|
HC GLUCOSE URINE RANDOM
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
CPT 82945
|
| Hospital Charge Code |
900912204
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$40.50 |
| Rate for Payer: Adventist Health Commercial |
$10.80
|
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$36.56
|
| Rate for Payer: Heritage Provider Network Senior |
$36.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.50
|
| Rate for Payer: Multiplan Commercial |
$40.50
|
|
|
HC GRAFIX CORE 3X4
|
Facility
|
IP
|
$113.00
|
|
|
Service Code
|
CPT Q4132 JW
|
| Hospital Charge Code |
900101473
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.45 |
| Max. Negotiated Rate |
$84.75 |
| Rate for Payer: Adventist Health Commercial |
$22.60
|
| Rate for Payer: Cash Price |
$62.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$51.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.32
|
| Rate for Payer: Heritage Provider Network Senior |
$52.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.25
|
| Rate for Payer: Multiplan Commercial |
$84.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.41
|
|
|
HC GRAFIX CORE 3X4
|
Facility
|
OP
|
$113.00
|
|
|
Service Code
|
CPT Q4132 JW
|
| Hospital Charge Code |
900101473
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.45 |
| Max. Negotiated Rate |
$96.05 |
| Rate for Payer: Adventist Health Commercial |
$22.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$60.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$96.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$62.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.75
|
| Rate for Payer: Blue Shield of California Commercial |
$68.93
|
| Rate for Payer: Blue Shield of California EPN |
$55.14
|
| Rate for Payer: Cash Price |
$62.15
|
| Rate for Payer: Cash Price |
$62.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$51.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$96.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.05
|
| Rate for Payer: Dignity Health Senior |
$96.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.32
|
| Rate for Payer: Heritage Provider Network Senior |
$52.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$37.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$53.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$79.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$79.10
|
| Rate for Payer: Multiplan Commercial |
$84.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$45.20
|
| Rate for Payer: TriValley Medical Group Senior |
$45.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$96.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.05
|
| Rate for Payer: Vantage Medical Group Senior |
$96.05
|
|
|
HC GRAFIX CORE 5X5
|
Facility
|
IP
|
$385.00
|
|
|
Service Code
|
CPT Q4132
|
| Hospital Charge Code |
900101472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$69.69 |
| Max. Negotiated Rate |
$288.75 |
| Rate for Payer: Adventist Health Commercial |
$77.00
|
| Rate for Payer: Cash Price |
$211.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$177.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$207.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$178.25
|
| Rate for Payer: Heritage Provider Network Senior |
$178.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$96.25
|
| Rate for Payer: Multiplan Commercial |
$288.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$139.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$127.47
|
|
|
HC GRAFIX CORE 5X5
|
Facility
|
OP
|
$385.00
|
|
|
Service Code
|
CPT Q4132
|
| Hospital Charge Code |
900101472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.50 |
| Max. Negotiated Rate |
$327.25 |
| Rate for Payer: Adventist Health Commercial |
$77.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$205.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$264.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$327.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$211.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$288.75
|
| Rate for Payer: Blue Shield of California Commercial |
$234.85
|
| Rate for Payer: Blue Shield of California EPN |
$187.88
|
| Rate for Payer: Cash Price |
$211.75
|
| Rate for Payer: Cash Price |
$211.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$177.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$327.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$327.25
|
| Rate for Payer: Dignity Health Senior |
$327.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$246.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$178.25
|
| Rate for Payer: Heritage Provider Network Senior |
$178.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$37.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$183.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$96.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$269.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$269.50
|
| Rate for Payer: Multiplan Commercial |
$288.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$154.00
|
| Rate for Payer: TriValley Medical Group Senior |
$154.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$139.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$127.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$327.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$327.25
|
| Rate for Payer: Vantage Medical Group Senior |
$327.25
|
|
|
HC GRAFIX PRIME 3X4
|
Facility
|
IP
|
$416.00
|
|
|
Service Code
|
CPT Q4133 JW
|
| Hospital Charge Code |
900101475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.30 |
| Max. Negotiated Rate |
$312.00 |
| Rate for Payer: Adventist Health Commercial |
$83.20
|
| Rate for Payer: Cash Price |
$228.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$191.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$224.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$192.61
