|
HC PET MYOCARDIAL PERF MULTI FLW
|
Facility
|
OP
|
$4,826.00
|
|
|
Service Code
|
CPT 78492
|
| Hospital Charge Code |
909301613
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$687.14 |
| Max. Negotiated Rate |
$3,713.89 |
| Rate for Payer: Adventist Health Commercial |
$965.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,648.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,315.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,932.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,150.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,954.68
|
| Rate for Payer: Blue Shield of California Commercial |
$1,208.34
|
| Rate for Payer: Blue Shield of California EPN |
$687.14
|
| Rate for Payer: Cash Price |
$2,171.70
|
| Rate for Payer: Cash Price |
$2,171.70
|
| Rate for Payer: Cash Price |
$2,171.70
|
| Rate for Payer: Cash Price |
$2,171.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,100.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,932.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,150.15
|
| Rate for Payer: Dignity Health Senior |
$1,954.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,169.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,954.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,465.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1,332.00
|
| Rate for Payer: Humana Medicare |
$1,954.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,954.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,713.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$873.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,306.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,206.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,462.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,462.90
|
| Rate for Payer: Multiplan Commercial |
$3,619.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$1,100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,659.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,659.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,932.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,150.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1,954.68
|
|
|
HC PET MYOCARDIAL PERF MULTI FLW
|
Facility
|
IP
|
$4,826.00
|
|
|
Service Code
|
CPT 78492
|
| Hospital Charge Code |
909301613
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$873.51 |
| Max. Negotiated Rate |
$3,619.50 |
| Rate for Payer: Adventist Health Commercial |
$965.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,315.46
|
| Rate for Payer: Cash Price |
$2,171.70
|
| Rate for Payer: Cash Price |
$2,171.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,513.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,267.20
|
| Rate for Payer: Heritage Provider Network Senior |
$3,267.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$873.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,206.50
|
| Rate for Payer: Multiplan Commercial |
$3,619.50
|
|
|
HC PET MYOCARDIAL PERF SGL FLW
|
Facility
|
OP
|
$4,192.00
|
|
|
Service Code
|
CPT 78491
|
| Hospital Charge Code |
909301602
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$551.89 |
| Max. Negotiated Rate |
$3,713.89 |
| Rate for Payer: Adventist Health Commercial |
$838.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,648.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,879.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,932.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,150.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,954.68
|
| Rate for Payer: Blue Shield of California Commercial |
$970.49
|
| Rate for Payer: Blue Shield of California EPN |
$551.89
|
| Rate for Payer: Cash Price |
$1,886.40
|
| Rate for Payer: Cash Price |
$1,886.40
|
| Rate for Payer: Cash Price |
$1,886.40
|
| Rate for Payer: Cash Price |
$1,886.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,100.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,932.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,150.15
|
| Rate for Payer: Dignity Health Senior |
$1,954.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,169.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,954.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,465.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1,332.00
|
| Rate for Payer: Humana Medicare |
$1,954.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,954.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,713.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$758.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,306.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,048.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,462.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,462.90
|
| Rate for Payer: Multiplan Commercial |
$3,144.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$1,100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,659.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,659.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,932.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,150.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1,954.68
|
|
|
HC PET MYOCARDIAL PERF SGL FLW
|
Facility
|
IP
|
$4,192.00
|
|
|
Service Code
|
CPT 78491
|
| Hospital Charge Code |
909301602
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$758.75 |
| Max. Negotiated Rate |
$3,144.00 |
| Rate for Payer: Adventist Health Commercial |
$838.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,879.90
|
| Rate for Payer: Cash Price |
$1,886.40
|
| Rate for Payer: Cash Price |
$1,886.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,513.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,837.98
|
| Rate for Payer: Heritage Provider Network Senior |
$2,837.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$758.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,048.00
|
| Rate for Payer: Multiplan Commercial |
$3,144.00
|
|
|
HC PET SCAN/GAMMA LYMPHOMA
|
Facility
|
OP
|
$13,049.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
909301467
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,954.68 |
| Max. Negotiated Rate |
$9,786.75 |
| Rate for Payer: Adventist Health Commercial |
$2,609.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,648.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8,964.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,932.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,150.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,954.68
|
| Rate for Payer: Blue Shield of California Commercial |
$8,074.57
|
| Rate for Payer: Blue Shield of California EPN |
$4,591.76
|
| Rate for Payer: Cash Price |
$5,872.05
|
| Rate for Payer: Cash Price |
$5,872.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8,481.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,932.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,150.15
|
| Rate for Payer: Dignity Health Senior |
