|
HC MYOCARDIAL PERFUSION SINGLE
|
Facility
|
IP
|
$2,870.00
|
|
|
Service Code
|
CPT 78453
|
| Hospital Charge Code |
909301385
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$519.47 |
| Max. Negotiated Rate |
$2,152.50 |
| Rate for Payer: Adventist Health Commercial |
$574.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,971.69
|
| Rate for Payer: Cash Price |
$1,291.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,942.99
|
| Rate for Payer: Heritage Provider Network Senior |
$1,942.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$519.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$717.50
|
| Rate for Payer: Multiplan Commercial |
$2,152.50
|
|
|
HC MYOCARD INFAR/PYP
|
Facility
|
OP
|
$2,062.00
|
|
|
Service Code
|
CPT 78466
|
| Hospital Charge Code |
909301382
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$136.53 |
| Max. Negotiated Rate |
$1,546.50 |
| Rate for Payer: Adventist Health Commercial |
$412.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$323.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,416.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$772.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$566.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$515.32
|
| Rate for Payer: Blue Shield of California Commercial |
$533.43
|
| Rate for Payer: Blue Shield of California EPN |
$303.35
|
| Rate for Payer: Cash Price |
$927.90
|
| Rate for Payer: Cash Price |
$927.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,340.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$772.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$566.85
|
| Rate for Payer: Dignity Health Senior |
$515.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,340.30
|
| Rate for Payer: EPIC Health Plan Medicare |
$515.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,276.38
|
| Rate for Payer: Heritage Provider Network Senior |
$1,276.38
|
| Rate for Payer: Humana Medicare |
$515.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$136.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$515.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$979.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$373.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$608.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$515.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$649.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$649.30
|
| Rate for Payer: Multiplan Commercial |
$1,546.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$566.85
|
| Rate for Payer: TriValley Medical Group Senior |
$515.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$772.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$566.85
|
| Rate for Payer: Vantage Medical Group Senior |
$515.32
|
|
|
HC MYOCARD INFAR/PYP
|
Facility
|
IP
|
$2,062.00
|
|
|
Service Code
|
CPT 78466
|
| Hospital Charge Code |
909301382
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$373.22 |
| Max. Negotiated Rate |
$1,546.50 |
| Rate for Payer: Adventist Health Commercial |
$412.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,416.59
|
| Rate for Payer: Cash Price |
$927.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,395.97
|
| Rate for Payer: Heritage Provider Network Senior |
$1,395.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$373.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$515.50
|
| Rate for Payer: Multiplan Commercial |
$1,546.50
|
|
|
HC MYOFACIAL RELEASE SOFT TISSUE OT
|
Facility
|
OP
|
$322.00
|
|
|
Service Code
|
CPT 97250
|
| Hospital Charge Code |
905104148
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$58.28 |
| Max. Negotiated Rate |
$343.00 |
| Rate for Payer: Adventist Health Commercial |
$64.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$172.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$221.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$273.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$177.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$241.50
|
| 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 |
$144.90
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$209.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$273.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$273.70
|
| Rate for Payer: Dignity Health Senior |
$273.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$209.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$199.32
|
| Rate for Payer: Heritage Provider Network Senior |
$199.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$155.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$58.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.50
|
| Rate for Payer: Multiplan Commercial |
$241.50
|
| 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 |
$273.70
|
| Rate for Payer: Vantage Medical Group Senior |
$273.70
|
|
|
HC MYOFACIAL RELEASE SOFT TISSUE OT
|
Facility
|
IP
|
$322.00
|
|
|
Service Code
|
CPT 97250
|
| Hospital Charge Code |
905104148
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$58.28 |
| Max. Negotiated Rate |
$241.50 |
| Rate for Payer: Adventist Health Commercial |
$64.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$221.21
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$217.99
|
| Rate for Payer: Heritage Provider Network Senior |
$217.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$58.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.50
|
| Rate for Payer: Multiplan Commercial |
$241.50
|
|
|
HC MYOGLOBIN SCREEN
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
CPT 81003
|
| Hospital Charge Code |
900910387
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$18.82 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.82
|
| Rate for Payer: Blue Shield of California Commercial |
$17.55
|
| Rate for Payer: Blue Shield of California EPN |
$13.72
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.48
|
| Rate for Payer: Dignity Health Senior |
$2.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$2.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.81
|
| Rate for Payer: Heritage Provider Network Senior |
$6.81
|
| Rate for Payer: Humana Medicare |
$2.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$8.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.25
|
| Rate for Payer: TriValley Medical Group Senior |
$2.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.48
|
| Rate for Payer: Vantage Medical Group Senior |
$2.25
|
|
|
HC MYOGLOBIN SCREEN
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
CPT 81003
|
| Hospital Charge Code |
900910387
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$17.74 |
| Max. Negotiated Rate |
$73.50 |
| Rate for Payer: Adventist Health Commercial |
$19.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$67.33
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$66.35
|