|
| Rate for Payer: Heritage Provider Network Senior |
$192.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$75.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$104.00
|
| Rate for Payer: Multiplan Commercial |
$312.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$150.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$137.74
|
|
|
HC GRAFIX PRIME 3X4
|
Facility
|
OP
|
$416.00
|
|
|
Service Code
|
CPT Q4133 JW
|
| Hospital Charge Code |
900101475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.30 |
| Max. Negotiated Rate |
$353.60 |
| Rate for Payer: Adventist Health Commercial |
$83.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$222.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$285.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$353.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$228.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$312.00
|
| Rate for Payer: Blue Shield of California Commercial |
$253.76
|
| Rate for Payer: Blue Shield of California EPN |
$203.01
|
| Rate for Payer: Cash Price |
$228.80
|
| Rate for Payer: Cash Price |
$228.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$191.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$353.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$353.60
|
| Rate for Payer: Dignity Health Senior |
$353.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$266.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$192.61
|
| Rate for Payer: Heritage Provider Network Senior |
$192.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$136.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$198.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$75.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$104.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$291.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$291.20
|
| Rate for Payer: Multiplan Commercial |
$312.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$166.40
|
| Rate for Payer: TriValley Medical Group Senior |
$166.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$150.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$137.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$353.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$353.60
|
| Rate for Payer: Vantage Medical Group Senior |
$353.60
|
|
|
HC GRAFIX PRIME 5X5
|
Facility
|
OP
|
$416.00
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
900101474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.30 |
| Max. Negotiated Rate |
$353.60 |
| Rate for Payer: Adventist Health Commercial |
$83.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$222.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$285.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$353.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$228.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$312.00
|
| Rate for Payer: Blue Shield of California Commercial |
$253.76
|
| Rate for Payer: Blue Shield of California EPN |
$203.01
|
| Rate for Payer: Cash Price |
$228.80
|
| Rate for Payer: Cash Price |
$228.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$191.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$353.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$353.60
|
| Rate for Payer: Dignity Health Senior |
$353.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$266.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$192.61
|
| Rate for Payer: Heritage Provider Network Senior |
$192.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$136.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$198.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$75.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$104.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$291.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$291.20
|
| Rate for Payer: Multiplan Commercial |
$312.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$166.40
|
| Rate for Payer: TriValley Medical Group Senior |
$166.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$150.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$137.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$353.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$353.60
|
| Rate for Payer: Vantage Medical Group Senior |
$353.60
|
|
|
HC GRAFIX PRIME 5X5
|
Facility
|
IP
|
$416.00
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
900101474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.30 |
| Max. Negotiated Rate |
$312.00 |
| Rate for Payer: Adventist Health Commercial |
$83.20
|
| Rate for Payer: Cash Price |
$228.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$191.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$224.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$192.61
|
| Rate for Payer: Heritage Provider Network Senior |
$192.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$75.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$104.00
|
| Rate for Payer: Multiplan Commercial |
$312.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$150.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$137.74
|
|
|
HC GRAFT APLIGRAF 7.5 CM
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
900101456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.73 |
| Max. Negotiated Rate |
$92.65 |
| Rate for Payer: Adventist Health Commercial |
$21.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$58.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$92.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$59.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$81.75
|
| Rate for Payer: Blue Shield of California Commercial |
$66.49
|
| Rate for Payer: Blue Shield of California EPN |
$53.19
|
| Rate for Payer: Cash Price |
$59.95
|
| Rate for Payer: Cash Price |
