACTOR IX PTC
|
Facility
|
IP
|
$480.00
|
|
|
Service Code
|
CPT 85250
|
| Hospital Charge Code |
900910029
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$86.88 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Adventist Health Commercial |
$96.00
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$324.96
|
| Rate for Payer: Heritage Provider Network Senior |
$324.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.00
|
| Rate for Payer: Multiplan Commercial |
$360.00
|
|
|
HC FACTOR IX PTC
|
Facility
|
OP
|
$480.00
|
|
|
Service Code
|
CPT 85250
|
| Hospital Charge Code |
900910029
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$19.04 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Adventist Health Commercial |
$96.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$256.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$329.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$173.82
|
| Rate for Payer: Blue Shield of California Commercial |
$153.22
|
| Rate for Payer: Blue Shield of California EPN |
$122.89
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$312.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.94
|
| Rate for Payer: Dignity Health Senior |
$19.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$312.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$19.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$297.12
|
| Rate for Payer: Heritage Provider Network Senior |
$297.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$228.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.88
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.99
|
| Rate for Payer: Multiplan Commercial |
$360.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.04
|
| Rate for Payer: TriValley Medical Group Senior |
$19.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.94
|
| Rate for Payer: Vantage Medical Group Senior |
$19.04
|
|
|
HC FACTOR V, ACG
|
Facility
|
OP
|
$322.00
|
|
|
Service Code
|
CPT 85220
|
| Hospital Charge Code |
900910060
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$17.65 |
| Max. Negotiated Rate |
$241.50 |
| Rate for Payer: Adventist Health Commercial |
$64.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$172.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$221.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$161.16
|
| Rate for Payer: Blue Shield of California Commercial |
$142.04
|
| Rate for Payer: Blue Shield of California EPN |
$113.93
|
| Rate for Payer: Cash Price |
$177.10
|
| Rate for Payer: Cash Price |
$177.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$209.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.41
|
| Rate for Payer: Dignity Health Senior |
$17.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$209.30
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$199.32
|
| Rate for Payer: Heritage Provider Network Senior |
$199.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$153.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$58.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$20.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.24
|
| Rate for Payer: Multiplan Commercial |
$241.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.65
|
| Rate for Payer: TriValley Medical Group Senior |
$17.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.41
|
| Rate for Payer: Vantage Medical Group Senior |
$17.65
|
|
|
HC FACTOR V, ACG
|
Facility
|
IP
|
$322.00
|
|
|
Service Code
|
CPT 85220
|
| Hospital Charge Code |
900910060
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$58.28 |
| Max. Negotiated Rate |
$241.50 |
| Rate for Payer: Adventist Health Commercial |
$64.40
|
| Rate for Payer: Cash Price |
$177.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$217.99
|
| Rate for Payer: Heritage Provider Network Senior |
$217.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$58.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.50
|
| Rate for Payer: Multiplan Commercial |
$241.50
|
|
|
HC FACTOR VIII AHG
|
Facility
|
OP
|
$364.00
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
900910028
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$17.90 |
| Max. Negotiated Rate |
$273.00 |
| Rate for Payer: Adventist Health Commercial |
$72.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$194.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$250.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$163.49
|
| Rate for Payer: Blue Shield of California Commercial |
$144.12
|
| Rate for Payer: Blue Shield of California EPN |
$115.59
|
| Rate for Payer: Cash Price |
$200.20
|
| Rate for Payer: Cash Price |
$200.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$236.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.69
|
| Rate for Payer: Dignity Health Senior |
$17.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$236.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$225.32
|
| Rate for Payer: Heritage Provider Network Senior |
$225.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$173.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$65.88
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$20.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.55
|
| Rate for Payer: Multiplan Commercial |
$273.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.90
|
| Rate for Payer: TriValley Medical Group Senior |