$1,954.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,481.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,954.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$8,077.33
|
| Rate for Payer: Heritage Provider Network Senior |
$8,077.33
|
| Rate for Payer: Humana Medicare |
$1,954.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,318.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,954.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,713.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,361.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,306.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,262.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,462.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,462.90
|
| Rate for Payer: Multiplan Commercial |
$9,786.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,150.15
|
| Rate for Payer: TriValley Medical Group Senior |
$1,954.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,932.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,150.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1,954.68
|
|
|
HC PET SCAN/GAMMA LYMPHOMA
|
Facility
|
IP
|
$13,049.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
909301467
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$2,361.87 |
| Max. Negotiated Rate |
$9,786.75 |
| Rate for Payer: Adventist Health Commercial |
$2,609.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8,964.66
|
| Rate for Payer: Cash Price |
$5,872.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$8,834.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8,834.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,361.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,262.25
|
| Rate for Payer: Multiplan Commercial |
$9,786.75
|
|
|
HC PET SCAN SKULL BASE TO MID THIGH
|
Facility
|
IP
|
$6,939.00
|
|
|
Service Code
|
CPT 78812
|
| Hospital Charge Code |
909301481
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,255.96 |
| Max. Negotiated Rate |
$5,204.25 |
| Rate for Payer: Adventist Health Commercial |
$1,387.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,767.09
|
| Rate for Payer: Cash Price |
$3,122.55
|
| Rate for Payer: Cash Price |
$3,122.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,513.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,697.70
|
| Rate for Payer: Heritage Provider Network Senior |
$4,697.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,255.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,734.75
|
| Rate for Payer: Multiplan Commercial |
$5,204.25
|
|
|
HC PET SCAN SKULL BASE TO MID THIGH
|
Facility
|
OP
|
$6,939.00
|
|
|
Service Code
|
CPT 78812
|
| Hospital Charge Code |
909301481
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,100.00 |
| Max. Negotiated Rate |
$7,600.79 |
| Rate for Payer: Adventist Health Commercial |
$1,387.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,648.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,767.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,932.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,150.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,954.68
|
| Rate for Payer: Blue Shield of California Commercial |
$7,600.79
|
| Rate for Payer: Blue Shield of California EPN |
$4,322.34
|
| Rate for Payer: Cash Price |
$3,122.55
|
| Rate for Payer: Cash Price |
$3,122.55
|
| Rate for Payer: Cash Price |
$3,122.55
|
| Rate for Payer: Cash Price |
$3,122.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,100.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,932.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,150.15
|
| Rate for Payer: Dignity Health Senior |
$1,954.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,169.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,954.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,465.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1,332.00
|
| Rate for Payer: Humana Medicare |
$1,954.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,162.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,954.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,713.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,255.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,306.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,734.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,462.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,462.90
|
| Rate for Payer: Multiplan Commercial |
$5,204.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$1,100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,659.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,659.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,932.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,150.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1,954.68
|
|
|
HC PET SCAN WHOLE BODY
|
Facility
|
IP
|
$9,275.00
|
|
|
Service Code
|
CPT 78813
|
| Hospital Charge Code |
909301482
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,678.78 |
| Max. Negotiated Rate |
$6,956.25 |
| Rate for Payer: Adventist Health Commercial |
$1,855.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,371.92
|
| Rate for Payer: Cash Price |
$4,173.75
|
| Rate for Payer: Cash Price |
$4,173.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,513.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,279.18
|
| Rate for Payer: Heritage Provider Network Senior |
$6,279.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,678.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,318.75
|
| Rate for Payer: Multiplan Commercial |
$6,956.25
|
|
|
HC PET SCAN WHOLE BODY
|
Facility
|
OP
|
$9,275.00
|
|
|
Service Code
|
CPT 78813
|
| Hospital Charge Code |
909301482
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,100.00 |
| Max. Negotiated Rate |
$8,074.57 |
| Rate for Payer: Adventist Health Commercial |
$1,855.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,648.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,371.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,932.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,150.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,954.68
|
| Rate for Payer: Blue Shield of California Commercial |
$8,074.57
|
| Rate for Payer: Blue Shield of California EPN |
$4,591.76
|
| Rate for Payer: Cash Price |
$4,173.75
|
| Rate for Payer: Cash Price |
$4,173.75
|
| Rate for Payer: Cash Price |
$4,173.75
|
| Rate for Payer: Cash Price |
$4,173.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,100.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,932.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,150.15
|
| Rate for Payer: Dignity Health Senior |
$1,954.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,169.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,954.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,465.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1,332.00
|
