|
HC MAMMARY DUCTOGRAM
|
Facility
|
OP
|
$3,611.00
|
|
|
Service Code
|
CPT 19030
|
| Hospital Charge Code |
909000103
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$302.02 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$722.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,480.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,069.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,986.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,708.25
|
| 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 |
$1,624.95
|
| Rate for Payer: Cash Price |
$1,624.95
|
| Rate for Payer: Cash Price |
$1,624.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,347.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,069.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,069.35
|
| Rate for Payer: Dignity Health Senior |
$3,069.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,235.21
|
| Rate for Payer: Heritage Provider Network Senior |
$2,235.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$302.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,740.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$653.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$902.75
|
| Rate for Payer: Multiplan Commercial |
$2,708.25
|
| 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 |
$3,069.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3,069.35
|
|
|
HC MAMMARY DUCTOGRAM
|
Facility
|
IP
|
$3,611.00
|
|
|
Service Code
|
CPT 19030
|
| Hospital Charge Code |
909000103
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$653.59 |
| Max. Negotiated Rate |
$2,708.25 |
| Rate for Payer: Adventist Health Commercial |
$722.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,480.76
|
| Rate for Payer: Cash Price |
$1,624.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,444.65
|
| Rate for Payer: Heritage Provider Network Senior |
$2,444.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$653.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$902.75
|
| Rate for Payer: Multiplan Commercial |
$2,708.25
|
|
|
HC MAMMOGRAPHY DIGITAL BILAT
|
Facility
|
OP
|
$640.00
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
909002011
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$115.84 |
| Max. Negotiated Rate |
$592.43 |
| Rate for Payer: Adventist Health Commercial |
$128.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$271.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$439.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$544.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$352.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$480.00
|
| Rate for Payer: Blue Shield of California Commercial |
$592.43
|
| Rate for Payer: Blue Shield of California EPN |
$336.89
|
| Rate for Payer: Cash Price |
$288.00
|
| Rate for Payer: Cash Price |
$288.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$416.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$544.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$544.00
|
| Rate for Payer: Dignity Health Senior |
$544.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$416.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$396.16
|
| Rate for Payer: Heritage Provider Network Senior |
$396.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$230.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$308.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$115.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$160.00
|
| Rate for Payer: Multiplan Commercial |
$480.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$200.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$200.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$544.00
|
| Rate for Payer: Vantage Medical Group Senior |
$544.00
|
|
|
HC MAMMOGRAPHY DIGITAL BILAT
|
Facility
|
IP
|
$640.00
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
909002011
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$115.84 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Adventist Health Commercial |
$128.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$439.68
|
| Rate for Payer: Cash Price |
$288.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$433.28
|
| Rate for Payer: Heritage Provider Network Senior |
$433.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$115.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$160.00
|
| Rate for Payer: Multiplan Commercial |
$480.00
|
|
|
HC MAMMOGRAPHY DIGITAL UNILAT ALL VIEWS
|
Facility
|
IP
|
$169.00
|
|
|
Service Code
|
CPT 77065
|
| Hospital Charge Code |
909002012
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$30.59 |
| Max. Negotiated Rate |
$126.75 |
| Rate for Payer: Adventist Health Commercial |
$33.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$116.10
|
| Rate for Payer: Cash Price |
$76.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$114.41
|
| Rate for Payer: Heritage Provider Network Senior |
$114.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.25
|
| Rate for Payer: Multiplan Commercial |
$126.75
|
|
|
HC MAMMOGRAPHY DIGITAL UNILAT ALL VIEWS
|
Facility
|
OP
|
$169.00
|
|
|
Service Code
|
CPT 77065
|
| Hospital Charge Code |
909002012
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$30.59 |
| Max. Negotiated Rate |
$404.53 |
| Rate for Payer: Adventist Health Commercial |
$33.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$211.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$116.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$143.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$92.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$126.75
|
| Rate for Payer: Blue Shield of California Commercial |
$404.53
|
| Rate for Payer: Blue Shield of California EPN |
$230.05
|
| Rate for Payer: Cash Price |
$76.05
|
| Rate for Payer: Cash Price |
$76.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$143.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$143.65
|
| Rate for Payer: Dignity Health Senior |
$143.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$109.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$104.61
|
| Rate for Payer: Heritage Provider Network Senior |
$104.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$182.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$81.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.25
|
| Rate for Payer: Multiplan Commercial |
$126.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$157.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$157.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$143.65
|
| Rate for Payer: Vantage Medical Group Senior |
$143.65
|
|
|
HC MAMOTOME PROBE 11 GA
|
Facility
|
OP
|
$833.00
|
|
| Hospital Charge Code |
906601882
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$150.77 |
| Max. Negotiated Rate |
$708.05 |
| Rate for Payer: Adventist Health Commercial |
$166.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$445.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$572.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$708.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$458.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$624.75
