|
HC LOW COST SKIN SUB T/A/L 1ST 100 SQCM
|
Facility
|
OP
|
$3,667.00
|
|
|
Service Code
|
CPT C5273
|
| Hospital Charge Code |
900101511
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$663.73 |
| Max. Negotiated Rate |
$4,329.13 |
| Rate for Payer: Adventist Health Commercial |
$733.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,519.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Blue Shield of California Commercial |
$2,277.21
|
| Rate for Payer: Blue Shield of California EPN |
$2,152.53
|
| Rate for Payer: Cash Price |
$1,650.15
|
| Rate for Payer: Cash Price |
$1,650.15
|
| Rate for Payer: Cash Price |
$1,650.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,383.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,269.87
|
| Rate for Payer: Heritage Provider Network Senior |
$2,269.87
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,329.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$663.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$916.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: Multiplan Commercial |
$2,750.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,506.34
|
| Rate for Payer: TriValley Medical Group Senior |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
HC LOW COST SKIN SUB T/A/L 1ST 25 SQCM
|
Facility
|
OP
|
$1,095.00
|
|
|
Service Code
|
CPT C5271
|
| Hospital Charge Code |
900101509
|
|
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 T/A/L 1ST 25 SQCM
|
Facility
|
IP
|
$1,095.00
|
|
|
Service Code
|
CPT C5271
|
| Hospital Charge Code |
900101509
|
|
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 T/A/L EACH ADD 100 SQCM
|
Facility
|
IP
|
$1,605.00
|
|
|
Service Code
|
CPT C5274
|
| Hospital Charge Code |
900101512
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$290.50 |
| Max. Negotiated Rate |
$1,203.75 |
| Rate for Payer: Adventist Health Commercial |
$321.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,102.64
|
| Rate for Payer: Cash Price |
$722.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,086.58
|
| Rate for Payer: Heritage Provider Network Senior |
$1,086.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$290.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$401.25
|
| Rate for Payer: Multiplan Commercial |
$1,203.75
|
|
|
HC LOW COST SKIN SUB T/A/L EACH ADD 100 SQCM
|
Facility
|
OP
|
$1,605.00
|
|
|
Service Code
|
CPT C5274
|
| Hospital Charge Code |
900101512
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$290.50 |
| Max. Negotiated Rate |
$3,224.00 |
| Rate for Payer: Adventist Health Commercial |
$321.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,102.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,364.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$882.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,203.75
|
| Rate for Payer: Blue Shield of California Commercial |
$996.70
|
| Rate for Payer: Blue Shield of California EPN |
$942.14
|
| Rate for Payer: Cash Price |
$722.25
|
| Rate for Payer: Cash Price |
$722.25
|
| Rate for Payer: Cash Price |
$722.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,043.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,364.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,364.25
|
| Rate for Payer: Dignity Health Senior |
$1,364.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$993.50
|
| Rate for Payer: Heritage Provider Network Senior |
$993.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$773.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$290.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$401.25
|
| Rate for Payer: Multiplan Commercial |
$1,203.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$802.50
|
| Rate for Payer: TriValley Medical Group Senior |
$802.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,364.25
|
| Rate for Payer: Vantage Medical Group Senior |
$1,364.25
|
|
|
HC LOW COST SKIN SUB T/A/L EACH ADD 25 SQCM
|
Facility
|
OP
|
$642.00
|
|
|
Service Code
|
CPT C5272
|
| Hospital Charge Code |
900101510
|
|
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 T/A/L EACH ADD 25 SQCM
|
Facility
|
IP
|
$642.00
|
|
|
Service Code
|
CPT C5272
|
| Hospital Charge Code |
900101510
|
|
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 LOWER EXT ARTERIAL EXAM, BILAT
|
Facility
|
IP
|
$1,452.00
|
|
|
Service Code
|
CPT 93924
|
| Hospital Charge Code |
908100113
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$262.81 |
| Max. Negotiated Rate |
$1,089.00 |
| Rate for Payer: Adventist Health Commercial |
$290.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$997.52
|
| Rate for Payer: Cash Price |
$653.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$983.00
|
| Rate for Payer: Heritage Provider Network Senior |
$983.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$262.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$363.00
|
| Rate for Payer: Multiplan Commercial |
$1,089.00
|
|
|
HC LOWER EXT ARTERIAL EXAM, BILAT
|
Facility
|
OP
|
$1,452.00
|
|
|
Service Code
|
CPT 93924
|
| Hospital Charge Code |
908100113
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$166.02 |
| Max. Negotiated Rate |
$1,089.00 |
| Rate for Payer: Adventist Health Commercial |
$290.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$453.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$997.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$292.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$214.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$195.17
|
| Rate for Payer: Blue Shield of California Commercial |
$739.08
|
| Rate for Payer: Blue Shield of California EPN |
$420.29
|
| Rate for Payer: Cash Price |
$653.40
|
| Rate for Payer: Cash Price |
$653.40
|
| Rate for Payer: Cash Price |
$653.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$943.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$292.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$214.69
|
| Rate for Payer: Dignity Health Senior |
$195.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$943.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$195.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$898.79
|
| Rate for Payer: Heritage Provider Network Senior |
$898.79
|
| Rate for Payer: Humana Medicare |
$195.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$166.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$195.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$370.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$262.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$230.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$363.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$245.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$245.91