| Rate for Payer: Humana Medicare |
$1,954.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,162.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,954.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,713.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,678.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,306.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,318.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,462.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,462.90
|
| Rate for Payer: Multiplan Commercial |
$6,956.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$1,100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,659.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,659.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,932.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,150.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1,954.68
|
|
|
HC PET TUMOR LIMITED
|
Facility
|
IP
|
$7,019.00
|
|
|
Service Code
|
CPT 78811
|
| Hospital Charge Code |
909301480
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,270.44 |
| Max. Negotiated Rate |
$5,264.25 |
| Rate for Payer: Adventist Health Commercial |
$1,403.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,822.05
|
| Rate for Payer: Cash Price |
$3,158.55
|
| Rate for Payer: Cash Price |
$3,158.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,513.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,751.86
|
| Rate for Payer: Heritage Provider Network Senior |
$4,751.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,270.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,754.75
|
| Rate for Payer: Multiplan Commercial |
$5,264.25
|
|
|
HC PET TUMOR LIMITED
|
Facility
|
OP
|
$7,019.00
|
|
|
Service Code
|
CPT 78811
|
| Hospital Charge Code |
909301480
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,100.00 |
| Max. Negotiated Rate |
$7,123.70 |
| Rate for Payer: Adventist Health Commercial |
$1,403.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,648.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,822.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,661.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,951.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,774.15
|
| Rate for Payer: Blue Shield of California Commercial |
$7,123.70
|
| Rate for Payer: Blue Shield of California EPN |
$4,051.03
|
| Rate for Payer: Cash Price |
$3,158.55
|
| Rate for Payer: Cash Price |
$3,158.55
|
| Rate for Payer: Cash Price |
$3,158.55
|
| Rate for Payer: Cash Price |
$3,158.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,100.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,661.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,951.56
|
| Rate for Payer: Dignity Health Senior |
$1,774.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,169.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,774.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,465.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1,332.00
|
| Rate for Payer: Humana Medicare |
$1,774.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,162.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,774.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,370.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,270.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,093.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,754.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,235.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,235.43
|
| Rate for Payer: Multiplan Commercial |
$5,264.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$1,100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,659.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,659.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,661.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,951.56
|
| Rate for Payer: Vantage Medical Group Senior |
$1,774.15
|
|
|
HC PHARMACOLOGIC AGENT ADMIN
|
Facility
|
IP
|
$1,808.00
|
|
|
Service Code
|
CPT 93463
|
| Hospital Charge Code |
906811410
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$327.25 |
| Max. Negotiated Rate |
$5,478.00 |
| Rate for Payer: Adventist Health Commercial |
$361.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,242.10
|
| Rate for Payer: Cash Price |
$813.60
|
| Rate for Payer: Cash Price |
$813.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,478.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,982.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$327.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$452.00
|
| Rate for Payer: Multiplan Commercial |
$1,356.00
|
|
|
HC PHARMACOLOGIC AGENT ADMIN
|
Facility
|
OP
|
$1,808.00
|
|
|
Service Code
|
CPT 93463
|
| Hospital Charge Code |
906811410
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$8,689.75 |
| Rate for Payer: Adventist Health Commercial |
$361.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$235.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,242.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,536.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$994.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,356.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,689.75
|
| Rate for Payer: Blue Shield of California EPN |
$7,468.44
|
| Rate for Payer: Cash Price |
$813.60
|
| Rate for Payer: Cash Price |
$813.60
|
| Rate for Payer: Cash Price |
$813.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,340.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,536.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,536.80
|
| Rate for Payer: Dignity Health Senior |
$1,536.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,175.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,119.15
|
| Rate for Payer: Heritage Provider Network Senior |
$1,119.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$137.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$871.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$327.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$452.00
|
| Rate for Payer: Multiplan Commercial |
$1,356.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,040.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$874.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,536.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1,536.80
|
|
|
HC PHARMACOLOGIC AGENT ADMIN
|
Facility
|
IP
|
$2,595.00
|
|
|
Service Code
|
CPT 93463
|
| Hospital Charge Code |
906820068
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$469.70 |
| Max. Negotiated Rate |
$5,478.00 |
| Rate for Payer: Adventist Health Commercial |
$519.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,782.76
|
| Rate for Payer: Cash Price |
$1,167.75
|
| Rate for Payer: Cash Price |
$1,167.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,478.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,982.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$469.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$648.75