|
| Rate for Payer: Blue Shield of California Commercial |
$517.29
|
| Rate for Payer: Blue Shield of California EPN |
$488.97
|
| Rate for Payer: Cash Price |
$374.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$541.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$708.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$708.05
|
| Rate for Payer: Dignity Health Senior |
$708.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$541.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$515.63
|
| Rate for Payer: Heritage Provider Network Senior |
$515.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$401.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$150.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$208.25
|
| Rate for Payer: Multiplan Commercial |
$624.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$708.05
|
| Rate for Payer: Vantage Medical Group Senior |
$708.05
|
|
|
HC MAMOTOME PROBE 11 GA
|
Facility
|
IP
|
$833.00
|
|
| Hospital Charge Code |
906601882
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$150.77 |
| Max. Negotiated Rate |
$624.75 |
| Rate for Payer: Adventist Health Commercial |
$166.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$572.27
|
| Rate for Payer: Cash Price |
$374.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$563.94
|
| Rate for Payer: Heritage Provider Network Senior |
$563.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$150.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$208.25
|
| Rate for Payer: Multiplan Commercial |
$624.75
|
|
|
HC MANDIBLE-COMPLETE
|
Facility
|
IP
|
$856.00
|
|
|
Service Code
|
CPT 70110
|
| Hospital Charge Code |
909001122
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$154.94 |
| Max. Negotiated Rate |
$642.00 |
| Rate for Payer: Adventist Health Commercial |
$171.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$588.07
|
| Rate for Payer: Cash Price |
$385.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$579.51
|
| Rate for Payer: Heritage Provider Network Senior |
$579.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$154.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$214.00
|
| Rate for Payer: Multiplan Commercial |
$642.00
|
|
|
HC MANDIBLE-COMPLETE
|
Facility
|
OP
|
$856.00
|
|
|
Service Code
|
CPT 70110
|
| Hospital Charge Code |
909001122
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.10 |
| Max. Negotiated Rate |
$642.00 |
| Rate for Payer: Adventist Health Commercial |
$171.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$60.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$588.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$206.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$151.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$137.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$148.88
|
| Rate for Payer: Blue Shield of California Commercial |
$127.22
|
| Rate for Payer: Blue Shield of California EPN |
$72.34
|
| Rate for Payer: Cash Price |
$385.20
|
| Rate for Payer: Cash Price |
$385.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$556.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$206.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$151.10
|
| Rate for Payer: Dignity Health Senior |
$137.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$556.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$137.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$529.86
|
| Rate for Payer: Heritage Provider Network Senior |
$529.86
|
| Rate for Payer: Humana Medicare |
$137.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$53.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$137.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$260.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$154.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$162.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$214.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$173.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$173.07
|
| Rate for Payer: Multiplan Commercial |
$642.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$137.36
|
| Rate for Payer: TriValley Medical Group Senior |
$137.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$206.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$151.10
|
| Rate for Payer: Vantage Medical Group Senior |
$137.36
|
|
|
HC MANDIBLE LIMITED
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 70100
|
| Hospital Charge Code |
909001123
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$39.16 |
| Max. Negotiated Rate |
$363.75 |
| Rate for Payer: Adventist Health Commercial |
$97.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$53.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$333.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$113.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$124.93
|
| Rate for Payer: Blue Shield of California Commercial |
$104.76
|
| Rate for Payer: Blue Shield of California EPN |
$59.57
|
| Rate for Payer: Cash Price |
$218.25
|
| Rate for Payer: Cash Price |
$218.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$315.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.89
|
| Rate for Payer: Dignity Health Senior |
$113.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$315.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$300.22
|
| Rate for Payer: Heritage Provider Network Senior |
$300.22
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$39.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$113.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$87.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$121.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$143.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$143.06
|
| Rate for Payer: Multiplan Commercial |
$363.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$113.54
|
| Rate for Payer: TriValley Medical Group Senior |
$113.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Vantage Medical Group Senior |
$113.54
|
|
|
HC MANDIBLE LIMITED
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 70100
|
| Hospital Charge Code |
909001123
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$87.78 |
| Max. Negotiated Rate |
$363.75 |
| Rate for Payer: Adventist Health Commercial |
$97.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$333.20
|
| Rate for Payer: Cash Price |
$218.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$328.34
|
| Rate for Payer: Heritage Provider Network Senior |
$328.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$87.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$121.25
|
| Rate for Payer: Multiplan Commercial |
$363.75
|
|
|
HC MANDIBLE-PANOREX
|
Facility
|
OP
|
$446.00
|
|
|
Service Code
|
CPT 70355
|
| Hospital Charge Code |
909001124
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$24.61 |
| Max. Negotiated Rate |
$334.50 |
| Rate for Payer: Adventist Health Commercial |
$89.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$306.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$113.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$136.54
