|
HC HSV 1&2 PCR
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
CPT 87529
|
| Hospital Charge Code |
900912307
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$15.20 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$54.10
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$56.87
|
| Rate for Payer: Heritage Provider Network Senior |
$56.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
|
|
HC HSV 1&2 PCR
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
CPT 87529
|
| Hospital Charge Code |
900912307
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$15.20 |
| Max. Negotiated Rate |
$322.42 |
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Adventist Health Commercial |
$14.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$43.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$52.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$52.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$322.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$322.42
|
| Rate for Payer: Blue Shield of California Commercial |
$282.47
|
| Rate for Payer: Blue Shield of California Commercial |
$282.47
|
| Rate for Payer: Blue Shield of California EPN |
$226.56
|
| Rate for Payer: Blue Shield of California EPN |
$226.56
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$31.95
|
| Rate for Payer: Cash Price |
$31.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$46.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$35.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$35.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$49.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.89
|
| Rate for Payer: EPIC Health Plan Medicare |
$35.09
|
| Rate for Payer: EPIC Health Plan Medicare |
$35.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$43.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.00
|
| Rate for Payer: Heritage Provider Network Senior |
$43.95
|
| Rate for Payer: Heritage Provider Network Senior |
$52.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$33.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$40.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$40.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$40.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$47.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$47.02
|
| Rate for Payer: Multiplan Commercial |
$53.25
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$35.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$35.09
|
| Rate for Payer: TriValley Medical Group Senior |
$35.09
|
| Rate for Payer: TriValley Medical Group Senior |
$35.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$37.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$37.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$52.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$52.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Vantage Medical Group Senior |
$35.09
|
| Rate for Payer: Vantage Medical Group Senior |
$35.09
|
|
|
HC HSV1ABG
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
CPT 86695
|
| Hospital Charge Code |
900913705
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$125.22 |
| Rate for Payer: Adventist Health Commercial |
$3.20
|
| Rate for Payer: Adventist Health Commercial |
$2.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$125.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$125.22
|
| Rate for Payer: Blue Shield of California Commercial |
$106.16
|
| Rate for Payer: Blue Shield of California Commercial |
$106.16
|
| Rate for Payer: Blue Shield of California EPN |
$85.15
|
| Rate for Payer: Blue Shield of California EPN |
$85.15
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.26
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.19
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.90
|
| Rate for Payer: Heritage Provider Network Senior |
$8.67
|
| Rate for Payer: Heritage Provider Network Senior |
$9.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17.67
|
| Rate for Payer: Multiplan Commercial |
$10.50
|
| Rate for Payer: Multiplan Commercial |
$12.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.19
|
| Rate for Payer: TriValley Medical Group Senior |
$13.19
|
| Rate for Payer: TriValley Medical Group Senior |
$13.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.51
|
| Rate for Payer: Vantage Medical Group Senior |
$13.19
|
| Rate for Payer: Vantage Medical Group Senior |
$13.19
|
|
|
HC HSV1ABG
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
CPT 86695
|
| Hospital Charge Code |
900913705
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Adventist Health Commercial |
$3.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.30
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.83
|
| Rate for Payer: Heritage Provider Network Senior |
$10.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.00
|
| Rate for Payer: Multiplan Commercial |
$12.00
|
|
|
HC HSV 1 IGG
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
CPT 86695
|
| Hospital Charge Code |
900913540
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$42.53 |
| Max. Negotiated Rate |
$176.25 |
| Rate for Payer: Adventist Health Commercial |
$47.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$151.34
|
| Rate for Payer: Cash Price |
$105.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$159.09
|
| Rate for Payer: Heritage Provider Network Senior |
$159.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$42.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.75
|
| Rate for Payer: Multiplan Commercial |
$176.25
|
|
|
HC HSV 1 IGG
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
CPT 86695
|
| Hospital Charge Code |
900913540
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$13.19 |
| Max. Negotiated Rate |
$176.25 |
| Rate for Payer: Adventist Health Commercial |
$47.00
|
| Rate for Payer: Adventist Health Commercial |
$23.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$71.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$145.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$125.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$125.22
|