| Rate for Payer: Heritage Provider Network Senior |
$66.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.50
|
| Rate for Payer: Multiplan Commercial |
$73.50
|
|
|
HC MYOGLOBIN (SERUM)
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT 83874
|
| Hospital Charge Code |
900910825
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$39.46 |
| Max. Negotiated Rate |
$163.50 |
| Rate for Payer: Adventist Health Commercial |
$43.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$149.77
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$147.59
|
| Rate for Payer: Heritage Provider Network Senior |
$147.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54.50
|
| Rate for Payer: Multiplan Commercial |
$163.50
|
|
|
HC MYOGLOBIN (SERUM)
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
CPT 83874
|
| Hospital Charge Code |
900910825
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$108.42 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$37.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$108.42
|
| Rate for Payer: Blue Shield of California Commercial |
$100.84
|
| Rate for Payer: Blue Shield of California EPN |
$78.83
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.21
|
| Rate for Payer: Dignity Health Senior |
$12.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.38
|
| Rate for Payer: Heritage Provider Network Senior |
$12.38
|
| Rate for Payer: Humana Medicare |
$12.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$17.91
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$24.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.28
|
| Rate for Payer: Multiplan Commercial |
$15.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.92
|
| Rate for Payer: TriValley Medical Group Senior |
$12.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.21
|
| Rate for Payer: Vantage Medical Group Senior |
$12.92
|
|
|
HC MYRINGOTOMY TUBE INFLATION
|
Facility
|
IP
|
$1,389.00
|
|
|
Service Code
|
CPT 69420
|
| Hospital Charge Code |
900501377
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$251.41 |
| Max. Negotiated Rate |
$1,041.75 |
| Rate for Payer: Adventist Health Commercial |
$277.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$954.24
|
| Rate for Payer: Cash Price |
$625.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$940.35
|
| Rate for Payer: Heritage Provider Network Senior |
$940.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$251.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$347.25
|
| Rate for Payer: Multiplan Commercial |
$1,041.75
|
|
|
HC MYRINGOTOMY TUBE INFLATION
|
Facility
|
OP
|
$1,389.00
|
|
|
Service Code
|
CPT 69420
|
| Hospital Charge Code |
900501377
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$251.41 |
| Max. Negotiated Rate |
$3,728.00 |
| Rate for Payer: Adventist Health Commercial |
$277.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$954.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$457.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$335.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$305.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$625.05
|
| Rate for Payer: Cash Price |
$625.05
|
| Rate for Payer: Cash Price |
$625.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$902.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$457.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$335.71
|
| Rate for Payer: Dignity Health Senior |
$305.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$902.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$305.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$940.35
|
| Rate for Payer: Heritage Provider Network Senior |
$940.35
|
| Rate for Payer: Humana Medicare |
$305.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$305.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$669.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$251.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$360.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$347.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$384.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$384.54
|
| Rate for Payer: Multiplan Commercial |
$1,041.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$504.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$464.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$457.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$335.71
|
| Rate for Payer: Vantage Medical Group Senior |
$305.19
|
|
|
HC NA (POC)
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
CPT 84295
|
| Hospital Charge Code |
900912116
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$61.50 |
| Rate for Payer: Adventist Health Commercial |
$16.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.33
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.51
|
| Rate for Payer: Heritage Provider Network Senior |
$55.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.50
|
| Rate for Payer: Multiplan Commercial |
$61.50
|
|
|
HC NA (POC)
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
CPT 84295
|
| Hospital Charge Code |
900912116
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.81 |
| Max. Negotiated Rate |
$61.50 |
| Rate for Payer: Adventist Health Commercial |
$16.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$40.12
|
| Rate for Payer: Blue Shield of California Commercial |
$37.56
|
| Rate for Payer: Blue Shield of California EPN |
$29.37
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.29
|
| Rate for Payer: Dignity Health Senior |
$4.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.30
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.76
|
| Rate for Payer: Heritage Provider Network Senior |
$50.76
|
| Rate for Payer: Humana Medicare |
$4.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.06
|
| Rate for Payer: Multiplan Commercial |
$61.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.81
|
| Rate for Payer: TriValley Medical Group Senior |
$4.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4.81
|
|
|
HC NASAL BONES
|
Facility
|
OP
|
$634.00
|
|
|
Service Code
|
CPT 70160
|
| Hospital Charge Code |
909001104
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$38.67 |
| Max. Negotiated Rate |
$475.50 |
| Rate for Payer: Adventist Health Commercial |
$126.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$54.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$435.56
|
| 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 |
$124.99
|
| 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 |
$285.30
|
| Rate for Payer: Cash Price |
$285.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$412.10
|
| 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 |
$412.10
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$392.45
|
| Rate for Payer: Heritage Provider Network Senior |
$392.45
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$38.67