$59.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$50.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$92.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$92.65
|
| Rate for Payer: Dignity Health Senior |
$92.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.47
|
| Rate for Payer: Heritage Provider Network Senior |
$50.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$30.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$51.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$76.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$76.30
|
| Rate for Payer: Multiplan Commercial |
$81.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.60
|
| Rate for Payer: TriValley Medical Group Senior |
$43.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$92.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$92.65
|
| Rate for Payer: Vantage Medical Group Senior |
$92.65
|
|
|
HC GRAFT APLIGRAF 7.5 CM
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
900101456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.73 |
| Max. Negotiated Rate |
$81.75 |
| Rate for Payer: Adventist Health Commercial |
$21.80
|
| Rate for Payer: Cash Price |
$59.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$50.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.47
|
| Rate for Payer: Heritage Provider Network Senior |
$50.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.25
|
| Rate for Payer: Multiplan Commercial |
$81.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.09
|
|
|
HC GRAFT COMPOSITE EAR OR NASAL
|
Facility
|
IP
|
$9,868.00
|
|
|
Service Code
|
CPT 15760
|
| Hospital Charge Code |
900515760
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,786.11 |
| Max. Negotiated Rate |
$7,401.00 |
| Rate for Payer: Adventist Health Commercial |
$1,973.60
|
| Rate for Payer: Cash Price |
$5,427.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,680.64
|
| Rate for Payer: Heritage Provider Network Senior |
$6,680.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,786.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,467.00
|
| Rate for Payer: Multiplan Commercial |
$7,401.00
|
|
|
HC GRAFT COMPOSITE EAR OR NASAL
|
Facility
|
OP
|
$9,868.00
|
|
|
Service Code
|
CPT 15760
|
| Hospital Charge Code |
900515760
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,973.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,779.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,486.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,556.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,324.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,959.00
|
| Rate for Payer: Cash Price |
$5,427.40
|
| Rate for Payer: Cash Price |
$5,427.40
|
| Rate for Payer: Cash Price |
$5,427.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6,414.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,486.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,556.64
|
| Rate for Payer: Dignity Health Senior |
$2,324.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,324.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,680.64
|
| Rate for Payer: Heritage Provider Network Senior |
$6,680.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$973.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,324.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,707.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,786.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,672.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,467.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,928.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,928.52
|
| Rate for Payer: Multiplan Commercial |
$7,401.00
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,550.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,267.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,486.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,556.64
|
| Rate for Payer: Vantage Medical Group Senior |
$2,324.22
|
|
|
HC GRAFT DERMA-FAT-FASCIA
|
Facility
|
OP
|
$8,193.00
|
|
|
Service Code
|
CPT 15770
|
| Hospital Charge Code |
900501750
|
|
Hospital Revenue Code
|
451
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,638.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,628.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,977.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,116.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,651.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,004.00
|
| Rate for Payer: Cash Price |
$4,506.15
|
| Rate for Payer: Cash Price |
$4,506.15
|
| Rate for Payer: Cash Price |
$4,506.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,325.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,977.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,116.79
|
| Rate for Payer: Dignity Health Senior |
$4,651.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,651.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,546.66
|
| Rate for Payer: Heritage Provider Network Senior |
$5,546.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$973.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,651.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,908.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,482.93
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,349.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,048.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,861.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,861.05
|
| Rate for Payer: Multiplan Commercial |
$6,144.75
|
| Rate for Payer: Multiplan WC |
$7,411.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,947.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,712.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,977.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,116.79
|
| Rate for Payer: Vantage Medical Group Senior |
$4,651.63
|
|
|
HC GRAFT DERMA-FAT-FASCIA
