|
HC IMPL PRIMATRIX AG 4CM X 4CM FENESTRATED
|
Facility
|
OP
|
$166.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101521
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.05 |
| Max. Negotiated Rate |
$141.10 |
| Rate for Payer: Adventist Health Commercial |
$33.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$88.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$114.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$141.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$91.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$124.50
|
| Rate for Payer: Blue Shield of California Commercial |
$101.26
|
| Rate for Payer: Blue Shield of California EPN |
$81.01
|
| Rate for Payer: Cash Price |
$91.30
|
| Rate for Payer: Cash Price |
$91.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$76.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$141.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$141.10
|
| Rate for Payer: Dignity Health Senior |
$141.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$106.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$76.86
|
| Rate for Payer: Heritage Provider Network Senior |
$76.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$65.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$79.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$116.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$116.20
|
| Rate for Payer: Multiplan Commercial |
$124.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$66.40
|
| Rate for Payer: TriValley Medical Group Senior |
$66.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$59.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$54.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$141.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$141.10
|
| Rate for Payer: Vantage Medical Group Senior |
$141.10
|
|
|
HC IMPL PRIMATRIX AG 4CM X 4CM FENESTRATED
|
Facility
|
IP
|
$166.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101521
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.05 |
| Max. Negotiated Rate |
$124.50 |
| Rate for Payer: Adventist Health Commercial |
$33.20
|
| Rate for Payer: Cash Price |
$91.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$76.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$89.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$76.86
|
| Rate for Payer: Heritage Provider Network Senior |
$76.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.50
|
| Rate for Payer: Multiplan Commercial |
$124.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$59.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$54.96
|
|
|
HC IMPL PRIMATRIX AG 4CM X 4CM MESH
|
Facility
|
IP
|
$166.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101522
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.05 |
| Max. Negotiated Rate |
$124.50 |
| Rate for Payer: Adventist Health Commercial |
$33.20
|
| Rate for Payer: Cash Price |
$91.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$76.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$89.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$76.86
|
| Rate for Payer: Heritage Provider Network Senior |
$76.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.50
|
| Rate for Payer: Multiplan Commercial |
$124.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$59.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$54.96
|
|
|
HC IMPL PRIMATRIX AG 4CM X 4CM MESH
|
Facility
|
OP
|
$166.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101522
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.05 |
| Max. Negotiated Rate |
$141.10 |
| Rate for Payer: Adventist Health Commercial |
$33.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$88.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$114.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$141.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$91.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$124.50
|
| Rate for Payer: Blue Shield of California Commercial |
$101.26
|
| Rate for Payer: Blue Shield of California EPN |
$81.01
|
| Rate for Payer: Cash Price |
$91.30
|
| Rate for Payer: Cash Price |
$91.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$76.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$141.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$141.10
|
| Rate for Payer: Dignity Health Senior |
$141.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$106.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$76.86
|
| Rate for Payer: Heritage Provider Network Senior |
$76.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$65.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$79.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$116.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$116.20
|
| Rate for Payer: Multiplan Commercial |
$124.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$66.40
|
| Rate for Payer: TriValley Medical Group Senior |
$66.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$59.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$54.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$141.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$141.10
|
| Rate for Payer: Vantage Medical Group Senior |
$141.10
|
|
|
HC IMPL PRIMATRIX AG 6CM X 6CM FENESTRATED
|
Facility
|
OP
|
$133.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101523
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.07 |
| Max. Negotiated Rate |
$113.05 |
| Rate for Payer: Adventist Health Commercial |
$26.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$71.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$91.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$113.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$73.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$99.75
|
| Rate for Payer: Blue Shield of California Commercial |
$81.13
|
| Rate for Payer: Blue Shield of California EPN |
$64.90
|
| Rate for Payer: Cash Price |
$73.15
|
| Rate for Payer: Cash Price |
$73.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$61.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$113.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$113.05
|
| Rate for Payer: Dignity Health Senior |
$113.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$61.58
|
| Rate for Payer: Heritage Provider Network Senior |
$61.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$65.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$63.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$93.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$93.10