|
| 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 |
$114.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$158.50
|
| 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 |
$475.50
|
| 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 |
$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 NASAL BONES
|
Facility
|
IP
|
$634.00
|
|
|
Service Code
|
CPT 70160
|
| Hospital Charge Code |
909001104
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$114.75 |
| Max. Negotiated Rate |
$475.50 |
| Rate for Payer: Adventist Health Commercial |
$126.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$435.56
|
| Rate for Payer: Cash Price |
$285.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$429.22
|
| Rate for Payer: Heritage Provider Network Senior |
$429.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$114.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$158.50
|
| Rate for Payer: Multiplan Commercial |
$475.50
|
|
|
HC NASAL ENDOSCOPY DIAGNOSTIC
|
Facility
|
IP
|
$487.00
|
|
|
Service Code
|
CPT 31231
|
| Hospital Charge Code |
900501401
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$88.15 |
| Max. Negotiated Rate |
$365.25 |
| Rate for Payer: Adventist Health Commercial |
$97.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$334.57
|
| Rate for Payer: Cash Price |
$219.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$329.70
|
| Rate for Payer: Heritage Provider Network Senior |
$329.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$88.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$121.75
|
| Rate for Payer: Multiplan Commercial |
$365.25
|
|
|
HC NASAL ENDOSCOPY DIAGNOSTIC
|
Facility
|
OP
|
$487.00
|
|
|
Service Code
|
CPT 31231
|
| Hospital Charge Code |
900501401
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$88.15 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$97.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$334.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$371.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$272.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$247.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$219.15
|
| Rate for Payer: Cash Price |
$219.15
|
| Rate for Payer: Cash Price |
$219.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$316.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$371.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$272.24
|
| Rate for Payer: Dignity Health Senior |
$247.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$247.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$329.70
|
| Rate for Payer: Heritage Provider Network Senior |
$329.70
|
| Rate for Payer: Humana Medicare |
$247.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$247.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$234.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$88.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$292.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$121.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$311.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$311.84
|
| Rate for Payer: Multiplan Commercial |
$365.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$176.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$162.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$371.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$272.24
|
| Rate for Payer: Vantage Medical Group Senior |
$247.49
|
|
|
HC NASAL ENDOSCOPY W/CONT HEMORRH
|
Facility
|
OP
|
$4,043.00
|
|
|
Service Code
|
CPT 31238
|
| Hospital Charge Code |
900501753
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$731.78 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$808.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,777.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,180.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,332.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,120.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$1,819.35
|
| Rate for Payer: Cash Price |
$1,819.35
|
| Rate for Payer: Cash Price |
$1,819.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,627.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,180.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,332.68
|
| Rate for Payer: Dignity Health Senior |
$2,120.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,120.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,737.11
|
| Rate for Payer: Heritage Provider Network Senior |
$2,737.11
|
| Rate for Payer: Humana Medicare |
$2,120.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,120.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,948.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$731.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,502.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,010.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,671.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,671.98
|
| Rate for Payer: Multiplan Commercial |
$3,032.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,468.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,350.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,180.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,332.68
|
| Rate for Payer: Vantage Medical Group Senior |
$2,120.62
|
|
|
HC NASAL ENDOSCOPY W/CONT HEMORRH
|
Facility
|
IP
|
$4,043.00
|
|
|
Service Code
|
CPT 31238
|
| Hospital Charge Code |
900501753
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$731.78 |
| Max. Negotiated Rate |
$3,032.25 |
| Rate for Payer: Adventist Health Commercial |
$808.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,777.54
|
| Rate for Payer: Cash Price |
$1,819.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,737.11
|
| Rate for Payer: Heritage Provider Network Senior |
$2,737.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$731.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,010.75
|
| Rate for Payer: Multiplan Commercial |
$3,032.25
|
|
|
HC NASAL I&D OF ABSCESS
|
Facility
|
OP
|
$1,408.00
|
|
|
Service Code
|
CPT 30000
|
| Hospital Charge Code |
902890339
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$254.85 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$281.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$967.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$457.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$335.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$305.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$633.60
|
| Rate for Payer: Cash Price |
$633.60
|
| Rate for Payer: Cash Price |
$633.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$915.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$457.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$335.71
|
| Rate for Payer: Dignity Health Senior |