| Rate for Payer: Blue Shield of California Commercial |
$106.16
|
| Rate for Payer: Blue Shield of California Commercial |
$106.16
|
| Rate for Payer: Blue Shield of California EPN |
$85.15
|
| Rate for Payer: Blue Shield of California EPN |
$85.15
|
| Rate for Payer: Cash Price |
$105.75
|
| Rate for Payer: Cash Price |
$105.75
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$75.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$152.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$138.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.44
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.19
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$145.47
|
| Rate for Payer: Heritage Provider Network Senior |
$71.80
|
| Rate for Payer: Heritage Provider Network Senior |
$145.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$55.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$112.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$42.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17.67
|
| Rate for Payer: Multiplan Commercial |
$87.00
|
| Rate for Payer: Multiplan Commercial |
$176.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.19
|
| Rate for Payer: TriValley Medical Group Senior |
$13.19
|
| Rate for Payer: TriValley Medical Group Senior |
$13.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.51
|
| Rate for Payer: Vantage Medical Group Senior |
$13.19
|
| Rate for Payer: Vantage Medical Group Senior |
$13.19
|
|
|
HC HSV2ABG
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
CPT 86696
|
| Hospital Charge Code |
900913706
|
|
Hospital Revenue Code
|
302
|
| 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 |
$15.46
|
| 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 Foundation Hospitals Medi-Cal |
$4.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
|
|
HC HSV2ABG
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
CPT 86696
|
| Hospital Charge Code |
900913706
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$183.65 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$183.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$183.65
|
| Rate for Payer: Blue Shield of California Commercial |
$155.81
|
| Rate for Payer: Blue Shield of California Commercial |
$155.81
|
| Rate for Payer: Blue Shield of California EPN |
$124.97
|
| Rate for Payer: Blue Shield of California EPN |
$124.97
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| 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: Cigna of CA HMO/PPO |
$15.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$19.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$19.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$19.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$19.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.86
|
| Rate for Payer: Heritage Provider Network Senior |
$12.38
|
| Rate for Payer: Heritage Provider Network Senior |
$14.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$9.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.93
|
| Rate for Payer: Multiplan Commercial |
$15.00
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.35
|
| Rate for Payer: TriValley Medical Group Senior |
$19.35
|
| Rate for Payer: TriValley Medical Group Senior |
$19.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.29
|
| Rate for Payer: Vantage Medical Group Senior |
$19.35
|
| Rate for Payer: Vantage Medical Group Senior |
$19.35
|
|
|
HC HSV 2 IGG
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
CPT 86696
|
| Hospital Charge Code |
900913541
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$42.53 |
| Max. Negotiated Rate |
$176.25 |
| Rate for Payer: Adventist Health Commercial |
$47.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$151.34
|
| Rate for Payer: Cash Price |
$105.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$159.09
|
| Rate for Payer: Heritage Provider Network Senior |
$159.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$42.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.75
|
| Rate for Payer: Multiplan Commercial |
$176.25
|
|
|
HC HSV 2 IGG
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
CPT 86696
|
| Hospital Charge Code |
900913541
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$19.35 |
| Max. Negotiated Rate |
$183.65 |
| Rate for Payer: Adventist Health Commercial |
$47.00
|
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$145.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$183.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$183.65
|
| Rate for Payer: Blue Shield of California Commercial |
$155.81
|
| Rate for Payer: Blue Shield of California Commercial |
$155.81
|
| Rate for Payer: Blue Shield of California EPN |
$124.97
|
| Rate for Payer: Blue Shield of California EPN |
$124.97
|
| Rate for Payer: Cash Price |
$105.75
|
| Rate for Payer: Cash Price |
$105.75
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$78.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$152.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$19.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$19.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$138.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$70.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$19.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$19.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$74.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$145.47
|
| Rate for Payer: Heritage Provider Network Senior |
$74.28
|
| Rate for Payer: Heritage Provider Network Senior |
$145.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$57.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$112.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$42.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.93
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$176.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.35
|
| Rate for Payer: TriValley Medical Group Senior |
$19.35
|
| Rate for Payer: TriValley Medical Group Senior |
$19.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.29
|
| Rate for Payer: Vantage Medical Group Senior |
$19.35
|
| Rate for Payer: Vantage Medical Group Senior |