|
| Rate for Payer: Multiplan Commercial |
$99.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$53.20
|
| Rate for Payer: TriValley Medical Group Senior |
$53.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$48.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$44.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$113.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$113.05
|
| Rate for Payer: Vantage Medical Group Senior |
$113.05
|
|
|
HC IMPL PRIMATRIX AG 6CM X 6CM FENESTRATED
|
Facility
|
IP
|
$133.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101523
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.07 |
| Max. Negotiated Rate |
$99.75 |
| Rate for Payer: Adventist Health Commercial |
$26.60
|
| Rate for Payer: Cash Price |
$73.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$61.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$61.58
|
| Rate for Payer: Heritage Provider Network Senior |
$61.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.25
|
| Rate for Payer: Multiplan Commercial |
$99.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$48.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$44.04
|
|
|
HC IMRT TREATMENT DELIVERY COMPLEX
|
Facility
|
OP
|
$2,530.00
|
|
|
Service Code
|
CPT 77386
|
| Hospital Charge Code |
909177386
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$457.93 |
| Max. Negotiated Rate |
$4,352.50 |
| Rate for Payer: Adventist Health Commercial |
$506.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,352.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,738.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,102.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$808.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$735.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,352.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1,543.30
|
| Rate for Payer: Blue Shield of California EPN |
$1,234.64
|
| Rate for Payer: Cash Price |
$1,391.50
|
| Rate for Payer: Cash Price |
$1,391.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,644.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,102.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$808.50
|
| Rate for Payer: Dignity Health Senior |
$735.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,644.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$735.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,566.07
|
| Rate for Payer: Heritage Provider Network Senior |
$1,566.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$735.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,206.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$457.93
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$845.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$632.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$926.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$926.10
|
| Rate for Payer: Multiplan Commercial |
$1,897.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$624.75
|
| Rate for Payer: TriValley Medical Group Senior |
$624.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,265.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,265.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,102.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$808.50
|
| Rate for Payer: Vantage Medical Group Senior |
$735.00
|
|
|
HC IMRT TREATMENT DELIVERY COMPLEX
|
Facility
|
IP
|
$2,530.00
|
|
|
Service Code
|
CPT 77386
|
| Hospital Charge Code |
909177386
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$457.93 |
| Max. Negotiated Rate |
$1,897.50 |
| Rate for Payer: Adventist Health Commercial |
$506.00
|
| Rate for Payer: Cash Price |
$1,391.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,712.81
|
| Rate for Payer: Heritage Provider Network Senior |
$1,712.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$457.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$632.50
|
| Rate for Payer: Multiplan Commercial |
$1,897.50
|
|
|
HC IMRT TREATMENT DELIVERY SIMPLE
|
Facility
|
OP
|
$2,216.00
|
|
|
Service Code
|
CPT 77385
|
| Hospital Charge Code |
909177385
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$401.10 |
| Max. Negotiated Rate |
$3,626.38 |
| Rate for Payer: Adventist Health Commercial |
$443.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,184.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,522.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,102.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$808.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$735.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,626.38
|
| Rate for Payer: Blue Shield of California Commercial |
$1,351.76
|
| Rate for Payer: Blue Shield of California EPN |
$1,081.41
|
| Rate for Payer: Cash Price |
$1,218.80
|
| Rate for Payer: Cash Price |
$1,218.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,440.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,102.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$808.50
|
| Rate for Payer: Dignity Health Senior |
$735.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,440.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$735.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,371.70
|
| Rate for Payer: Heritage Provider Network Senior |
$1,371.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$735.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,057.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$401.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$845.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$554.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$926.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$926.10
|
| Rate for Payer: Multiplan Commercial |
$1,662.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$624.75
|
| Rate for Payer: TriValley Medical Group Senior |
$624.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,108.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,108.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,102.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$808.50
|
| Rate for Payer: Vantage Medical Group Senior |
$735.00
|
|
|
HC IMRT TREATMENT DELIVERY SIMPLE
|
Facility
|
IP
|
$2,216.00
|
|
|
Service Code
|
CPT 77385
|
| Hospital Charge Code |
909177385
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$401.10 |
| Max. Negotiated Rate |
$1,662.00 |
| Rate for Payer: Adventist Health Commercial |
$443.20
|
| Rate for Payer: Cash Price |
$1,218.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,500.23
|
