|
HC MRI BRST BI W WO CNTRST W CAD
|
Facility
|
IP
|
$5,241.00
|
|
|
Service Code
|
CPT 77049
|
| Hospital Charge Code |
908801210
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$929.00 |
| Max. Negotiated Rate |
$3,930.75 |
| Rate for Payer: Adventist Health Commercial |
$1,048.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,600.57
|
| Rate for Payer: Cash Price |
$2,358.45
|
| Rate for Payer: Cash Price |
$2,358.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,548.16
|
| Rate for Payer: Heritage Provider Network Senior |
$3,548.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$948.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,310.25
|
| Rate for Payer: Multiplan Commercial |
$3,930.75
|
|
|
HC MRI BRST BI W WO CNTRST W CAD
|
Facility
|
OP
|
$4,885.00
|
|
|
Service Code
|
CPT 77049
|
| Hospital Charge Code |
908801210
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$4,152.25 |
| Rate for Payer: Adventist Health Commercial |
$977.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$814.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,356.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,152.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,686.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,663.75
|
| Rate for Payer: Blue Shield of California Commercial |
$1,593.16
|
| Rate for Payer: Blue Shield of California EPN |
$905.98
|
| Rate for Payer: Cash Price |
$2,198.25
|
| Rate for Payer: Cash Price |
$2,198.25
|
| Rate for Payer: Cash Price |
$2,198.25
|
| Rate for Payer: Cash Price |
$2,198.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,152.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,152.25
|
| Rate for Payer: Dignity Health Senior |
$4,152.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$527.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,354.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$884.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,221.25
|
| Rate for Payer: Multiplan Commercial |
$3,663.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$468.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$468.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,152.25
|
| Rate for Payer: Vantage Medical Group Senior |
$4,152.25
|
|
|
HC MRI BRST UNI W WO CTRST W CAD
|
Facility
|
OP
|
$4,507.00
|
|
|
Service Code
|
CPT 77048
|
| Hospital Charge Code |
908801215
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$3,830.95 |
| Rate for Payer: Adventist Health Commercial |
$901.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$814.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,096.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,830.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,478.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,380.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1,601.04
|
| Rate for Payer: Blue Shield of California EPN |
$910.46
|
| Rate for Payer: Cash Price |
$2,028.15
|
| Rate for Payer: Cash Price |
$2,028.15
|
| Rate for Payer: Cash Price |
$2,028.15
|
| Rate for Payer: Cash Price |
$2,028.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,830.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,830.95
|
| Rate for Payer: Dignity Health Senior |
$3,830.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$517.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,172.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$815.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,126.75
|
| Rate for Payer: Multiplan Commercial |
$3,380.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$471.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$471.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,830.95
|
| Rate for Payer: Vantage Medical Group Senior |
$3,830.95
|
|
|
HC MRI BRST UNI W WO CTRST W CAD
|
Facility
|
IP
|
$5,454.00
|
|
|
Service Code
|
CPT 77048
|
| Hospital Charge Code |
908801215
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$929.00 |
| Max. Negotiated Rate |
$4,090.50 |
| Rate for Payer: Adventist Health Commercial |
$1,090.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,746.90
|
| Rate for Payer: Cash Price |
$2,454.30
|
| Rate for Payer: Cash Price |
$2,454.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,692.36
|
| Rate for Payer: Heritage Provider Network Senior |
$3,692.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$987.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,363.50
|
| Rate for Payer: Multiplan Commercial |
$4,090.50
|
|
|
HC MRI CHEST W/ CONTRAST
|
Facility
|
OP
|
$4,104.00
|
|
|
Service Code
|
CPT 71551
|
| Hospital Charge Code |
908801201
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$3,078.00 |
| Rate for Payer: Adventist Health Commercial |
$820.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,574.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,819.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,500.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,100.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,000.40
|
| Rate for Payer: Blue Shield of California Commercial |
$2,718.36
|
| Rate for Payer: Blue Shield of California EPN |
$1,545.85
|
| Rate for Payer: Cash Price |
$1,846.80
|
| Rate for Payer: Cash Price |
$1,846.80
|
| Rate for Payer: Cash Price |
$1,846.80
|
| Rate for Payer: Cash Price |
$1,846.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,500.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,100.44
|
| Rate for Payer: Dignity Health Senior |
$1,000.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,000.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Humana Medicare |
$1,000.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$583.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,000.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,900.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$742.82
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,180.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,026.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,260.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,260.50
|
| Rate for Payer: Multiplan Commercial |
$3,078.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$697.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$697.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,500.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,100.44
|
| Rate for Payer: Vantage Medical Group Senior |
$1,000.40
|
|
|
HC MRI CHEST W/ CONTRAST
