|
HC LOCM (HEXABRIX) PER ML
|
Facility
|
IP
|
$4.30
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081002
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.95
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.91
|
| Rate for Payer: Heritage Provider Network Senior |
$2.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$3.22
|
|
|
HC LOCM (HEXABRIX) PER ML
|
Facility
|
OP
|
$4.30
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081002
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$3.66 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$2.67
|
| Rate for Payer: Blue Shield of California EPN |
$2.52
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.66
|
| Rate for Payer: Dignity Health Senior |
$3.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.66
|
| Rate for Payer: Heritage Provider Network Senior |
$2.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$3.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.72
|
| Rate for Payer: TriValley Medical Group Senior |
$1.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.66
|
| Rate for Payer: Vantage Medical Group Senior |
$3.66
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 180
|
Facility
|
IP
|
$9.40
|
|
|
Service Code
|
CPT Q9965
|
| Hospital Charge Code |
909081004
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.05 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.46
|
| Rate for Payer: Cash Price |
$4.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.36
|
| Rate for Payer: Heritage Provider Network Senior |
$6.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$7.05
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 180
|
Facility
|
OP
|
$9.40
|
|
|
Service Code
|
CPT Q9965
|
| Hospital Charge Code |
909081004
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$7.99 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: Blue Shield of California Commercial |
$5.84
|
| Rate for Payer: Blue Shield of California EPN |
$5.52
|
| Rate for Payer: Cash Price |
$4.23
|
| Rate for Payer: Cash Price |
$4.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.99
|
| Rate for Payer: Dignity Health Senior |
$7.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.82
|
| Rate for Payer: Heritage Provider Network Senior |
$5.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$7.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.76
|
| Rate for Payer: TriValley Medical Group Senior |
$3.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.99
|
| Rate for Payer: Vantage Medical Group Senior |
$7.99
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 240
|
Facility
|
OP
|
$2.95
|
|
|
Service Code
|
CPT Q9966
|
| Hospital Charge Code |
909081005
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.51 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$1.83
|
| Rate for Payer: Blue Shield of California EPN |
$1.73
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.51
|
| Rate for Payer: Dignity Health Senior |
$2.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.83
|
| Rate for Payer: Heritage Provider Network Senior |
$1.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$2.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.18
|
| Rate for Payer: TriValley Medical Group Senior |
$1.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.51
|
| Rate for Payer: Vantage Medical Group Senior |
$2.51
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 240
|
Facility
|
IP
|
$2.95
|
|
|
Service Code
|
CPT Q9966
|
| Hospital Charge Code |
909081005
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.03
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.00
|
| Rate for Payer: Heritage Provider Network Senior |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$2.21
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 300
|
Facility
|
OP
|
$3.38
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081006
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$2.10
|
| Rate for Payer: Blue Shield of California EPN |
$1.98
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.87
|
| Rate for Payer: Dignity Health Senior |
$2.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.09
|
| Rate for Payer: Heritage Provider Network Senior |
$2.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$2.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.35
|
| Rate for Payer: TriValley Medical Group Senior |
$1.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.87
|
| Rate for Payer: Vantage Medical Group Senior |
$2.87
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 300
|
Facility
|
IP
|
$3.38
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081006
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.32
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.29
|
| Rate for Payer: Heritage Provider Network Senior |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$2.54
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 350-370
|
Facility
|
IP
|
$4.28
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081007
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$3.21 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.94
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.90
|
| Rate for Payer: Heritage Provider Network Senior |
$2.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: Multiplan Commercial |
$3.21
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 350-370
|
Facility
|
OP
|
$4.28
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081007
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$3.64 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$2.66