|
| Rate for Payer: Multiplan Commercial |
$1,946.25
|
|
|
HC PHARMACOLOGIC AGENT ADMIN
|
Facility
|
OP
|
$2,595.00
|
|
|
Service Code
|
CPT 93463
|
| Hospital Charge Code |
906820068
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$8,689.75 |
| Rate for Payer: Adventist Health Commercial |
$519.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$235.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,782.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,205.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,427.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,946.25
|
| Rate for Payer: Blue Shield of California Commercial |
$8,689.75
|
| Rate for Payer: Blue Shield of California EPN |
$7,468.44
|
| Rate for Payer: Cash Price |
$1,167.75
|
| Rate for Payer: Cash Price |
$1,167.75
|
| Rate for Payer: Cash Price |
$1,167.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,340.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,205.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,205.75
|
| Rate for Payer: Dignity Health Senior |
$2,205.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,686.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,606.30
|
| Rate for Payer: Heritage Provider Network Senior |
$1,606.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$137.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,250.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$469.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$648.75
|
| Rate for Payer: Multiplan Commercial |
$1,946.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,040.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$874.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,205.75
|
| Rate for Payer: Vantage Medical Group Senior |
$2,205.75
|
|
|
HC PHARM-CHLORIDE IV SOLUTION
|
Facility
|
IP
|
$17.00
|
|
| Hospital Charge Code |
900912107
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$12.75 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.68
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.51
|
| Rate for Payer: Heritage Provider Network Senior |
$11.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| Rate for Payer: Multiplan Commercial |
$12.75
|
|
|
HC PHARM-CHLORIDE IV SOLUTION
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
900912107
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.00
|
| Rate for Payer: Blue Shield of California Commercial |
$12.42
|
| Rate for Payer: Blue Shield of California EPN |
$11.74
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.00
|
| Rate for Payer: Dignity Health Senior |
$17.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.38
|
| Rate for Payer: Heritage Provider Network Senior |
$12.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$15.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.00
|
| Rate for Payer: Vantage Medical Group Senior |
$17.00
|
|
|
HC PHARM-GLUCOSE IV SOLUTION
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
CPT 81099
|
| Hospital Charge Code |
900912109
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$14.45 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.75
|
| Rate for Payer: Blue Shield of California Commercial |
$10.56
|
| Rate for Payer: Blue Shield of California EPN |
$9.98
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.45
|
| Rate for Payer: Dignity Health Senior |
$14.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Senior |
$10.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| Rate for Payer: Multiplan Commercial |
$12.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.45
|
| Rate for Payer: Vantage Medical Group Senior |
$14.45
|
|
|
HC PHARM-GLUCOSE IV SOLUTION
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
CPT 81099
|
| Hospital Charge Code |
900912109
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.49
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.25
|
| Rate for Payer: Heritage Provider Network Senior |
$16.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
|
|
HC PHARM-PHOSPHORUS IV SOLUTION
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
900912108
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.00
|
| Rate for Payer: Blue Shield of California Commercial |
$12.42
|
| Rate for Payer: Blue Shield of California EPN |
$11.74
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.00
|
| Rate for Payer: Dignity Health Senior |
$17.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.38
|
| Rate for Payer: Heritage Provider Network Senior |
$12.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$15.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.00
|
| Rate for Payer: Vantage Medical Group Senior |
$17.00
|
|
|
HC PHARM-PHOSPHORUS IV SOLUTION
|
Facility
|
IP
|
$17.00
|
|
| Hospital Charge Code |
900912108
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$12.75 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.68
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.51
|
| Rate for Payer: Heritage Provider Network Senior |
$11.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| Rate for Payer: Multiplan Commercial |
$12.75
|
|
|
HC PHARM-POTASSIUM IV SOLUTION
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
900912106
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.00
|
| Rate for Payer: Blue Shield of California Commercial |
$12.42
|
| Rate for Payer: Blue Shield of California EPN |
$11.74
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.00
|
| Rate for Payer: Dignity Health Senior |
$17.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.38
|
| Rate for Payer: Heritage Provider Network Senior |
$12.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$15.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.00
|
| Rate for Payer: Vantage Medical Group Senior |
$17.00
|
|
|
HC PHARM-POTASSIUM IV SOLUTION
|
Facility
|
IP
|
$17.00
|
|
| Hospital Charge Code |
900912106
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$12.75 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.68
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.51
|
| Rate for Payer: Heritage Provider Network Senior |
$11.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| Rate for Payer: Multiplan Commercial |
$12.75
|
|
|
HC PHARM-SODIUM IV SOLUTION
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
900912105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.00
|
| Rate for Payer: Blue Shield of California Commercial |
$12.42
|
| Rate for Payer: Blue Shield of California EPN |
$11.74
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.00
|
| Rate for Payer: Dignity Health Senior |
$17.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.38
|
| Rate for Payer: Heritage Provider Network Senior |
$12.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$15.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.00
|
| Rate for Payer: Vantage Medical Group Senior |
$17.00
|
|