|
Facility
|
IP
|
$8,193.00
|
|
|
Service Code
|
CPT 15770
|
| Hospital Charge Code |
900501750
|
|
Hospital Revenue Code
|
451
|
| Min. Negotiated Rate |
$1,482.93 |
| Max. Negotiated Rate |
$6,144.75 |
| Rate for Payer: Adventist Health Commercial |
$1,638.60
|
| Rate for Payer: Cash Price |
$4,506.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,546.66
|
| Rate for Payer: Heritage Provider Network Senior |
$5,546.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,482.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,048.25
|
| Rate for Payer: Multiplan Commercial |
$6,144.75
|
|
|
HC GRAFT, IM, CONDUIT
|
Facility
|
OP
|
$595.00
|
|
|
Service Code
|
CPT 93564
|
| Hospital Charge Code |
906811413
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$77.16 |
| Max. Negotiated Rate |
$8,962.13 |
| Rate for Payer: Adventist Health Commercial |
$119.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7,402.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$408.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$505.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$327.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$446.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,959.00
|
| 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 |
$327.25
|
| Rate for Payer: Cash Price |
$327.25
|
| Rate for Payer: Cash Price |
$327.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,340.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$505.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$505.75
|
| Rate for Payer: Dignity Health Senior |
$505.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$386.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$368.31
|
| Rate for Payer: Heritage Provider Network Senior |
$368.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$77.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$283.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$148.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$416.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$416.50
|
| Rate for Payer: Multiplan Commercial |
$446.25
|
| 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 |
$505.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$505.75
|
| Rate for Payer: Vantage Medical Group Senior |
$505.75
|
|
|
HC GRAFT, IM, CONDUIT
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 93564
|
| Hospital Charge Code |
906820070
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$77.16 |
| Max. Negotiated Rate |
$8,962.13 |
| Rate for Payer: Adventist Health Commercial |
$140.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7,402.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$480.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$595.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$385.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$525.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,959.00
|
| 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 |
$385.00
|
| Rate for Payer: Cash Price |
$385.00
|
| Rate for Payer: Cash Price |
$385.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,340.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$595.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$595.00
|
| Rate for Payer: Dignity Health Senior |
$595.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$455.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$433.30
|
| Rate for Payer: Heritage Provider Network Senior |
$433.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$77.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$333.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$126.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$175.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$490.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$490.00
|
| Rate for Payer: Multiplan Commercial |
$525.00
|
| 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 |
$595.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$595.00
|
| Rate for Payer: Vantage Medical Group Senior |
$595.00
|
|
|
HC GRAFT, IM, CONDUIT
|
Facility
|
IP
|
$595.00
|
|
|
Service Code
|
CPT 93564
|
| Hospital Charge Code |
906811413
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$107.69 |
| Max. Negotiated Rate |
$5,478.00 |
| Rate for Payer: Adventist Health Commercial |
$119.00
|
| Rate for Payer: Cash Price |
$327.25
|
| Rate for Payer: Cash Price |
$327.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,478.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,982.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$148.75
|
| Rate for Payer: Multiplan Commercial |
$446.25
|
|
|
HC GRAFT, IM, CONDUIT
|
Facility
|
IP
|
$700.00
|
|
|
Service Code
|
CPT 93564
|
| Hospital Charge Code |
906820070
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$126.70 |
| Max. Negotiated Rate |
$5,478.00 |
| Rate for Payer: Adventist Health Commercial |
$140.00
|
| Rate for Payer: Cash Price |
$385.00
|
| Rate for Payer: Cash Price |
$385.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,478.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,982.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$126.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$175.00
|
| Rate for Payer: Multiplan Commercial |
$525.00
|
|
|
HC GRAFTJACKET PER SQ CM
|
Facility
|
OP
|
$12,303.00
|
|
|
Service Code
|
CPT Q4107
|
| Hospital Charge Code |
900101462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.07 |
| Max. Negotiated Rate |
$10,457.55 |
| Rate for Payer: Adventist Health Commercial |
$2,460.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6,575.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8,452.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,457.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6,766.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9,227.25