|
Facility
|
IP
|
$6,422.00
|
|
|
Service Code
|
CPT 71551
|
| Hospital Charge Code |
908801201
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$929.00 |
| Max. Negotiated Rate |
$4,816.50 |
| Rate for Payer: Adventist Health Commercial |
$1,284.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,411.91
|
| Rate for Payer: Cash Price |
$2,889.90
|
| Rate for Payer: Cash Price |
$2,889.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,347.69
|
| Rate for Payer: Heritage Provider Network Senior |
$4,347.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,162.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,605.50
|
| Rate for Payer: Multiplan Commercial |
$4,816.50
|
|
|
HC MRI CHEST, W/O CONT
|
Facility
|
OP
|
$3,671.00
|
|
|
Service Code
|
CPT 71550
|
| Hospital Charge Code |
908801200
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$306.16 |
| Max. Negotiated Rate |
$2,753.25 |
| Rate for Payer: Adventist Health Commercial |
$734.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,574.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,521.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$459.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$336.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$306.16
|
| Rate for Payer: Blue Shield of California Commercial |
$2,267.32
|
| Rate for Payer: Blue Shield of California EPN |
$1,289.36
|
| Rate for Payer: Cash Price |
$1,651.95
|
| Rate for Payer: Cash Price |
$1,651.95
|
| Rate for Payer: Cash Price |
$1,651.95
|
| Rate for Payer: Cash Price |
$1,651.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$459.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$336.78
|
| Rate for Payer: Dignity Health Senior |
$306.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$306.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Humana Medicare |
$306.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$528.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$306.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$581.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$664.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$361.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$917.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$385.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$385.76
|
| Rate for Payer: Multiplan Commercial |
$2,753.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$541.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$541.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$459.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$336.78
|
| Rate for Payer: Vantage Medical Group Senior |
$306.16
|
|
|
HC MRI CHEST, W/O CONT
|
Facility
|
IP
|
$4,331.00
|
|
|
Service Code
|
CPT 71550
|
| Hospital Charge Code |
908801200
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$783.91 |
| Max. Negotiated Rate |
$3,248.25 |
| Rate for Payer: Adventist Health Commercial |
$866.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,975.40
|
| Rate for Payer: Cash Price |
$1,948.95
|
| Rate for Payer: Cash Price |
$1,948.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,932.09
|
| Rate for Payer: Heritage Provider Network Senior |
$2,932.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$783.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,082.75
|
| Rate for Payer: Multiplan Commercial |
$3,248.25
|
|
|
HC MRI CHEST W WO CONTRAST
|
Facility
|
OP
|
$4,859.00
|
|
|
Service Code
|
CPT 71552
|
| Hospital Charge Code |
908801202
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$4,994.03 |
| Rate for Payer: Adventist Health Commercial |
$971.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,574.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,338.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$720.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$528.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$480.50
|
| Rate for Payer: Blue Shield of California Commercial |
$4,994.03
|
| Rate for Payer: Blue Shield of California EPN |
$2,839.95
|
| Rate for Payer: Cash Price |
$2,186.55
|
| Rate for Payer: Cash Price |
$2,186.55
|
| Rate for Payer: Cash Price |
$2,186.55
|
| Rate for Payer: Cash Price |
$2,186.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$720.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$528.55
|
| Rate for Payer: Dignity Health Senior |
$480.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$480.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Humana Medicare |
$480.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$736.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$480.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$912.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$879.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$566.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,214.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$605.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$605.43
|
| Rate for Payer: Multiplan Commercial |
$3,644.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$854.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$854.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$720.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$528.55
|
| Rate for Payer: Vantage Medical Group Senior |
$480.50
|
|
|
HC MRI CHEST W WO CONTRAST
|
Facility
|
IP
|
$6,907.00
|
|
|
Service Code
|
CPT 71552
|
| Hospital Charge Code |
908801202
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$929.00 |
| Max. Negotiated Rate |
$5,180.25 |
| Rate for Payer: Adventist Health Commercial |
$1,381.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,745.11
|
| Rate for Payer: Cash Price |
$3,108.15
|
| Rate for Payer: Cash Price |
$3,108.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,676.04
|
| Rate for Payer: Heritage Provider Network Senior |
$4,676.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,250.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,726.75
|
| Rate for Payer: Multiplan Commercial |
$5,180.25
|
|
|
HC MRI FETAL PELVIC IMG 1ST FETUS
|
Facility
|
OP
|
$1,226.00
|
|
|
Service Code
|
CPT 74712
|
| Hospital Charge Code |
908874712
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$221.91 |
| Max. Negotiated Rate |
$4,872.33 |
| Rate for Payer: Adventist Health Commercial |