| Rate for Payer: Heritage Provider Network Senior |
$1,500.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$401.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$554.00
|
| Rate for Payer: Multiplan Commercial |
$1,662.00
|
|
|
HC IN111 PENTETATE 0.5 MCI DTPA
|
Facility
|
OP
|
$3,258.00
|
|
|
Service Code
|
CPT A9548
|
| Hospital Charge Code |
909301523
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$589.70 |
| Max. Negotiated Rate |
$2,443.50 |
| Rate for Payer: Adventist Health Commercial |
$651.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$894.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$786.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$786.82
|
| Rate for Payer: Blue Shield of California Commercial |
$1,987.38
|
| Rate for Payer: Blue Shield of California EPN |
$1,589.90
|
| Rate for Payer: Cash Price |
$1,791.90
|
| Rate for Payer: Cash Price |
$1,791.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,117.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$894.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$786.82
|
| Rate for Payer: Dignity Health Senior |
$786.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,085.12
|
| Rate for Payer: EPIC Health Plan Medicare |
$715.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,016.70
|
| Rate for Payer: Heritage Provider Network Senior |
$2,016.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,265.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$715.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,554.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$589.70
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$822.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$814.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$901.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$901.27
|
| Rate for Payer: Multiplan Commercial |
$2,443.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$786.82
|
| Rate for Payer: TriValley Medical Group Senior |
$715.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,177.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,078.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$894.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$786.82
|
| Rate for Payer: Vantage Medical Group Senior |
$786.82
|
|
|
HC IN111 PENTETATE 0.5 MCI DTPA
|
Facility
|
IP
|
$3,258.00
|
|
|
Service Code
|
CPT A9548
|
| Hospital Charge Code |
909301523
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$589.70 |
| Max. Negotiated Rate |
$2,443.50 |
| Rate for Payer: Adventist Health Commercial |
$651.60
|
| Rate for Payer: Cash Price |
$1,791.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,759.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,205.67
|
| Rate for Payer: Heritage Provider Network Senior |
$2,205.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$589.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$814.50
|
| Rate for Payer: Multiplan Commercial |
$2,443.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,177.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,078.72
|
|
|
HC IN111 PENTETRTID/OCTRE/LT 6MCI
|
Facility
|
OP
|
$19,095.00
|
|
|
Service Code
|
CPT A9572
|
| Hospital Charge Code |
909301570
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,914.61 |
| Max. Negotiated Rate |
$14,321.25 |
| Rate for Payer: Adventist Health Commercial |
$3,819.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,393.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,106.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,106.07
|
| Rate for Payer: Blue Shield of California Commercial |
$11,647.95
|
| Rate for Payer: Blue Shield of California EPN |
$9,318.36
|
| Rate for Payer: Cash Price |
$10,502.25
|
| Rate for Payer: Cash Price |
$10,502.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8,783.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,393.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,106.07
|
| Rate for Payer: Dignity Health Senior |
$2,106.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,220.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,914.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$8,840.99
|
| Rate for Payer: Heritage Provider Network Senior |
$8,840.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,914.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,108.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,456.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,201.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4,773.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,412.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,412.41
|
| Rate for Payer: Multiplan Commercial |
$14,321.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,638.00
|
| Rate for Payer: TriValley Medical Group Senior |
$7,638.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6,899.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,322.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,393.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,106.07
|
| Rate for Payer: Vantage Medical Group Senior |
$2,106.07
|
|
|
HC IN111 PENTETRTID/OCTRE/LT 6MCI
|
Facility
|
IP
|
$19,095.00
|
|
|
Service Code
|
CPT A9572
|
| Hospital Charge Code |
909301570
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,456.20 |
| Max. Negotiated Rate |
$14,321.25 |
| Rate for Payer: Adventist Health Commercial |
$3,819.00
|
| Rate for Payer: Cash Price |
$10,502.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8,783.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$10,311.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$8,840.99
|
| Rate for Payer: Heritage Provider Network Senior |
$8,840.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,456.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4,773.75
|
| Rate for Payer: Multiplan Commercial |
$14,321.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6,899.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,322.35
|
|
|
HC IN111 PROSTASCINT UP TO 10 MCI
|
Facility
|
OP
|
$8,469.00
|
|
|
Service Code
|
CPT A9507
|
| Hospital Charge Code |
909301255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,532.89 |
| Max. Negotiated Rate |
$7,198.65 |
| Rate for Payer: Adventist Health Commercial |
$1,693.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,198.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,657.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6,351.75
|
| Rate for Payer: Blue Shield of California Commercial |
$5,166.09
|
| Rate for Payer: Blue Shield of California EPN |