$17.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.69
|
| Rate for Payer: Vantage Medical Group Senior |
$17.90
|
|
|
HC FACTOR VIII AHG
|
Facility
|
IP
|
$364.00
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
900910028
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$65.88 |
| Max. Negotiated Rate |
$273.00 |
| Rate for Payer: Adventist Health Commercial |
$72.80
|
| Rate for Payer: Cash Price |
$200.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$246.43
|
| Rate for Payer: Heritage Provider Network Senior |
$246.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$65.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.00
|
| Rate for Payer: Multiplan Commercial |
$273.00
|
|
|
HC FACTOR VII, (PROCONVERTIN)
|
Facility
|
IP
|
$445.00
|
|
|
Service Code
|
CPT 85230
|
| Hospital Charge Code |
900910027
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$80.55 |
| Max. Negotiated Rate |
$333.75 |
| Rate for Payer: Adventist Health Commercial |
$89.00
|
| Rate for Payer: Cash Price |
$244.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$301.26
|
| Rate for Payer: Heritage Provider Network Senior |
$301.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.25
|
| Rate for Payer: Multiplan Commercial |
$333.75
|
|
|
HC FACTOR VII, (PROCONVERTIN)
|
Facility
|
OP
|
$445.00
|
|
|
Service Code
|
CPT 85230
|
| Hospital Charge Code |
900910027
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$17.90 |
| Max. Negotiated Rate |
$333.75 |
| Rate for Payer: Adventist Health Commercial |
$89.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$237.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$305.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$163.49
|
| Rate for Payer: Blue Shield of California Commercial |
$144.12
|
| Rate for Payer: Blue Shield of California EPN |
$115.59
|
| Rate for Payer: Cash Price |
$244.75
|
| Rate for Payer: Cash Price |
$244.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$289.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.69
|
| Rate for Payer: Dignity Health Senior |
$17.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$289.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$275.45
|
| Rate for Payer: Heritage Provider Network Senior |
$275.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$212.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.55
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$20.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.55
|
| Rate for Payer: Multiplan Commercial |
$333.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.90
|
| Rate for Payer: TriValley Medical Group Senior |
$17.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.69
|
| Rate for Payer: Vantage Medical Group Senior |
$17.90
|
|
|
HC FACTOR V LEIDEN MUTATION
|
Facility
|
OP
|
$727.00
|
|
|
Service Code
|
CPT 81241
|
| Hospital Charge Code |
900912323
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$73.37 |
| Max. Negotiated Rate |
$545.25 |
| Rate for Payer: Adventist Health Commercial |
$145.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$388.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$499.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$110.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$80.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$73.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$367.86
|
| Rate for Payer: Blue Shield of California Commercial |
$443.47
|
| Rate for Payer: Blue Shield of California EPN |
$354.78
|
| Rate for Payer: Cash Price |
$399.85
|
| Rate for Payer: Cash Price |
$399.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$472.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$110.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$80.71
|
| Rate for Payer: Dignity Health Senior |
$73.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$472.55
|
| Rate for Payer: EPIC Health Plan Medicare |
$73.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$450.01
|
| Rate for Payer: Heritage Provider Network Senior |
$450.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$73.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$346.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$131.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$84.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$181.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$92.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$92.45
|
| Rate for Payer: Multiplan Commercial |
$545.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$73.37
|
| Rate for Payer: TriValley Medical Group Senior |
$73.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$79.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$79.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$110.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$80.71
|
| Rate for Payer: Vantage Medical Group Senior |
$73.37
|
|
|
HC FACTOR V LEIDEN MUTATION
|
Facility
|
IP
|
$727.00
|
|
|
Service Code
|
CPT 81241
|
| Hospital Charge Code |
900912323
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$131.59 |
| Max. Negotiated Rate |
$545.25 |
| Rate for Payer: Adventist Health Commercial |
$145.40
|
| Rate for Payer: Cash Price |
$399.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$492.18
|
| Rate for Payer: Heritage Provider Network Senior |