$245.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$814.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$842.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$459.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$336.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$306.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,872.33
|
| Rate for Payer: Blue Shield of California Commercial |
$1,810.83
|
| Rate for Payer: Blue Shield of California EPN |
$1,029.76
|
| Rate for Payer: Cash Price |
$551.70
|
| Rate for Payer: Cash Price |
$551.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$796.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$459.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$336.78
|
| Rate for Payer: Dignity Health Senior |
$306.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$796.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$306.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$758.89
|
| Rate for Payer: Heritage Provider Network Senior |
$758.89
|
| Rate for Payer: Humana Medicare |
$306.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$625.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$306.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$581.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$221.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$361.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$306.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$385.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$385.76
|
| Rate for Payer: Multiplan Commercial |
$919.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$306.16
|
| Rate for Payer: TriValley Medical Group Senior |
$306.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$437.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$437.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$459.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$336.78
|
| Rate for Payer: Vantage Medical Group Senior |
$306.16
|
|
|
HC MRI FETAL PELVIC IMG 1ST FETUS
|
Facility
|
IP
|
$1,226.00
|
|
|
Service Code
|
CPT 74712
|
| Hospital Charge Code |
908874712
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$221.91 |
| Max. Negotiated Rate |
$919.50 |
| Rate for Payer: Adventist Health Commercial |
$245.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$842.26
|
| Rate for Payer: Cash Price |
$551.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$830.00
|
| Rate for Payer: Heritage Provider Network Senior |
$830.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$221.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$306.50
|
| Rate for Payer: Multiplan Commercial |
$919.50
|
|
|
HC MRI FETAL PELVIC IMG ADD FETUS
|
Facility
|
IP
|
$613.00
|
|
|
Service Code
|
CPT 74713
|
| Hospital Charge Code |
908874713
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$110.95 |
| Max. Negotiated Rate |
$459.75 |
| Rate for Payer: Adventist Health Commercial |
$122.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$421.13
|
| Rate for Payer: Cash Price |
$275.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$415.00
|
| Rate for Payer: Heritage Provider Network Senior |
$415.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$110.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$153.25
|
| Rate for Payer: Multiplan Commercial |
$459.75
|
|
|
HC MRI FETAL PELVIC IMG ADD FETUS
|
Facility
|
OP
|
$613.00
|
|
|
Service Code
|
CPT 74713
|
| Hospital Charge Code |
908874713
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$110.95 |
| Max. Negotiated Rate |
$2,087.69 |
| Rate for Payer: Adventist Health Commercial |
$122.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$814.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$421.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$521.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$337.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$459.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,087.69
|
| Rate for Payer: Blue Shield of California Commercial |
$775.98
|
| Rate for Payer: Blue Shield of California EPN |
$441.28
|
| Rate for Payer: Cash Price |
$275.85
|
| Rate for Payer: Cash Price |
$275.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$398.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$521.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$521.05
|
| Rate for Payer: Dignity Health Senior |
$521.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$398.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$379.45
|
| Rate for Payer: Heritage Provider Network Senior |
$379.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$301.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$295.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$110.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$153.25
|
| Rate for Payer: Multiplan Commercial |
$459.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$521.05
|
| Rate for Payer: Vantage Medical Group Senior |
$521.05
|
|
|
HC MRI GUID BX/NEEDLE LOC/ASPIR
|
Facility
|
OP
|
$5,198.00
|
|
|
Service Code
|
CPT 77021
|
| Hospital Charge Code |
909002020
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$4,418.30 |
| Rate for Payer: Adventist Health Commercial |
$1,039.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$814.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,571.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,418.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,858.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,898.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1,795.03
|
| Rate for Payer: Blue Shield of California EPN |
$1,020.78
|
| Rate for Payer: Cash Price |
$2,339.10
|
| Rate for Payer: Cash Price |
$2,339.10
|
| Rate for Payer: Cash Price |
$2,339.10
|
| Rate for Payer: Cash Price |
$2,339.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,418.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,418.30
|
| Rate for Payer: Dignity Health Senior |
$4,418.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$572.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,505.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$940.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,299.50
|
| Rate for Payer: Multiplan Commercial |
$3,898.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,418.30
|
| Rate for Payer: Vantage Medical Group Senior |
$4,418.30
|
|
|
HC MRI GUID BX/NEEDLE LOC/ASPIR
|
Facility
|
IP
|
$3,706.00
|
|
|
Service Code
|
CPT 77021
|
| Hospital Charge Code |
909002020
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$670.79 |
| Max. Negotiated Rate |