|
| Rate for Payer: Blue Shield of California EPN |
$2.51
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.64
|
| Rate for Payer: Dignity Health Senior |
$3.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.65
|
| Rate for Payer: Heritage Provider Network Senior |
$2.65
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: Multiplan Commercial |
$3.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.71
|
| Rate for Payer: TriValley Medical Group Senior |
$1.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.64
|
| Rate for Payer: Vantage Medical Group Senior |
$3.64
|
|
|
HC LOCM (VISIPAQUE) 320 PER ML
|
Facility
|
OP
|
$4.27
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081008
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$3.63 |
| Rate for Payer: Adventist Health Commercial |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$2.65
|
| Rate for Payer: Blue Shield of California EPN |
$2.51
|
| Rate for Payer: Cash Price |
$1.92
|
| Rate for Payer: Cash Price |
$1.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.63
|
| Rate for Payer: Dignity Health Senior |
$3.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.64
|
| Rate for Payer: Heritage Provider Network Senior |
$2.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.71
|
| Rate for Payer: TriValley Medical Group Senior |
$1.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.63
|
| Rate for Payer: Vantage Medical Group Senior |
$3.63
|
|
|
HC LOCM (VISIPAQUE) 320 PER ML
|
Facility
|
IP
|
$4.27
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081008
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Adventist Health Commercial |
$0.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.93
|
| Rate for Payer: Cash Price |
$1.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.89
|
| Rate for Payer: Heritage Provider Network Senior |
$2.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
|
|
HC LOOPOGRAM (ILEAL CONDUIT)
|
Facility
|
IP
|
$965.00
|
|
|
Service Code
|
CPT 50690
|
| Hospital Charge Code |
909000207
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$174.66 |
| Max. Negotiated Rate |
$723.75 |
| Rate for Payer: Adventist Health Commercial |
$193.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$662.96
|
| Rate for Payer: Cash Price |
$434.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$653.30
|
| Rate for Payer: Heritage Provider Network Senior |
$653.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$174.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$241.25
|
| Rate for Payer: Multiplan Commercial |
$723.75
|
|
|
HC LOOPOGRAM (ILEAL CONDUIT)
|
Facility
|
OP
|
$965.00
|
|
|
Service Code
|
CPT 50690
|
| Hospital Charge Code |
909000207
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$174.66 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$193.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$662.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$820.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$530.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$723.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,689.75
|
| Rate for Payer: Blue Shield of California EPN |
$7,468.44
|
| Rate for Payer: Cash Price |
$434.25
|
| Rate for Payer: Cash Price |
$434.25
|
| Rate for Payer: Cash Price |
$434.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$627.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$820.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$820.25
|
| Rate for Payer: Dignity Health Senior |
$820.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$597.34
|
| Rate for Payer: Heritage Provider Network Senior |
$597.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$419.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$465.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$174.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$241.25
|
| Rate for Payer: Multiplan Commercial |
$723.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,040.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$874.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$820.25
|
| Rate for Payer: Vantage Medical Group Senior |
$820.25
|
|
|
HC LO SAGITT RIGID PANEL PREFAB
|
Facility
|
OP
|
$710.00
|
|
|
Service Code
|
CPT L0627
|
| Hospital Charge Code |
905350627
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$142.00 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$142.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$340.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$487.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$603.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$390.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$532.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$440.91
|
| Rate for Payer: Blue Shield of California EPN |
$416.77
|
| Rate for Payer: Cash Price |
$319.50
|
| Rate for Payer: Cash Price |
$319.50
|
| Rate for Payer: Cash Price |
$319.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$326.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$603.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$603.50
|
| Rate for Payer: Dignity Health Senior |
$603.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$454.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$328.73
|
| Rate for Payer: Heritage Provider Network Senior |
$328.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$403.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$355.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$355.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$355.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$177.50