$492.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$131.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$181.75
|
| Rate for Payer: Multiplan Commercial |
$545.25
|
|
|
HC FACTOR V LEIDEN MUTATN B INDI
|
Facility
|
IP
|
$431.00
|
|
|
Service Code
|
CPT 81241
|
| Hospital Charge Code |
900913619
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$78.01 |
| Max. Negotiated Rate |
$323.25 |
| Rate for Payer: Adventist Health Commercial |
$86.20
|
| Rate for Payer: Cash Price |
$237.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$291.79
|
| Rate for Payer: Heritage Provider Network Senior |
$291.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$78.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.75
|
| Rate for Payer: Multiplan Commercial |
$323.25
|
|
|
HC FACTOR V LEIDEN MUTATN B INDI
|
Facility
|
OP
|
$431.00
|
|
|
Service Code
|
CPT 81241
|
| Hospital Charge Code |
900913619
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$73.37 |
| Max. Negotiated Rate |
$367.86 |
| Rate for Payer: Adventist Health Commercial |
$86.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$230.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$296.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$110.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$80.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$73.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$367.86
|
| Rate for Payer: Blue Shield of California Commercial |
$262.91
|
| Rate for Payer: Blue Shield of California EPN |
$210.33
|
| Rate for Payer: Cash Price |
$237.05
|
| Rate for Payer: Cash Price |
$237.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$280.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$110.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$80.71
|
| Rate for Payer: Dignity Health Senior |
$73.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$280.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$73.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$266.79
|
| Rate for Payer: Heritage Provider Network Senior |
$266.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$73.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$205.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$78.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$84.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$92.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$92.45
|
| Rate for Payer: Multiplan Commercial |
$323.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$73.37
|
| Rate for Payer: TriValley Medical Group Senior |
$73.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$79.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$79.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$110.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$80.71
|
| Rate for Payer: Vantage Medical Group Senior |
$73.37
|
|
|
HC FACTOR XII HAGEMANN
|
Facility
|
IP
|
$512.00
|
|
|
Service Code
|
CPT 85280
|
| Hospital Charge Code |
900910062
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$92.67 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Adventist Health Commercial |
$102.40
|
| Rate for Payer: Cash Price |
$281.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$346.62
|
| Rate for Payer: Heritage Provider Network Senior |
$346.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$92.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$128.00
|
| Rate for Payer: Multiplan Commercial |
$384.00
|
|
|
HC FACTOR XII HAGEMANN
|
Facility
|
OP
|
$512.00
|
|
|
Service Code
|
CPT 85280
|
| Hospital Charge Code |
900910062
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$19.35 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Adventist Health Commercial |
$102.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$273.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$351.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$176.64
|
| Rate for Payer: Blue Shield of California Commercial |
$155.75
|
| Rate for Payer: Blue Shield of California EPN |
$124.92
|
| Rate for Payer: Cash Price |
$281.60
|
| Rate for Payer: Cash Price |
$281.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$332.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.29
|
| Rate for Payer: Dignity Health Senior |
$19.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$332.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$19.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$316.93
|
| Rate for Payer: Heritage Provider Network Senior |
$316.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$244.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$92.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$128.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$24.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$24.38
|
| Rate for Payer: Multiplan Commercial |
$384.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.35
|
| Rate for Payer: TriValley Medical Group Senior |
$19.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.29
|
| Rate for Payer: Vantage Medical Group Senior |
$19.35
|
|
|
HC FACTOR XIII ANTIGEN
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
CPT 85390
|
| Hospital Charge Code |
900912036
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$8.87 |
| Max. Negotiated Rate |
$36.75 |
| Rate for Payer: Adventist Health Commercial |
$9.80
|
| Rate for Payer: Cash Price |
$26.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.17