$2,779.50 |
| Rate for Payer: Adventist Health Commercial |
$741.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,546.02
|
| Rate for Payer: Cash Price |
$1,667.70
|
| Rate for Payer: Cash Price |
$1,667.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,508.96
|
| Rate for Payer: Heritage Provider Network Senior |
$2,508.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$670.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$926.50
|
| Rate for Payer: Multiplan Commercial |
$2,779.50
|
|
|
HC MRI INSERTABLE IMAGING COIL
|
Facility
|
OP
|
$525.00
|
|
|
Service Code
|
CPT C1770
|
| Hospital Charge Code |
908801710
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$105.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$252.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$360.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$446.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$288.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$393.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$326.02
|
| Rate for Payer: Blue Shield of California EPN |
$308.18
|
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$241.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$446.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$446.25
|
| Rate for Payer: Dignity Health Senior |
$446.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$336.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$243.08
|
| Rate for Payer: Heritage Provider Network Senior |
$243.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$262.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$262.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$262.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.25
|
| Rate for Payer: Multiplan Commercial |
$393.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$191.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$175.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$446.25
|
| Rate for Payer: Vantage Medical Group Senior |
$446.25
|
|
|
HC MRI INSERTABLE IMAGING COIL
|
Facility
|
IP
|
$525.00
|
|
|
Service Code
|
CPT C1770
|
| Hospital Charge Code |
908801710
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$105.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$252.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$360.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$241.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$283.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$355.42
|
| Rate for Payer: Heritage Provider Network Senior |
$355.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$262.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$262.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$262.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.25
|
| Rate for Payer: Multiplan Commercial |
$393.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$191.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$175.40
|
|
|
HC MRI LOWER EXTREMITY W/O CON
|
Facility
|
IP
|
$4,520.00
|
|
|
Service Code
|
CPT 73718
|
| Hospital Charge Code |
908801402
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$818.12 |
| Max. Negotiated Rate |
$3,390.00 |
| Rate for Payer: Adventist Health Commercial |
$904.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,105.24
|
| Rate for Payer: Cash Price |
$2,034.00
|
| Rate for Payer: Cash Price |
$2,034.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,060.04
|
| Rate for Payer: Heritage Provider Network Senior |
$3,060.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$818.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,130.00
|
| Rate for Payer: Multiplan Commercial |
$3,390.00
|
|
|
HC MRI LOWER EXTREMITY W/O CON
|
Facility
|
OP
|
$3,310.00
|
|
|
Service Code
|
CPT 73718
|
| Hospital Charge Code |
908801402
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$306.16 |
| Max. Negotiated Rate |
$2,482.50 |
| Rate for Payer: Adventist Health Commercial |
$662.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,574.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,273.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$459.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$336.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$306.16
|
| Rate for Payer: Blue Shield of California Commercial |
$2,258.89
|
| Rate for Payer: Blue Shield of California EPN |
$1,284.56
|
| Rate for Payer: Cash Price |
$1,489.50
|
| Rate for Payer: Cash Price |
$1,489.50
|
| Rate for Payer: Cash Price |
$1,489.50
|
| Rate for Payer: Cash Price |
$1,489.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$459.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$336.78
|
| Rate for Payer: Dignity Health Senior |
$306.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$306.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Humana Medicare |
$306.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$343.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$306.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$581.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$599.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$361.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$827.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$385.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$385.76
|
| Rate for Payer: Multiplan Commercial |
$2,482.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$541.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$541.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$459.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$336.78
|
| Rate for Payer: Vantage Medical Group Senior |
$306.16
|
|
|
HC MRI LOWER EXTREM WO CONT
|
Facility
|
IP
|
$5,434.00
|
|
|
Service Code
|
CPT 73720
|
| Hospital Charge Code |
908801399
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$929.00 |
| Max. Negotiated Rate |
$4,075.50 |
| Rate for Payer: Adventist Health Commercial |
$1,086.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,733.16
|
| Rate for Payer: Cash Price |
$2,445.30
|
| Rate for Payer: Cash Price |
$2,445.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,678.82
|
| Rate for Payer: Heritage Provider Network Senior |
$3,678.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$983.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,358.50
|
| Rate for Payer: Multiplan Commercial |
$4,075.50
|
|
|
HC MRI LOWER EXTREM WO CONT
|
Facility
|
OP
|
$4,142.00
|
|
|
Service Code
|
CPT 73720
|