|
| Rate for Payer: Multiplan Commercial |
$1,089.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$214.69
|
| Rate for Payer: TriValley Medical Group Senior |
$195.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,025.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$864.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$292.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$214.69
|
| Rate for Payer: Vantage Medical Group Senior |
$195.17
|
|
|
HC LOW FREQ NON-CONTACT/THRMAL US
|
Facility
|
OP
|
$453.00
|
|
|
Service Code
|
CPT 97610
|
| Hospital Charge Code |
900803112
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$48.65 |
| Max. Negotiated Rate |
$501.00 |
| Rate for Payer: Adventist Health Commercial |
$90.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$48.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$311.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Blue Shield of California Commercial |
$281.31
|
| Rate for Payer: Blue Shield of California EPN |
$265.91
|
| Rate for Payer: Cash Price |
$203.85
|
| Rate for Payer: Cash Price |
$203.85
|
| Rate for Payer: Cash Price |
$203.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$294.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: Dignity Health Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$294.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$250.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$280.41
|
| Rate for Payer: Heritage Provider Network Senior |
$280.41
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$475.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.99
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$295.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$113.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.18
|
| Rate for Payer: Multiplan Commercial |
$339.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$275.15
|
| Rate for Payer: TriValley Medical Group Senior |
$250.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$501.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$422.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Vantage Medical Group Senior |
$250.14
|
|
|
HC LOW FREQ NON-CONTACT/THRMAL US
|
Facility
|
IP
|
$453.00
|
|
|
Service Code
|
CPT 97610
|
| Hospital Charge Code |
900803112
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$81.99 |
| Max. Negotiated Rate |
$339.75 |
| Rate for Payer: Adventist Health Commercial |
$90.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$311.21
|
| Rate for Payer: Cash Price |
$203.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$306.68
|
| Rate for Payer: Heritage Provider Network Senior |
$306.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$113.25
|
| Rate for Payer: Multiplan Commercial |
$339.75
|
|
|
HC LOW MIGRAT STAGE IV CONF & ID
|
Facility
|
IP
|
$271.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900910511
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.05 |
| Max. Negotiated Rate |
$203.25 |
| Rate for Payer: Adventist Health Commercial |
$54.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$186.18
|
| Rate for Payer: Cash Price |
$121.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$183.47
|
| Rate for Payer: Heritage Provider Network Senior |
$183.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.75
|
| Rate for Payer: Multiplan Commercial |
$203.25
|
|
|
HC LOW MIGRAT STAGE IV CONF & ID
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900910511
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$40.72 |
| Max. Negotiated Rate |
$515.78 |
| Rate for Payer: Adventist Health Commercial |
$45.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$165.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$154.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$62.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$515.78
|
| Rate for Payer: Blue Shield of California Commercial |
$446.14
|
| Rate for Payer: Blue Shield of California EPN |
$348.77
|
| Rate for Payer: Cash Price |
$101.25
|
| Rate for Payer: Cash Price |
$101.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$146.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$93.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.35
|
| Rate for Payer: Dignity Health Senior |
$62.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$146.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$62.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$139.28
|
| Rate for Payer: Heritage Provider Network Senior |
$139.28
|
| Rate for Payer: Humana Medicare |
$62.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$67.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$62.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$118.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$73.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$78.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78.30
|
| Rate for Payer: Multiplan Commercial |
$168.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$62.14
|
| Rate for Payer: TriValley Medical Group Senior |
$62.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$67.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$67.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: Vantage Medical Group Senior |
$62.14
|
|
|
HC LSO SAG-CORO REGID FRAME PRE
|
Facility
|
OP
|
$1,940.00
|
|
|
Service Code
|
CPT L0631
|
| Hospital Charge Code |
905350631
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$388.00 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$388.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$931.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,332.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,649.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,067.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,455.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,204.74
|
| Rate for Payer: Blue Shield of California EPN |
$1,138.78
|
| Rate for Payer: Cash Price |
$873.00
|
| Rate for Payer: Cash Price |
$873.00
|
| Rate for Payer: Cash Price |
$873.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$892.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,649.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,649.00
|
| Rate for Payer: Dignity Health Senior |
$1,649.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,241.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$898.22
|
| Rate for Payer: Heritage Provider Network Senior |