|
| Rate for Payer: Blue Shield of California Commercial |
$7,504.83
|
| Rate for Payer: Blue Shield of California EPN |
$6,003.86
|
| Rate for Payer: Cash Price |
$6,766.65
|
| Rate for Payer: Cash Price |
$6,766.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,659.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,457.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$10,457.55
|
| Rate for Payer: Dignity Health Senior |
$10,457.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,873.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,696.29
|
| Rate for Payer: Heritage Provider Network Senior |
$5,696.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$155.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,868.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,226.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,075.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,612.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,612.10
|
| Rate for Payer: Multiplan Commercial |
$9,227.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,921.20
|
| Rate for Payer: TriValley Medical Group Senior |
$4,921.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,445.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4,073.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,457.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10,457.55
|
| Rate for Payer: Vantage Medical Group Senior |
$10,457.55
|
|
|
HC GRAFTJACKET PER SQ CM
|
Facility
|
IP
|
$12,303.00
|
|
|
Service Code
|
CPT Q4107
|
| Hospital Charge Code |
900101462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,226.84 |
| Max. Negotiated Rate |
$9,227.25 |
| Rate for Payer: Adventist Health Commercial |
$2,460.60
|
| Rate for Payer: Cash Price |
$6,766.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,659.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,643.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,696.29
|
| Rate for Payer: Heritage Provider Network Senior |
$5,696.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,226.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,075.75
|
| Rate for Payer: Multiplan Commercial |
$9,227.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,445.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4,073.52
|
|
|
HC GRAM POSITIVE SENSITIVITY MIC
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
900912491
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.65 |
| Max. Negotiated Rate |
$78.92 |
| Rate for Payer: Adventist Health Commercial |
$14.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$39.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$50.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$78.92
|
| Rate for Payer: Blue Shield of California Commercial |
$69.58
|
| Rate for Payer: Blue Shield of California EPN |
$55.81
|
| Rate for Payer: Cash Price |
$40.70
|
| Rate for Payer: Cash Price |
$40.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.52
|
| Rate for Payer: Dignity Health Senior |
$8.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.10
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$45.81
|
| Rate for Payer: Heritage Provider Network Senior |
$45.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$35.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.90
|
| Rate for Payer: Multiplan Commercial |
$55.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.65
|
| Rate for Payer: TriValley Medical Group Senior |
$8.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.52
|
| Rate for Payer: Vantage Medical Group Senior |
$8.65
|
|
|
HC GRAM POSITIVE SENSITIVITY MIC
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
900912491
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.39 |
| Max. Negotiated Rate |
$55.50 |
| Rate for Payer: Adventist Health Commercial |
$14.80
|
| Rate for Payer: Cash Price |
$40.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.10
|
| Rate for Payer: Heritage Provider Network Senior |
$50.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.50
|
| Rate for Payer: Multiplan Commercial |
$55.50
|
|
|
HC GRAM STAIN
|
Facility
|
OP
|
$156.00
|
|
|
Service Code
|
CPT 87205
|
| Hospital Charge Code |
900911705
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$117.00 |
| Rate for Payer: Adventist Health Commercial |
$31.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$83.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$107.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$38.97
|
| Rate for Payer: Blue Shield of California Commercial |
$34.33
|
| Rate for Payer: Blue Shield of California EPN |
$27.54
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$101.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.70
|
| Rate for Payer: Dignity Health Senior |
$4.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$101.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$96.56
|
| Rate for Payer: Heritage Provider Network Senior |
$96.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$74.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.38
|
| Rate for Payer: Multiplan Commercial |
$117.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.27
|
| Rate for Payer: TriValley Medical Group Senior |
$4.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.70
|
| Rate for Payer: Vantage Medical Group Senior |
$4.27
|
|
|
HC GRAM STAIN
|
Facility
|
IP
|
$156.00
|
|
|
Service Code
|
CPT 87205
|
| Hospital Charge Code |
900911705
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$28.24 |
| Max. Negotiated Rate |
$117.00 |
| Rate for Payer: Adventist Health Commercial |
$31.20
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$105.61
|
| Rate for Payer: Heritage Provider Network Senior |
$105.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.00
|
| Rate for Payer: Multiplan Commercial |
$117.00
|
|