|
| Rate for Payer: Blue Shield of California Commercial |
$117.39
|
| Rate for Payer: Blue Shield of California EPN |
$66.75
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$289.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.89
|
| Rate for Payer: Dignity Health Senior |
$113.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$289.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$276.07
|
| Rate for Payer: Heritage Provider Network Senior |
$276.07
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$113.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$143.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$143.06
|
| Rate for Payer: Multiplan Commercial |
$334.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$113.54
|
| Rate for Payer: TriValley Medical Group Senior |
$113.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$51.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$51.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Vantage Medical Group Senior |
$113.54
|
|
|
HC MANDIBLE-PANOREX
|
Facility
|
IP
|
$446.00
|
|
|
Service Code
|
CPT 70355
|
| Hospital Charge Code |
909001124
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$80.73 |
| Max. Negotiated Rate |
$334.50 |
| Rate for Payer: Adventist Health Commercial |
$89.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$306.40
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$301.94
|
| Rate for Payer: Heritage Provider Network Senior |
$301.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.50
|
| Rate for Payer: Multiplan Commercial |
$334.50
|
|
|
HC MANUAL THRPY TECHNIQUES 15 MIN MCAL
|
Facility
|
IP
|
$304.00
|
|
|
Service Code
|
CPT 97140
|
| Hospital Charge Code |
900400053
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$55.02 |
| Max. Negotiated Rate |
$228.00 |
| Rate for Payer: Adventist Health Commercial |
$60.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$208.85
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$205.81
|
| Rate for Payer: Heritage Provider Network Senior |
$205.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.00
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
|
|
HC MANUAL THRPY TECHNIQUES 15 MIN MCAL
|
Facility
|
OP
|
$304.00
|
|
|
Service Code
|
CPT 97140
|
| Hospital Charge Code |
901300057
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$34.65 |
| Max. Negotiated Rate |
$343.00 |
| Rate for Payer: Adventist Health Commercial |
$60.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$45.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$208.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$258.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$167.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$228.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$306.00
|
| Rate for Payer: Blue Shield of California Commercial |
$343.00
|
| Rate for Payer: Blue Shield of California EPN |
$295.00
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$197.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$258.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$258.40
|
| Rate for Payer: Dignity Health Senior |
$258.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$197.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$188.18
|
| Rate for Payer: Heritage Provider Network Senior |
$188.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$34.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$146.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.00
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$248.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$209.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$258.40
|
| Rate for Payer: Vantage Medical Group Senior |
$258.40
|
|
|
HC MANUAL THRPY TECHNIQUES 15 MIN MCAL
|
Facility
|
OP
|
$304.00
|
|
|
Service Code
|
CPT 97140
|
| Hospital Charge Code |
900400053
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$34.65 |
| Max. Negotiated Rate |
$343.00 |
| Rate for Payer: Adventist Health Commercial |
$60.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$45.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$208.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$258.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$167.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$228.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$306.00
|
| Rate for Payer: Blue Shield of California Commercial |
$343.00
|
| Rate for Payer: Blue Shield of California EPN |
$295.00
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$197.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$258.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$258.40
|
| Rate for Payer: Dignity Health Senior |
$258.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$197.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$188.18
|
| Rate for Payer: Heritage Provider Network Senior |
$188.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$34.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$146.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.00
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$248.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$209.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$258.40
|
| Rate for Payer: Vantage Medical Group Senior |
$258.40
|
|
|
HC MANUAL THRPY TECHNIQUES 15 MIN MCAL
|
Facility
|
IP
|
$304.00
|
|
|
Service Code
|
CPT 97140
|
| Hospital Charge Code |
901300057
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$55.02 |
| Max. Negotiated Rate |
$228.00 |
| Rate for Payer: Adventist Health Commercial |
$60.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$208.85
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$205.81
|
| Rate for Payer: Heritage Provider Network Senior |
$205.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.00
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
|
|
HC MANUAL THRPY TECHNIQUES 15 MIN OT
|
Facility
|
OP
|
$148.00
|
|
|
Service Code
|
CPT 97140
|
| Hospital Charge Code |
905197140
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$26.79 |
| Max. Negotiated Rate |
$343.00 |
| Rate for Payer: Adventist Health Commercial |
$29.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$45.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$101.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$125.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$81.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$111.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$306.00
|
| Rate for Payer: Blue Shield of California Commercial |
$343.00
|
| Rate for Payer: Blue Shield of California EPN |
$295.00
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$96.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$125.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$125.80
|
| Rate for Payer: Dignity Health Senior |
$125.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$91.61
|
| Rate for Payer: Heritage Provider Network Senior |