$898.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,006.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$970.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$970.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$970.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$485.00
|
| Rate for Payer: Multiplan Commercial |
$1,455.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$707.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$648.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,649.00
|
| Rate for Payer: Vantage Medical Group Senior |
$1,649.00
|
|
|
HC LSO SAG-CORO REGID FRAME PRE
|
Facility
|
IP
|
$1,940.00
|
|
|
Service Code
|
CPT L0631
|
| Hospital Charge Code |
905350631
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$388.00 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$388.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$931.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,332.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$873.00
|
| Rate for Payer: Cash Price |
$873.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$892.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,047.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,313.38
|
| Rate for Payer: Heritage Provider Network Senior |
$7,571.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$970.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$970.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$970.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$485.00
|
| Rate for Payer: Multiplan Commercial |
$1,455.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$707.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$648.15
|
|
|
HC LUMBAR DISCOGRAPHY, 1 LEVEL
|
Facility
|
IP
|
$1,327.00
|
|
|
Service Code
|
CPT 62290
|
| Hospital Charge Code |
909000183
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$240.19 |
| Max. Negotiated Rate |
$995.25 |
| Rate for Payer: Adventist Health Commercial |
$265.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$911.65
|
| Rate for Payer: Cash Price |
$597.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$898.38
|
| Rate for Payer: Heritage Provider Network Senior |
$898.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$240.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$331.75
|
| Rate for Payer: Multiplan Commercial |
$995.25
|
|
|
HC LUMBAR DISCOGRAPHY, 1 LEVEL
|
Facility
|
OP
|
$1,327.00
|
|
|
Service Code
|
CPT 62290
|
| Hospital Charge Code |
909000183
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$199.21 |
| Max. Negotiated Rate |
$8,689.75 |
| Rate for Payer: Adventist Health Commercial |
$265.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$911.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,127.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$729.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$995.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| 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 |
$597.15
|
| Rate for Payer: Cash Price |
$597.15
|
| Rate for Payer: Cash Price |
$597.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$862.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,127.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,127.95
|
| Rate for Payer: Dignity Health Senior |
$1,127.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$796.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$821.41
|
| Rate for Payer: Heritage Provider Network Senior |
$821.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$199.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$639.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$240.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$331.75
|
| Rate for Payer: Multiplan Commercial |
$995.25
|
| 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 |
$1,127.95
|
| Rate for Payer: Vantage Medical Group Senior |
$1,127.95
|
|
|
HC LUMBAR PUNCTURE FOR MYELOGR
|
Facility
|
OP
|
$1,098.00
|
|
|
Service Code
|
CPT 62284
|
| Hospital Charge Code |
909000181
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$138.23 |
| Max. Negotiated Rate |
$8,689.75 |
| Rate for Payer: Adventist Health Commercial |
$219.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$754.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$933.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$603.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$823.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| 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 |
$494.10
|
| Rate for Payer: Cash Price |
$494.10
|
| Rate for Payer: Cash Price |
$494.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$713.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$933.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$933.30
|
| Rate for Payer: Dignity Health Senior |
$933.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$658.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$679.66
|
| Rate for Payer: Heritage Provider Network Senior |
$679.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$138.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$529.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$198.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$274.50
|
| Rate for Payer: Multiplan Commercial |
$823.50
|
| 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 |
$933.30
|
| Rate for Payer: Vantage Medical Group Senior |
$933.30
|
|
|
HC LUMBAR PUNCTURE FOR MYELOGR
|
Facility
|
IP
|
$1,098.00
|
|
|
Service Code
|
CPT 62284
|
| Hospital Charge Code |
909000181
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$198.74 |
| Max. Negotiated Rate |
$823.50 |
| Rate for Payer: Adventist Health Commercial |
$219.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$754.33
|
| Rate for Payer: Cash Price |
$494.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$743.35
|
| Rate for Payer: Heritage Provider Network Senior |
$743.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$198.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$274.50
|
| Rate for Payer: Multiplan Commercial |
$823.50
|
|
|
HC LUMBAR/SACRAL FACET INJ 3RD EA
|
Facility
|
IP
|
$682.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
909020044
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$123.44 |
| Max. Negotiated Rate |
$511.50 |
| Rate for Payer: Adventist Health Commercial |
$136.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$468.53
|
| Rate for Payer: Cash Price |
$306.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$461.71
|
| Rate for Payer: Heritage Provider Network Senior |