$4,132.87
|
| Rate for Payer: Cash Price |
$4,657.95
|
| Rate for Payer: Cash Price |
$4,657.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,895.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,198.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,198.65
|
| Rate for Payer: Dignity Health Senior |
$7,198.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,420.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,921.15
|
| Rate for Payer: Heritage Provider Network Senior |
$3,921.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,648.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,039.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,532.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,117.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,928.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,928.30
|
| Rate for Payer: Multiplan Commercial |
$6,351.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,387.60
|
| Rate for Payer: TriValley Medical Group Senior |
$3,387.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,059.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,804.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,198.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,198.65
|
| Rate for Payer: Vantage Medical Group Senior |
$7,198.65
|
|
|
HC IN111 PROSTASCINT UP TO 10 MCI
|
Facility
|
IP
|
$8,469.00
|
|
|
Service Code
|
CPT A9507
|
| Hospital Charge Code |
909301255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,532.89 |
| Max. Negotiated Rate |
$6,351.75 |
| Rate for Payer: Adventist Health Commercial |
$1,693.80
|
| Rate for Payer: Cash Price |
$4,657.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,895.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,573.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,921.15
|
| Rate for Payer: Heritage Provider Network Senior |
$3,921.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,532.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,117.25
|
| Rate for Payer: Multiplan Commercial |
$6,351.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,059.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,804.09
|
|
|
HC IN111 ZEVALIN UP TO 5 MCI
|
Facility
|
OP
|
$2,612.00
|
|
|
Service Code
|
CPT A9542
|
| Hospital Charge Code |
909301342
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$472.77 |
| Max. Negotiated Rate |
$5,654.55 |
| Rate for Payer: Adventist Health Commercial |
$522.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$997.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$877.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$877.82
|
| Rate for Payer: Blue Shield of California Commercial |
$1,593.32
|
| Rate for Payer: Blue Shield of California EPN |
$1,274.66
|
| Rate for Payer: Cash Price |
$1,436.60
|
| Rate for Payer: Cash Price |
$1,436.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,697.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$997.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$877.82
|
| Rate for Payer: Dignity Health Senior |
$877.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,697.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$798.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,616.83
|
| Rate for Payer: Heritage Provider Network Senior |
$1,616.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,654.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$798.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,245.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$472.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$917.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$653.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,005.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,005.51
|
| Rate for Payer: Multiplan Commercial |
$1,959.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$877.82
|
| Rate for Payer: TriValley Medical Group Senior |
$798.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,306.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,306.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$997.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$877.82
|
| Rate for Payer: Vantage Medical Group Senior |
$877.82
|
|
|
HC IN111 ZEVALIN UP TO 5 MCI
|
Facility
|
IP
|
$2,612.00
|
|
|
Service Code
|
CPT A9542
|
| Hospital Charge Code |
909301342
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$472.77 |
| Max. Negotiated Rate |
$1,959.00 |
| Rate for Payer: Adventist Health Commercial |
$522.40
|
| Rate for Payer: Cash Price |
$1,436.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,768.32
|
| Rate for Payer: Heritage Provider Network Senior |
$1,768.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$472.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$653.00
|
| Rate for Payer: Multiplan Commercial |
$1,959.00
|
|
|
HC INCISE/DRAIN TEAR GLAND
|
Facility
|
OP
|
$692.00
|
|
|
Service Code
|
CPT 68400
|
| Hospital Charge Code |
900501642
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3,531.00 |
| Rate for Payer: Adventist Health Commercial |
$138.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$475.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,845.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,353.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,230.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| Rate for Payer: Cash Price |
$380.60
|
| Rate for Payer: Cash Price |
$380.60
|
| Rate for Payer: Cash Price |
$380.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$449.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,845.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,353.69
|
| Rate for Payer: Dignity Health Senior |
$1,230.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$449.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,230.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$468.48
|
| Rate for Payer: Heritage Provider Network Senior |
$468.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$973.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,230.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$330.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$125.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,415.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$173.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,550.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,550.59
|
| Rate for Payer: Multiplan Commercial |
$519.00
|
| Rate for Payer: Multiplan WC |