$91.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$34.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$71.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.00
|
| Rate for Payer: Multiplan Commercial |
$111.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$248.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$209.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$125.80
|
| Rate for Payer: Vantage Medical Group Senior |
$125.80
|
|
|
HC MANUAL THRPY TECHNIQUES 15 MIN OT
|
Facility
|
IP
|
$148.00
|
|
|
Service Code
|
CPT 97140
|
| Hospital Charge Code |
905197140
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$26.79 |
| Max. Negotiated Rate |
$111.00 |
| Rate for Payer: Adventist Health Commercial |
$29.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$101.68
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$100.20
|
| Rate for Payer: Heritage Provider Network Senior |
$100.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.00
|
| Rate for Payer: Multiplan Commercial |
$111.00
|
|
|
HC MANUAL THRPY TECHNIQUES 15 MIN PT
|
Facility
|
OP
|
$148.00
|
|
|
Service Code
|
CPT 97140
|
| Hospital Charge Code |
900417140
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$26.79 |
| Max. Negotiated Rate |
$343.00 |
| Rate for Payer: Adventist Health Commercial |
$29.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$45.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$101.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$125.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$81.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$111.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$306.00
|
| Rate for Payer: Blue Shield of California Commercial |
$343.00
|
| Rate for Payer: Blue Shield of California EPN |
$295.00
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$96.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$125.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$125.80
|
| Rate for Payer: Dignity Health Senior |
$125.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$91.61
|
| Rate for Payer: Heritage Provider Network Senior |
$91.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$34.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$71.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.00
|
| Rate for Payer: Multiplan Commercial |
$111.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$248.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$209.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$125.80
|
| Rate for Payer: Vantage Medical Group Senior |
$125.80
|
|
|
HC MANUAL THRPY TECHNIQUES 15 MIN PT
|
Facility
|
IP
|
$289.00
|
|
|
Service Code
|
CPT 97140
|
| Hospital Charge Code |
905103160
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$52.31 |
| Max. Negotiated Rate |
$216.75 |
| Rate for Payer: Adventist Health Commercial |
$57.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$198.54
|
| Rate for Payer: Cash Price |
$130.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$195.65
|
| Rate for Payer: Heritage Provider Network Senior |
$195.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.25
|
| Rate for Payer: Multiplan Commercial |
$216.75
|
|
|
HC MANUAL THRPY TECHNIQUES 15 MIN PT
|
Facility
|
IP
|
$148.00
|
|
|
Service Code
|
CPT 97140
|
| Hospital Charge Code |
900417140
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$26.79 |
| Max. Negotiated Rate |
$111.00 |
| Rate for Payer: Adventist Health Commercial |
$29.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$101.68
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$100.20
|
| Rate for Payer: Heritage Provider Network Senior |
$100.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.00
|
| Rate for Payer: Multiplan Commercial |
$111.00
|
|
|
HC MANUAL THRPY TECHNIQUES 15 MIN PT
|
Facility
|
OP
|
$289.00
|
|
|
Service Code
|
CPT 97140
|
| Hospital Charge Code |
905103160
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$34.65 |
| Max. Negotiated Rate |
$343.00 |
| Rate for Payer: Adventist Health Commercial |
$57.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$45.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$198.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$245.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$158.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$216.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$306.00
|
| Rate for Payer: Blue Shield of California Commercial |
$343.00
|
| Rate for Payer: Blue Shield of California EPN |
$295.00
|
| Rate for Payer: Cash Price |
$130.05
|
| Rate for Payer: Cash Price |
$130.05
|
| Rate for Payer: Cash Price |
$130.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$187.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$245.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$245.65
|
| Rate for Payer: Dignity Health Senior |
$245.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$187.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$178.89
|
| Rate for Payer: Heritage Provider Network Senior |
$178.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$34.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$139.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.25
|
| Rate for Payer: Multiplan Commercial |
$216.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$248.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$209.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$245.65
|
| Rate for Payer: Vantage Medical Group Senior |
$245.65
|
|
|
HC MARSUPIALIZATION OF BARTHOLINS GLAND CYST
|
Facility
|
OP
|
$6,301.00
|
|
|
Service Code
|
CPT 56440
|
| Hospital Charge Code |
900556440
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$936.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,260.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,328.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,906.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Cash Price |
$2,835.45
|
| Rate for Payer: Cash Price |
$2,835.45
|
| Rate for Payer: Cash Price |
$2,835.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,095.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,296.80
|
| Rate for Payer: Dignity Health Senior |
$3,906.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,906.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,265.78
|
| Rate for Payer: Heritage Provider Network Senior |
$4,265.78
|
| Rate for Payer: Humana Medicare |
$3,906.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,906.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,037.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,140.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,609.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,575.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,921.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,921.79
|
| Rate for Payer: Multiplan Commercial |
$4,725.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,287.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,105.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: Vantage Medical Group Senior |
$3,906.18
|
|