$19.35
|
|
|
HC HUMERUS
|
Facility
|
IP
|
$549.00
|
|
|
Service Code
|
CPT 73060
|
| Hospital Charge Code |
909001508
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$99.37 |
| Max. Negotiated Rate |
$411.75 |
| Rate for Payer: Adventist Health Commercial |
$109.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$353.56
|
| Rate for Payer: Cash Price |
$247.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$371.67
|
| Rate for Payer: Heritage Provider Network Senior |
$371.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$99.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.25
|
| Rate for Payer: Multiplan Commercial |
$411.75
|
|
|
HC HUMERUS
|
Facility
|
OP
|
$549.00
|
|
|
Service Code
|
CPT 73060
|
| Hospital Charge Code |
909001508
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$71.68 |
| Max. Negotiated Rate |
$411.75 |
| Rate for Payer: Adventist Health Commercial |
$109.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$339.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$167.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$123.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$111.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$154.95
|
| Rate for Payer: Blue Shield of California Commercial |
$120.91
|
| Rate for Payer: Blue Shield of California EPN |
$97.23
|
| Rate for Payer: Cash Price |
$247.05
|
| Rate for Payer: Cash Price |
$247.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$356.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$167.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$123.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$111.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$323.91
|
| Rate for Payer: EPIC Health Plan Medicare |
$111.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$339.83
|
| Rate for Payer: Heritage Provider Network Senior |
$339.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$111.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$261.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$99.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$128.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$149.99
|
| Rate for Payer: Multiplan Commercial |
$411.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$111.93
|
| Rate for Payer: TriValley Medical Group Senior |
$111.93
|
| 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 |
$167.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$123.12
|
| Rate for Payer: Vantage Medical Group Senior |
$111.93
|
|
|
HC HYDRATION INFUSION EA ADDL HR
|
Facility
|
IP
|
$124.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
910196361
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$22.44 |
| Max. Negotiated Rate |
$93.00 |
| Rate for Payer: Adventist Health Commercial |
$24.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$79.86
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$83.95
|
| Rate for Payer: Heritage Provider Network Senior |
$83.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$22.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.00
|
| Rate for Payer: Multiplan Commercial |
$93.00
|
|
|
HC HYDRATION INFUSION EA ADDL HR
|
Facility
|
OP
|
$124.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
910196361
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$22.44 |
| Max. Negotiated Rate |
$1,992.00 |
| Rate for Payer: Adventist Health Commercial |
$24.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$60.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,992.00
|
| Rate for Payer: Blue Shield of California Commercial |
$58.90
|
| Rate for Payer: Blue Shield of California EPN |
$46.87
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$80.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$90.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$66.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$60.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$60.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$83.95
|
| Rate for Payer: Heritage Provider Network Senior |
$83.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$60.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$59.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$22.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$69.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$80.71
|
| Rate for Payer: Multiplan Commercial |
$93.00
|
| Rate for Payer: Multiplan WC |
$93.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$74.40
|
| Rate for Payer: TriValley Medical Group Senior |
$74.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$90.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$66.25
|
| Rate for Payer: Vantage Medical Group Senior |
$60.23
|
|
|
HC HYDRATION INFUSION EA ADDL HR
|
Facility
|
IP
|
$124.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
910196361
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$22.44 |
| Max. Negotiated Rate |
$93.00 |
| Rate for Payer: Adventist Health Commercial |
$24.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$79.86
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$83.95
|
| Rate for Payer: Heritage Provider Network Senior |
$83.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$22.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.00
|
| Rate for Payer: Multiplan Commercial |
$93.00
|
|
|
HC HYDRATION INFUSION EA ADDL HR
|
Facility
|
OP
|
$124.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
910196361
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$22.44 |
| Max. Negotiated Rate |
$638.00 |
| Rate for Payer: Adventist Health Commercial |
$24.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$60.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$62.02
|
| Rate for Payer: Blue Shield of California Commercial |
$638.00
|
| Rate for Payer: Blue Shield of California EPN |
$512.00
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$80.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$90.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$66.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$60.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.16