$1,960.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$248.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$229.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,845.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,353.69
|
| Rate for Payer: Vantage Medical Group Senior |
$1,230.63
|
|
|
HC INCISE/DRAIN TEAR GLAND
|
Facility
|
IP
|
$692.00
|
|
|
Service Code
|
CPT 68400
|
| Hospital Charge Code |
900501642
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$125.25 |
| Max. Negotiated Rate |
$519.00 |
| Rate for Payer: Adventist Health Commercial |
$138.40
|
| Rate for Payer: Cash Price |
$380.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$468.48
|
| Rate for Payer: Heritage Provider Network Senior |
$468.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$125.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$173.00
|
| Rate for Payer: Multiplan Commercial |
$519.00
|
|
|
HC INCISIONAL BX SKIN SINGLE LSN
|
Facility
|
IP
|
$949.00
|
|
|
Service Code
|
CPT 11106
|
| Hospital Charge Code |
900511106
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$171.77 |
| Max. Negotiated Rate |
$711.75 |
| Rate for Payer: Adventist Health Commercial |
$189.80
|
| Rate for Payer: Cash Price |
$521.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$642.47
|
| Rate for Payer: Heritage Provider Network Senior |
$642.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$171.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$237.25
|
| Rate for Payer: Multiplan Commercial |
$711.75
|
|
|
HC INCISIONAL BX SKIN SINGLE LSN
|
Facility
|
OP
|
$949.00
|
|
|
Service Code
|
CPT 11106
|
| Hospital Charge Code |
900511106
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$189.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$651.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,166.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$855.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$777.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$521.95
|
| Rate for Payer: Cash Price |
$521.95
|
| Rate for Payer: Cash Price |
$521.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$616.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,166.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$855.55
|
| Rate for Payer: Dignity Health Senior |
$777.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$777.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$587.43
|
| Rate for Payer: Heritage Provider Network Senior |
$956.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$220.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$777.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,477.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$171.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$894.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$237.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$979.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$979.99
|
| Rate for Payer: Multiplan Commercial |
$711.75
|
| Rate for Payer: Multiplan WC |
$1,239.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$855.55
|
| Rate for Payer: TriValley Medical Group Senior |
$855.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,731.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,298.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,166.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$855.55
|
| Rate for Payer: Vantage Medical Group Senior |
$777.77
|
|
|
HC INCISION DRAIN DEEP RECTAL ABSCESS
|
Facility
|
OP
|
$5,873.00
|
|
|
Service Code
|
CPT 45020
|
| Hospital Charge Code |
900501241
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,174.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,034.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,226.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,832.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,484.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,959.00
|
| Rate for Payer: Cash Price |
$3,230.15
|
| Rate for Payer: Cash Price |
$3,230.15
|
| Rate for Payer: Cash Price |
$3,230.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,817.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,226.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,832.93
|
| Rate for Payer: Dignity Health Senior |
$3,484.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,484.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,976.02
|
| Rate for Payer: Heritage Provider Network Senior |
$3,976.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$973.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,484.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,801.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,063.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,007.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,468.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,390.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,390.44
|
| Rate for Payer: Multiplan Commercial |
$4,404.75
|
| Rate for Payer: Multiplan WC |
$5,551.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,113.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,944.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,226.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,832.93
|
| Rate for Payer: Vantage Medical Group Senior |
$3,484.48
|
|
|
HC INCISION DRAIN DEEP RECTAL ABSCESS
|
Facility
|
IP
|
$5,873.00
|
|
|
Service Code
|
CPT 45020
|
| Hospital Charge Code |
900501241
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,063.01 |
| Max. Negotiated Rate |
$4,404.75 |
| Rate for Payer: Adventist Health Commercial |
$1,174.60
|
| Rate for Payer: Cash Price |
$3,230.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,976.02
|
| Rate for Payer: Heritage Provider Network Senior |
$3,976.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,063.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,468.25
|
| Rate for Payer: Multiplan Commercial |
$4,404.75
|
|
|
HC INCISION/DRAIN FOREARM/WRIST
|
Facility
|
IP
|
$5,215.00
|
|
|
Service Code
|
CPT 25028
|
| Hospital Charge Code |
900501423
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$943.91 |
| Max. Negotiated Rate |
$3,911.25 |
| Rate for Payer: Adventist Health Commercial |
$1,043.00
|
| Rate for Payer: Cash Price |
$2,868.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,530.55
|
| Rate for Payer: Heritage Provider Network Senior |
$3,530.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$943.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,303.75
|
| Rate for Payer: Multiplan Commercial |
$3,911.25
|
|