|
| Rate for Payer: Heritage Provider Network Senior |
$33.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.25
|
| Rate for Payer: Multiplan Commercial |
$36.75
|
|
|
HC FACTOR XIII ANTIGEN
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
CPT 85390
|
| Hospital Charge Code |
900912036
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$8.87 |
| Max. Negotiated Rate |
$47.08 |
| Rate for Payer: Adventist Health Commercial |
$9.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$47.08
|
| Rate for Payer: Blue Shield of California Commercial |
$41.59
|
| Rate for Payer: Blue Shield of California EPN |
$33.36
|
| Rate for Payer: Cash Price |
$26.95
|
| Rate for Payer: Cash Price |
$26.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.03
|
| Rate for Payer: Dignity Health Senior |
$15.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$15.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.33
|
| Rate for Payer: Heritage Provider Network Senior |
$30.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$19.50
|
| Rate for Payer: Multiplan Commercial |
$36.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.48
|
| Rate for Payer: TriValley Medical Group Senior |
$15.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.03
|
| Rate for Payer: Vantage Medical Group Senior |
$15.48
|
|
|
HC FACTOR XIII SCREEN
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
CPT 85291
|
| Hospital Charge Code |
900910023
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$27.33 |
| Max. Negotiated Rate |
$113.25 |
| Rate for Payer: Adventist Health Commercial |
$30.20
|
| Rate for Payer: Cash Price |
$83.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$102.23
|
| Rate for Payer: Heritage Provider Network Senior |
$102.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.75
|
| Rate for Payer: Multiplan Commercial |
$113.25
|
|
|
HC FACTOR XIII SCREEN
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
CPT 85291
|
| Hospital Charge Code |
900910023
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$9.11 |
| Max. Negotiated Rate |
$113.25 |
| Rate for Payer: Adventist Health Commercial |
$30.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$80.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$103.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$81.13
|
| Rate for Payer: Blue Shield of California Commercial |
$71.54
|
| Rate for Payer: Blue Shield of California EPN |
$57.38
|
| Rate for Payer: Cash Price |
$83.05
|
| Rate for Payer: Cash Price |
$83.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$98.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.02
|
| Rate for Payer: Dignity Health Senior |
$9.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$98.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$9.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$93.47
|
| Rate for Payer: Heritage Provider Network Senior |
$93.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$72.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.48
|
| Rate for Payer: Multiplan Commercial |
$113.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.11
|
| Rate for Payer: TriValley Medical Group Senior |
$9.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.02
|
| Rate for Payer: Vantage Medical Group Senior |
$9.11
|
|
|
HC FACTOR XI PTA
|
Facility
|
IP
|
$461.00
|
|
|
Service Code
|
CPT 85270
|
| Hospital Charge Code |
900910061
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$83.44 |
| Max. Negotiated Rate |
$345.75 |
| Rate for Payer: Adventist Health Commercial |
$92.20
|
| Rate for Payer: Cash Price |
$253.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$312.10
|
| Rate for Payer: Heritage Provider Network Senior |
$312.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$83.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$115.25
|
| Rate for Payer: Multiplan Commercial |
$345.75
|
|
|
HC FACTOR XI PTA
|
Facility
|
OP
|
$461.00
|
|
|
Service Code
|
CPT 85270
|
| Hospital Charge Code |
900910061
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$17.90 |
| Max. Negotiated Rate |
$345.75 |
| Rate for Payer: Adventist Health Commercial |
$92.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$246.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$316.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$163.49
|
| Rate for Payer: Blue Shield of California Commercial |
$144.12
|
| Rate for Payer: Blue Shield of California EPN |
$115.59
|
| Rate for Payer: Cash Price |
$253.55
|
| Rate for Payer: Cash Price |
$253.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$299.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.69
|
| Rate for Payer: Dignity Health Senior |
$17.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$299.65
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$285.36
|
| Rate for Payer: Heritage Provider Network Senior |
$285.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$219.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$83.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$20.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$115.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.55
|
| Rate for Payer: Multiplan Commercial |
$345.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.90
|
| Rate for Payer: TriValley Medical Group Senior |
$17.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.69