$305.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$305.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$953.22
|
| Rate for Payer: Heritage Provider Network Senior |
$953.22
|
| Rate for Payer: Humana Medicare |
$305.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$305.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$678.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$254.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$360.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$352.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$384.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$384.54
|
| Rate for Payer: Multiplan Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$511.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$470.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$457.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$335.71
|
| Rate for Payer: Vantage Medical Group Senior |
$305.19
|
|
|
HC NASAL I&D OF ABSCESS
|
Facility
|
IP
|
$1,408.00
|
|
|
Service Code
|
CPT 30000
|
| Hospital Charge Code |
902890339
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$254.85 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Adventist Health Commercial |
$281.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$967.30
|
| Rate for Payer: Cash Price |
$633.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$953.22
|
| Rate for Payer: Heritage Provider Network Senior |
$953.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$254.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$352.00
|
| Rate for Payer: Multiplan Commercial |
$1,056.00
|
|
|
HC NASO/ORGSTRC TUBE PLCM FS GDNC
|
Facility
|
IP
|
$414.00
|
|
|
Service Code
|
CPT 43752
|
| Hospital Charge Code |
906743752
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$74.93 |
| Max. Negotiated Rate |
$310.50 |
| Rate for Payer: Adventist Health Commercial |
$82.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$284.42
|
| Rate for Payer: Cash Price |
$186.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$280.28
|
| Rate for Payer: Heritage Provider Network Senior |
$280.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$74.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$103.50
|
| Rate for Payer: Multiplan Commercial |
$310.50
|
|
|
HC NASO/ORGSTRC TUBE PLCM FS GDNC
|
Facility
|
OP
|
$414.00
|
|
|
Service Code
|
CPT 43752
|
| Hospital Charge Code |
906743752
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$74.93 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$82.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$284.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$746.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$547.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$497.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$186.30
|
| Rate for Payer: Cash Price |
$186.30
|
| Rate for Payer: Cash Price |
$186.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$269.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$746.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$547.60
|
| Rate for Payer: Dignity Health Senior |
$497.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$497.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$280.28
|
| Rate for Payer: Heritage Provider Network Senior |
$280.28
|
| Rate for Payer: Humana Medicare |
$497.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$497.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$199.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$74.93
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$587.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$103.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$627.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$627.25
|
| Rate for Payer: Multiplan Commercial |
$310.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$150.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$138.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$746.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$547.60
|
| Rate for Payer: Vantage Medical Group Senior |
$497.82
|
|
|
HC NASO/ORGSTRC TUBE PLCM FS GDNC
|
Facility
|
IP
|
$414.00
|
|
|
Service Code
|
CPT 43752
|
| Hospital Charge Code |
906743752
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$74.93 |
| Max. Negotiated Rate |
$310.50 |
| Rate for Payer: Adventist Health Commercial |
$82.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$284.42
|
| Rate for Payer: Cash Price |
$186.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$280.28
|
| Rate for Payer: Heritage Provider Network Senior |
$280.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$74.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$103.50
|
| Rate for Payer: Multiplan Commercial |
$310.50
|
|
|
HC NASO/ORGSTRC TUBE PLCM FS GDNC
|
Facility
|
OP
|
$414.00
|
|
|
Service Code
|
CPT 43752
|
| Hospital Charge Code |
906743752
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$74.93 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$82.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$284.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$746.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$547.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$497.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,086.22
|
| Rate for Payer: Blue Shield of California EPN |
$933.56
|
| Rate for Payer: Cash Price |
$186.30
|
| Rate for Payer: Cash Price |
$186.30
|
| Rate for Payer: Cash Price |
$186.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$269.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$746.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$547.60
|
| Rate for Payer: Dignity Health Senior |
$497.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$497.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$256.27
|
| Rate for Payer: Heritage Provider Network Senior |
$612.32
|
| Rate for Payer: Humana Medicare |
$497.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$202.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$497.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$945.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$74.93
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$587.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$103.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$627.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$627.25
|
| Rate for Payer: Multiplan Commercial |
$310.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$425.00
|
| Rate for Payer: TriValley Medical Group Senior |
$425.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,040.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$874.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$746.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$547.60
|
| Rate for Payer: Vantage Medical Group Senior |
$497.82
|
|