| Hospital Charge Code |
908801399
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$5,016.44 |
| Rate for Payer: Adventist Health Commercial |
$828.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,574.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,845.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$720.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$528.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$480.50
|
| Rate for Payer: Blue Shield of California Commercial |
$5,016.44
|
| Rate for Payer: Blue Shield of California EPN |
$2,852.70
|
| Rate for Payer: Cash Price |
$1,863.90
|
| Rate for Payer: Cash Price |
$1,863.90
|
| Rate for Payer: Cash Price |
$1,863.90
|
| Rate for Payer: Cash Price |
$1,863.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$720.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$528.55
|
| Rate for Payer: Dignity Health Senior |
$480.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$480.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Humana Medicare |
$480.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$519.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$480.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$912.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$749.70
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$566.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,035.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$605.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$605.43
|
| Rate for Payer: Multiplan Commercial |
$3,106.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$854.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$854.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$720.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$528.55
|
| Rate for Payer: Vantage Medical Group Senior |
$480.50
|
|
|
HC MRI L-SPINE W & WO CONTRAST
|
Facility
|
OP
|
$4,480.00
|
|
|
Service Code
|
CPT 72158
|
| Hospital Charge Code |
908801124
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$5,082.43 |
| Rate for Payer: Adventist Health Commercial |
$896.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,574.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,077.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$720.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$528.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$480.50
|
| Rate for Payer: Blue Shield of California Commercial |
$5,082.43
|
| Rate for Payer: Blue Shield of California EPN |
$2,890.22
|
| Rate for Payer: Cash Price |
$2,016.00
|
| Rate for Payer: Cash Price |
$2,016.00
|
| Rate for Payer: Cash Price |
$2,016.00
|
| Rate for Payer: Cash Price |
$2,016.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$720.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$528.55
|
| Rate for Payer: Dignity Health Senior |
$480.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$480.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Humana Medicare |
$480.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$487.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$480.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$912.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$810.88
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$566.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,120.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$605.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$605.43
|
| Rate for Payer: Multiplan Commercial |
$3,360.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$854.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$854.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$720.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$528.55
|
| Rate for Payer: Vantage Medical Group Senior |
$480.50
|
|
|
HC MRI L-SPINE W & WO CONTRAST
|
Facility
|
IP
|
$7,495.00
|
|
|
Service Code
|
CPT 72158
|
| Hospital Charge Code |
908801124
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$929.00 |
| Max. Negotiated Rate |
$5,621.25 |
| Rate for Payer: Adventist Health Commercial |
$1,499.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,149.06
|
| Rate for Payer: Cash Price |
$3,372.75
|
| Rate for Payer: Cash Price |
$3,372.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,074.12
|
| Rate for Payer: Heritage Provider Network Senior |
$5,074.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,356.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,873.75
|
| Rate for Payer: Multiplan Commercial |
$5,621.25
|
|
|
HC MRI LUMBAR SPINE W CONTRAST
|
Facility
|
OP
|
$4,256.00
|
|
|
Service Code
|
CPT 72149
|
| Hospital Charge Code |
908801122
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$3,192.00 |
| Rate for Payer: Adventist Health Commercial |
$851.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,574.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,923.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$720.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$528.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$480.50
|
| Rate for Payer: Blue Shield of California Commercial |
$2,743.62
|
| Rate for Payer: Blue Shield of California EPN |
$1,560.21
|
| Rate for Payer: Cash Price |
$1,915.20
|
| Rate for Payer: Cash Price |
$1,915.20
|
| Rate for Payer: Cash Price |
$1,915.20
|
| Rate for Payer: Cash Price |
$1,915.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$720.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$528.55
|
| Rate for Payer: Dignity Health Senior |
$480.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$480.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Humana Medicare |
$480.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$414.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$480.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$912.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$770.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$566.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,064.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$605.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$605.43
|
| Rate for Payer: Multiplan Commercial |
$3,192.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$697.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$697.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$720.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$528.55
|
| Rate for Payer: Vantage Medical Group Senior |
$480.50
|
|