|
| Rate for Payer: Vantage Medical Group Senior |
$17.90
|
|
|
HC FACTOR X STUART-PROWER
|
Facility
|
IP
|
$517.00
|
|
|
Service Code
|
CPT 85260
|
| Hospital Charge Code |
900910076
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$93.58 |
| Max. Negotiated Rate |
$387.75 |
| Rate for Payer: Adventist Health Commercial |
$103.40
|
| Rate for Payer: Cash Price |
$284.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$350.01
|
| Rate for Payer: Heritage Provider Network Senior |
$350.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$93.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$129.25
|
| Rate for Payer: Multiplan Commercial |
$387.75
|
|
|
HC FACTOR X STUART-PROWER
|
Facility
|
OP
|
$517.00
|
|
|
Service Code
|
CPT 85260
|
| Hospital Charge Code |
900910076
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$17.90 |
| Max. Negotiated Rate |
$387.75 |
| Rate for Payer: Adventist Health Commercial |
$103.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$276.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$355.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$163.49
|
| Rate for Payer: Blue Shield of California Commercial |
$144.12
|
| Rate for Payer: Blue Shield of California EPN |
$115.59
|
| Rate for Payer: Cash Price |
$284.35
|
| Rate for Payer: Cash Price |
$284.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$336.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.69
|
| Rate for Payer: Dignity Health Senior |
$17.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$336.05
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$320.02
|
| Rate for Payer: Heritage Provider Network Senior |
$320.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$246.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$93.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$20.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$129.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.55
|
| Rate for Payer: Multiplan Commercial |
$387.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.90
|
| Rate for Payer: TriValley Medical Group Senior |
$17.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.69
|
| Rate for Payer: Vantage Medical Group Senior |
$17.90
|
|
|
HC FALLOPIAN TUBE CATHETERIZATION
|
Facility
|
IP
|
$1,202.00
|
|
|
Service Code
|
CPT 74742
|
| Hospital Charge Code |
909001872
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$217.56 |
| Max. Negotiated Rate |
$901.50 |
| Rate for Payer: Adventist Health Commercial |
$240.40
|
| Rate for Payer: Cash Price |
$661.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$813.75
|
| Rate for Payer: Heritage Provider Network Senior |
$813.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$217.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$300.50
|
| Rate for Payer: Multiplan Commercial |
$901.50
|
|
|
HC FALLOPIAN TUBE CATHETERIZATION
|
Facility
|
OP
|
$1,202.00
|
|
|
Service Code
|
CPT 74742
|
| Hospital Charge Code |
909001872
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$217.56 |
| Max. Negotiated Rate |
$1,021.70 |
| Rate for Payer: Adventist Health Commercial |
$240.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$642.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$825.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,021.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$661.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$901.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$818.26
|
| Rate for Payer: Blue Shield of California Commercial |
$664.90
|
| Rate for Payer: Blue Shield of California EPN |
$534.69
|
| Rate for Payer: Cash Price |
$661.10
|
| Rate for Payer: Cash Price |
$661.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$781.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,021.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,021.70
|
| Rate for Payer: Dignity Health Senior |
$1,021.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$781.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$744.04
|
| Rate for Payer: Heritage Provider Network Senior |
$744.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$573.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$217.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$300.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$841.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$841.40
|
| Rate for Payer: Multiplan Commercial |
$901.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$601.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$601.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,021.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,021.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1,021.70
|
|
|
HC FALLOPIAN TUBE RECANALIZATION
|
Facility
|
IP
|
$9,197.00
|
|
|
Service Code
|
CPT 58345
|
| Hospital Charge Code |
909000177
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,664.66 |
| Max. Negotiated Rate |
$6,897.75 |
| Rate for Payer: Adventist Health Commercial |
$1,839.40
|
| Rate for Payer: Cash Price |
$5,058.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,226.37
|
| Rate for Payer: Heritage Provider Network Senior |
$6,226.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,664.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,299.25
|
| Rate for Payer: Multiplan Commercial |
$6,897.75
|
|