|
| Rate for Payer: Multiplan Commercial |
$532.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$258.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$237.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$603.50
|
| Rate for Payer: Vantage Medical Group Senior |
$603.50
|
|
|
HC LO SAGITT RIGID PANEL PREFAB
|
Facility
|
IP
|
$710.00
|
|
|
Service Code
|
CPT L0627
|
| Hospital Charge Code |
905350627
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$142.00 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$142.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$340.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$487.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$319.50
|
| Rate for Payer: Cash Price |
$319.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$326.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$383.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$480.67
|
| Rate for Payer: Heritage Provider Network Senior |
$7,571.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$355.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$355.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$355.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$177.50
|
| Rate for Payer: Multiplan Commercial |
$532.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$258.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$237.21
|
|
|
HC LOW COST SKIN SUB F/S/N/G/H/F 1ST 100 SQCM
|
Facility
|
OP
|
$1,095.00
|
|
|
Service Code
|
CPT C5277
|
| Hospital Charge Code |
900101515
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$198.20 |
| Max. Negotiated Rate |
$3,224.00 |
| Rate for Payer: Adventist Health Commercial |
$219.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$752.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$784.71
|
| Rate for Payer: Blue Shield of California Commercial |
$680.00
|
| Rate for Payer: Blue Shield of California EPN |
$642.76
|
| Rate for Payer: Cash Price |
$492.75
|
| Rate for Payer: Cash Price |
$492.75
|
| Rate for Payer: Cash Price |
$492.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$711.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$863.18
|
| Rate for Payer: Dignity Health Senior |
$784.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$784.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$677.80
|
| Rate for Payer: Heritage Provider Network Senior |
$677.80
|
| Rate for Payer: Humana Medicare |
$784.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$784.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,490.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$198.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$925.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$273.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$988.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$988.73
|
| Rate for Payer: Multiplan Commercial |
$821.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$863.18
|
| Rate for Payer: TriValley Medical Group Senior |
$863.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: Vantage Medical Group Senior |
$784.71
|
|
|
HC LOW COST SKIN SUB F/S/N/G/H/F 1ST 100 SQCM
|
Facility
|
IP
|
$1,095.00
|
|
|
Service Code
|
CPT C5277
|
| Hospital Charge Code |
900101515
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$198.20 |
| Max. Negotiated Rate |
$821.25 |
| Rate for Payer: Adventist Health Commercial |
$219.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$752.26
|
| Rate for Payer: Cash Price |
$492.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$741.32
|
| Rate for Payer: Heritage Provider Network Senior |
$741.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$198.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$273.75
|
| Rate for Payer: Multiplan Commercial |
$821.25
|
|
|
HC LOW COST SKIN SUB F/S/N/G/H/F 1ST 25 SQCM
|
Facility
|
OP
|
$1,095.00
|
|
|
Service Code
|
CPT C5275
|
| Hospital Charge Code |
900101513
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$198.20 |
| Max. Negotiated Rate |
$3,224.00 |
| Rate for Payer: Adventist Health Commercial |
$219.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$752.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$784.71
|
| Rate for Payer: Blue Shield of California Commercial |
$680.00
|
| Rate for Payer: Blue Shield of California EPN |
$642.76
|
| Rate for Payer: Cash Price |
$492.75
|
| Rate for Payer: Cash Price |
$492.75
|
| Rate for Payer: Cash Price |
$492.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$711.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$863.18
|
| Rate for Payer: Dignity Health Senior |
$784.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$784.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$677.80
|
| Rate for Payer: Heritage Provider Network Senior |
$677.80
|
| Rate for Payer: Humana Medicare |
$784.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$784.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,490.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$198.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$925.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$273.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$988.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$988.73
|
| Rate for Payer: Multiplan Commercial |
$821.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$863.18
|
| Rate for Payer: TriValley Medical Group Senior |
$863.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: Vantage Medical Group Senior |
$784.71
|
|
|