|
| Rate for Payer: EPIC Health Plan Medicare |
$60.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$76.76
|
| Rate for Payer: Heritage Provider Network Senior |
$76.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$60.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$59.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$22.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$69.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$80.71
|
| Rate for Payer: Multiplan Commercial |
$93.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$66.25
|
| Rate for Payer: TriValley Medical Group Senior |
$60.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$626.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$526.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$90.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$66.25
|
| Rate for Payer: Vantage Medical Group Senior |
$60.23
|
|
|
HC HYDRATION INFUSION INITIAL 31-90MIN
|
Facility
|
OP
|
$733.00
|
|
|
Service Code
|
CPT 96360
|
| Hospital Charge Code |
910196360
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$132.67 |
| Max. Negotiated Rate |
$1,992.00 |
| Rate for Payer: Adventist Health Commercial |
$146.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$452.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$410.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$300.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$273.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,992.00
|
| Rate for Payer: Blue Shield of California Commercial |
$348.18
|
| Rate for Payer: Blue Shield of California EPN |
$277.07
|
| Rate for Payer: Cash Price |
$329.85
|
| Rate for Payer: Cash Price |
$329.85
|
| Rate for Payer: Cash Price |
$329.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$476.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$410.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$300.93
|
| Rate for Payer: Dignity Health Medicare Advantage |
$273.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$476.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$273.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$496.24
|
| Rate for Payer: Heritage Provider Network Senior |
$496.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$273.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$349.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$132.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$314.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$183.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$366.58
|
| Rate for Payer: Multiplan Commercial |
$549.75
|
| Rate for Payer: Multiplan WC |
$426.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$439.80
|
| Rate for Payer: TriValley Medical Group Senior |
$439.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$410.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$300.93
|
| Rate for Payer: Vantage Medical Group Senior |
$273.57
|
|
|
HC HYDRATION INFUSION INITIAL 31-90MIN
|
Facility
|
OP
|
$733.00
|
|
|
Service Code
|
CPT 96360
|
| Hospital Charge Code |
910196360
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$132.67 |
| Max. Negotiated Rate |
$638.00 |
| Rate for Payer: Adventist Health Commercial |
$146.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$452.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$410.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$300.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$273.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$366.65
|
| Rate for Payer: Blue Shield of California Commercial |
$638.00
|
| Rate for Payer: Blue Shield of California EPN |
$512.00
|
| Rate for Payer: Cash Price |
$329.85
|
| Rate for Payer: Cash Price |
$329.85
|
| Rate for Payer: Cash Price |
$329.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$476.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$410.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$300.93
|
| Rate for Payer: Dignity Health Medicare Advantage |
$273.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$432.47
|
| Rate for Payer: EPIC Health Plan Medicare |
$273.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$453.73
|
| Rate for Payer: Heritage Provider Network Senior |
$453.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$273.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$349.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$132.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$314.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$183.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$366.58
|
| Rate for Payer: Multiplan Commercial |
$549.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$300.93
|
| Rate for Payer: TriValley Medical Group Senior |
$273.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$626.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$526.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$410.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$300.93
|
| Rate for Payer: Vantage Medical Group Senior |
$273.57
|
|
|
HC HYDRATION INFUSION INITIAL 31-90MIN
|
Facility
|
IP
|
$733.00
|
|
|
Service Code
|
CPT 96360
|
| Hospital Charge Code |
910196360
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$132.67 |
| Max. Negotiated Rate |
$549.75 |
| Rate for Payer: Adventist Health Commercial |
$146.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$472.05
|
| Rate for Payer: Cash Price |
$329.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$496.24
|
| Rate for Payer: Heritage Provider Network Senior |
$496.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$132.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$183.25
|
| Rate for Payer: Multiplan Commercial |
$549.75
|
|
|
HC HYDRATION INFUSION INITIAL 31-90MIN
|
Facility
|
IP
|
$733.00
|
|
|
Service Code
|
CPT 96360
|
| Hospital Charge Code |
910196360
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$132.67 |
| Max. Negotiated Rate |
$549.75 |
| Rate for Payer: Adventist Health Commercial |
$146.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$472.05
|
| Rate for Payer: Cash Price |