$461.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$123.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$170.50
|
| Rate for Payer: Multiplan Commercial |
$511.50
|
|
|
HC LUMBAR/SACRAL FACET INJ 3RD EA
|
Facility
|
OP
|
$682.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
909020044
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$115.58 |
| Max. Negotiated Rate |
$3,517.28 |
| Rate for Payer: Adventist Health Commercial |
$136.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$468.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$579.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$375.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$511.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,517.28
|
| Rate for Payer: Blue Shield of California EPN |
$3,022.94
|
| Rate for Payer: Cash Price |
$306.90
|
| Rate for Payer: Cash Price |
$306.90
|
| Rate for Payer: Cash Price |
$306.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$443.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$579.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$579.70
|
| Rate for Payer: Dignity Health Senior |
$579.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$409.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$422.16
|
| Rate for Payer: Heritage Provider Network Senior |
$422.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$115.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$328.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$123.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$170.50
|
| Rate for Payer: Multiplan Commercial |
$511.50
|
| 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 |
$579.70
|
| Rate for Payer: Vantage Medical Group Senior |
$579.70
|
|
|
HC LUMBAR/SACRAL FACET INJECT/ADD
|
Facility
|
IP
|
$1,496.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
909000186
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$270.78 |
| Max. Negotiated Rate |
$1,122.00 |
| Rate for Payer: Adventist Health Commercial |
$299.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,027.75
|
| Rate for Payer: Cash Price |
$673.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,012.79
|
| Rate for Payer: Heritage Provider Network Senior |
$1,012.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$270.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$374.00
|
| Rate for Payer: Multiplan Commercial |
$1,122.00
|
|
|
HC LUMBAR/SACRAL FACET INJECT/ADD
|
Facility
|
OP
|
$1,496.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
909000186
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$113.83 |
| Max. Negotiated Rate |
$3,517.28 |
| Rate for Payer: Adventist Health Commercial |
$299.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,027.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,271.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$822.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,122.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,517.28
|
| Rate for Payer: Blue Shield of California EPN |
$3,022.94
|
| Rate for Payer: Cash Price |
$673.20
|
| Rate for Payer: Cash Price |
$673.20
|
| Rate for Payer: Cash Price |
$673.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$972.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,271.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,271.60
|
| Rate for Payer: Dignity Health Senior |
$1,271.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$897.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$926.02
|
| Rate for Payer: Heritage Provider Network Senior |
$926.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$113.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$721.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$270.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$374.00
|
| Rate for Payer: Multiplan Commercial |
$1,122.00
|
| 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 |
$1,271.60
|
| Rate for Payer: Vantage Medical Group Senior |
$1,271.60
|
|
|
HC LUMBAR/SACRAL FACET INJECT/INT
|
Facility
|
IP
|
$2,935.00
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
909000185
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$531.24 |
| Max. Negotiated Rate |
$2,201.25 |
| Rate for Payer: Adventist Health Commercial |
$587.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,016.34
|
| Rate for Payer: Cash Price |
$1,320.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,987.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1,987.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$531.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$733.75
|
| Rate for Payer: Multiplan Commercial |
$2,201.25
|
|
|
HC LUMBAR/SACRAL FACET INJECT/INT
|
Facility
|
OP
|
$2,935.00
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
909000185
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$225.34 |
| Max. Negotiated Rate |
$3,517.28 |
| Rate for Payer: Adventist Health Commercial |
$587.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,016.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,138.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,517.28
|
| Rate for Payer: Blue Shield of California EPN |
$3,022.94
|
| Rate for Payer: Cash Price |
$1,320.75
|
| Rate for Payer: Cash Price |
$1,320.75
|
| Rate for Payer: Cash Price |
$1,320.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,907.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,252.71
|
| Rate for Payer: Dignity Health Senior |
$1,138.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,761.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,138.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,816.76
|
| Rate for Payer: Heritage Provider Network Senior |
$1,400.76
|
| Rate for Payer: Humana Medicare |
$1,138.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$225.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,138.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,163.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$531.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,343.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$733.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,434.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,434.93
|
| Rate for Payer: Multiplan Commercial |
$2,201.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,252.71
|
| Rate for Payer: TriValley Medical Group Senior |
$1,252.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,600.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,188.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1,138.83
|
|