HC LOW COST SKIN SUB F/S/N/G/H/F 1ST 25 SQCM
|
Facility
|
IP
|
$1,095.00
|
|
|
Service Code
|
CPT C5275
|
| Hospital Charge Code |
900101513
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$198.20 |
| Max. Negotiated Rate |
$821.25 |
| Rate for Payer: Adventist Health Commercial |
$219.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$752.26
|
| Rate for Payer: Cash Price |
$492.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$741.32
|
| Rate for Payer: Heritage Provider Network Senior |
$741.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$198.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$273.75
|
| Rate for Payer: Multiplan Commercial |
$821.25
|
|
|
HC LOW COST SKIN SUB F/S/N/G/H/F ADD 100 SQCM
|
Facility
|
OP
|
$642.00
|
|
|
Service Code
|
CPT C5278
|
| Hospital Charge Code |
900101516
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$116.20 |
| Max. Negotiated Rate |
$3,224.00 |
| Rate for Payer: Adventist Health Commercial |
$128.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$441.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$545.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$353.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$481.50
|
| Rate for Payer: Blue Shield of California Commercial |
$398.68
|
| Rate for Payer: Blue Shield of California EPN |
$376.85
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$417.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$545.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$545.70
|
| Rate for Payer: Dignity Health Senior |
$545.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$397.40
|
| Rate for Payer: Heritage Provider Network Senior |
$397.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$309.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$116.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$160.50
|
| Rate for Payer: Multiplan Commercial |
$481.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$321.00
|
| Rate for Payer: TriValley Medical Group Senior |
$321.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$545.70
|
| Rate for Payer: Vantage Medical Group Senior |
$545.70
|
|
|
HC LOW COST SKIN SUB F/S/N/G/H/F ADD 100 SQCM
|
Facility
|
IP
|
$642.00
|
|
|
Service Code
|
CPT C5278
|
| Hospital Charge Code |
900101516
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$116.20 |
| Max. Negotiated Rate |
$481.50 |
| Rate for Payer: Adventist Health Commercial |
$128.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$441.05
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$434.63
|
| Rate for Payer: Heritage Provider Network Senior |
$434.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$116.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$160.50
|
| Rate for Payer: Multiplan Commercial |
$481.50
|
|
|
HC LOW COST SKIN SUB F/S/N/G/H/F ADD 25 SQCM
|
Facility
|
OP
|
$642.00
|
|
|
Service Code
|
CPT C5276
|
| Hospital Charge Code |
900101514
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$116.20 |
| Max. Negotiated Rate |
$3,224.00 |
| Rate for Payer: Adventist Health Commercial |
$128.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$441.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$545.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$353.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$481.50
|
| Rate for Payer: Blue Shield of California Commercial |
$398.68
|
| Rate for Payer: Blue Shield of California EPN |
$376.85
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$417.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$545.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$545.70
|
| Rate for Payer: Dignity Health Senior |
$545.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$397.40
|
| Rate for Payer: Heritage Provider Network Senior |
$397.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$309.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$116.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$160.50
|
| Rate for Payer: Multiplan Commercial |
$481.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$321.00
|
| Rate for Payer: TriValley Medical Group Senior |
$321.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$545.70
|
| Rate for Payer: Vantage Medical Group Senior |
$545.70
|
|
|
HC LOW COST SKIN SUB F/S/N/G/H/F ADD 25 SQCM
|
Facility
|
IP
|
$642.00
|
|
|
Service Code
|
CPT C5276
|
| Hospital Charge Code |
900101514
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$116.20 |
| Max. Negotiated Rate |
$481.50 |
| Rate for Payer: Adventist Health Commercial |
$128.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$441.05
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$434.63
|
| Rate for Payer: Heritage Provider Network Senior |
$434.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$116.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$160.50
|
| Rate for Payer: Multiplan Commercial |
$481.50
|
|
|
HC LOW COST SKIN SUB T/A/L 1ST 100 SQCM
|
Facility
|
IP
|
$3,667.00
|
|
|
Service Code
|
CPT C5273
|
| Hospital Charge Code |
900101511
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$663.73 |
| Max. Negotiated Rate |
$2,750.25 |
| Rate for Payer: Adventist Health Commercial |
$733.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,519.23
|
| Rate for Payer: Cash Price |
$1,650.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,482.56
|
| Rate for Payer: Heritage Provider Network Senior |
$2,482.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$663.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$916.75
|
| Rate for Payer: Multiplan Commercial |
$2,750.25
|
|