$329.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$496.24
|
| Rate for Payer: Heritage Provider Network Senior |
$496.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$132.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$183.25
|
| Rate for Payer: Multiplan Commercial |
$549.75
|
|
|
HC HYDROCOIL
|
Facility
|
OP
|
$3,744.00
|
|
| Hospital Charge Code |
909020028
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$748.80 |
| Max. Negotiated Rate |
$13,770.00 |
| Rate for Payer: Adventist Health Commercial |
$748.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,313.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,182.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,059.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,808.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,770.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,505.09
|
| Rate for Payer: Blue Shield of California EPN |
$1,505.09
|
| Rate for Payer: Cash Price |
$1,684.80
|
| Rate for Payer: Cash Price |
$1,684.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,722.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,182.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,182.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,182.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,396.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,733.47
|
| Rate for Payer: Heritage Provider Network Senior |
$1,733.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,872.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,872.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,872.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$936.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,620.80
|
| Rate for Payer: Multiplan Commercial |
$2,808.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,352.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,239.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,182.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,182.40
|
| Rate for Payer: Vantage Medical Group Senior |
$3,182.40
|
|
|
HC HYDROCOIL
|
Facility
|
IP
|
$3,744.00
|
|
| Hospital Charge Code |
909020028
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$748.80 |
| Max. Negotiated Rate |
$13,808.00 |
| Rate for Payer: Adventist Health Commercial |
$748.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,411.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,808.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,505.09
|
| Rate for Payer: Blue Shield of California EPN |
$1,505.09
|
| Rate for Payer: Cash Price |
$1,684.80
|
| Rate for Payer: Cash Price |
$1,684.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,722.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,021.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,733.47
|
| Rate for Payer: Heritage Provider Network Senior |
$1,733.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,872.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,872.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,872.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$936.00
|
| Rate for Payer: Multiplan Commercial |
$2,808.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,352.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,239.64
|
|
|
HC HYDROCOIL DETACHMENT CONTROLLE
|
Facility
|
OP
|
$828.00
|
|
| Hospital Charge Code |
909020029
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.87 |
| Max. Negotiated Rate |
$703.80 |
| Rate for Payer: Adventist Health Commercial |
$165.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$511.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$703.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$455.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$621.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$414.17
|
| Rate for Payer: Blue Shield of California Commercial |
$505.08
|
| Rate for Payer: Blue Shield of California EPN |
$404.06
|
| Rate for Payer: Cash Price |
$372.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$538.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$703.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$703.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$703.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$488.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$512.53
|
| Rate for Payer: Heritage Provider Network Senior |
$512.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$394.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$207.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$579.60
|
| Rate for Payer: Multiplan Commercial |
$621.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$414.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$414.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$703.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$703.80
|
| Rate for Payer: Vantage Medical Group Senior |
$703.80
|
|
|
HC HYDROCOIL DETACHMENT CONTROLLE
|
Facility
|
IP
|
$828.00
|
|
| Hospital Charge Code |
909020029
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.87 |
| Max. Negotiated Rate |
$621.00 |
| Rate for Payer: Adventist Health Commercial |
$165.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$533.23
|
| Rate for Payer: Cash Price |
$372.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$560.56
|
| Rate for Payer: Heritage Provider Network Senior |
$560.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$207.00
|
| Rate for Payer: Multiplan Commercial |
$621.00
|
|
|
HC HYSTEROSALPINGOGRAM
|
Facility
|
IP
|
$453.00
|
|
|
Service Code
|
CPT 58340
|
| Hospital Charge Code |
909000176
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$81.99 |
| Max. Negotiated Rate |
$339.75 |
| Rate for Payer: Adventist Health Commercial |
$90.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$291.73
|
| Rate for Payer: Cash Price |
$203.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$306.68
|
| Rate for Payer: Heritage Provider Network Senior |
$306.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$81.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$113.25
|
| Rate for Payer: Multiplan Commercial |
$339.75
|
|
