|
HC INFUSION EA ADD HOUR
|
Facility
|
IP
|
$117.00
|
|
|
Service Code
|
CPT 96366
|
| Hospital Charge Code |
910196366
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$21.18 |
| Max. Negotiated Rate |
$87.75 |
| Rate for Payer: Adventist Health Commercial |
$23.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$75.35
|
| Rate for Payer: Cash Price |
$52.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$79.21
|
| Rate for Payer: Heritage Provider Network Senior |
$79.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.25
|
| Rate for Payer: Multiplan Commercial |
$87.75
|
|
|
HC INFUSION INITAL HOUR GT 16MIN
|
Facility
|
OP
|
$1,029.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
949000306
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$186.25 |
| Max. Negotiated Rate |
$771.75 |
| Rate for Payer: Adventist Health Commercial |
$205.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$635.92
|
| 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 |
$509.00
|
| 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 |
$463.05
|
| Rate for Payer: Cash Price |
$463.05
|
| Rate for Payer: Cash Price |
$463.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$668.85
|
| 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 |
$607.11
|
| Rate for Payer: EPIC Health Plan Medicare |
$273.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$636.95
|
| Rate for Payer: Heritage Provider Network Senior |
$636.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$273.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$490.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$186.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$314.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$257.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$366.58
|
| Rate for Payer: Multiplan Commercial |
$771.75
|
| 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 INFUSION INITAL HOUR GT 16MIN
|
Facility
|
IP
|
$1,029.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
949000306
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$186.25 |
| Max. Negotiated Rate |
$771.75 |
| Rate for Payer: Adventist Health Commercial |
$205.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$662.68
|
| Rate for Payer: Cash Price |
$463.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$696.63
|
| Rate for Payer: Heritage Provider Network Senior |
$696.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$186.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$257.25
|
| Rate for Payer: Multiplan Commercial |
$771.75
|
|
|
HC INFUSION INITAL HOUR GT 16MIN
|
Facility
|
OP
|
$1,029.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
940100114
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$186.25 |
| Max. Negotiated Rate |
$771.75 |
| Rate for Payer: Adventist Health Commercial |
$205.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$635.92
|
| 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 |
$509.00
|
| 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 |
$463.05
|
| Rate for Payer: Cash Price |
$463.05
|
| Rate for Payer: Cash Price |
$463.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$668.85
|
| 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 |
$607.11
|
| Rate for Payer: EPIC Health Plan Medicare |
$273.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$636.95
|
| Rate for Payer: Heritage Provider Network Senior |
$636.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$273.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$490.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$186.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$314.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$257.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$366.58
|
| Rate for Payer: Multiplan Commercial |
$771.75
|
| 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 INFUSION INITAL HOUR GT 16MIN
|
Facility
|
IP
|
$1,029.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
940100114
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$186.25 |
| Max. Negotiated Rate |
$771.75 |
| Rate for Payer: Adventist Health Commercial |
$205.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$662.68
|
| Rate for Payer: Cash Price |
$463.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$696.63
|
| Rate for Payer: Heritage Provider Network Senior |
$696.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$186.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$257.25
|
| Rate for Payer: Multiplan Commercial |
$771.75
|
|
|
HC INFUSION INITIAL HOUR GT 16MIN
|
Facility
|
OP
|
$733.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
910196365
|
|
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 |
$509.00
|
| 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 INFUSION INITIAL HOUR GT 16MIN
|
Facility
|
IP
|
$733.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
910196365
|
|
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 INFUSION INITIAL HOUR GT 16MIN
|
Facility
|
OP
|
$733.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
910196365
|
|
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 INFUSION INITIAL HOUR GT 16MIN
|
Facility
|
IP
|
$733.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
910196365
|
|
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 INFUSION/THROMBOLYSIS,CEREBRAL
|
Facility
|
IP
|
$611.00
|
|
|
Service Code
|
CPT 37195
|
| Hospital Charge Code |
909081375
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$110.59 |
| Max. Negotiated Rate |
$458.25 |
| Rate for Payer: Adventist Health Commercial |
$122.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$393.48
|
| Rate for Payer: Cash Price |
$274.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$413.65
|
| Rate for Payer: Heritage Provider Network Senior |
$413.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$110.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$152.75
|
| Rate for Payer: Multiplan Commercial |
$458.25
|
|
|
HC INFUSION/THROMBOLYSIS,CEREBRAL
|
Facility
|
OP
|
$611.00
|
|
|
Service Code
|
CPT 37195
|
| Hospital Charge Code |
909081375
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$110.59 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$122.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$377.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$637.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$467.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$424.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,158.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$274.95
|
| Rate for Payer: Cash Price |
$274.95
|
| Rate for Payer: Cash Price |
$274.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$397.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$637.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$467.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$424.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$424.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$378.21
|
| Rate for Payer: Heritage Provider Network Senior |
$522.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$424.83
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$807.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$110.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$488.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$152.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$569.27
|
| Rate for Payer: Multiplan Commercial |
$458.25
|
| Rate for Payer: Multiplan WC |
$671.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$467.31
|
| Rate for Payer: TriValley Medical Group Senior |
$467.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,093.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$637.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$467.31
|
| Rate for Payer: Vantage Medical Group Senior |
$424.83
|
|
|
HC INFUSION WIRE
|
Facility
|
IP
|
$504.00
|
|
| Hospital Charge Code |
909081247
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$91.22 |
| Max. Negotiated Rate |
$378.00 |
| Rate for Payer: Adventist Health Commercial |
$100.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$324.58
|
| Rate for Payer: Cash Price |
$226.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$341.21
|
| Rate for Payer: Heritage Provider Network Senior |
$341.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$91.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$126.00
|
| Rate for Payer: Multiplan Commercial |
$378.00
|
|
|
HC INFUSION WIRE
|
Facility
|
OP
|
$504.00
|
|
| Hospital Charge Code |
909081247
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$91.22 |
| Max. Negotiated Rate |
$428.40 |
| Rate for Payer: Adventist Health Commercial |
$100.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$311.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$428.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$277.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$378.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$252.10
|
| Rate for Payer: Blue Shield of California Commercial |
$307.44
|
| Rate for Payer: Blue Shield of California EPN |
$245.95
|
| Rate for Payer: Cash Price |
$226.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$327.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$428.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$428.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$428.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$297.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$311.98
|
| Rate for Payer: Heritage Provider Network Senior |
$311.98
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$240.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$91.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$126.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$352.80
|
| Rate for Payer: Multiplan Commercial |
$378.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$252.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$252.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$428.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$428.40
|
| Rate for Payer: Vantage Medical Group Senior |
$428.40
|
|
|
HC INHALED NITRIC OXIDE PER HR
|
Facility
|
IP
|
$435.00
|
|
| Hospital Charge Code |
900800402
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.73 |
| Max. Negotiated Rate |
$326.25 |
| Rate for Payer: Adventist Health Commercial |
$87.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$280.14
|
| Rate for Payer: Cash Price |
$195.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$234.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$294.50
|
| Rate for Payer: Heritage Provider Network Senior |
$294.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$78.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.75
|
| Rate for Payer: Multiplan Commercial |
$326.25
|
|
|
HC INHALED NITRIC OXIDE PER HR
|
Facility
|
OP
|
$435.00
|
|
| Hospital Charge Code |
900800402
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.73 |
| Max. Negotiated Rate |
$369.75 |
| Rate for Payer: Adventist Health Commercial |
$87.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$268.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$369.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$239.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$326.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$217.59
|
| Rate for Payer: Blue Shield of California Commercial |
$265.35
|
| Rate for Payer: Blue Shield of California EPN |
$212.28
|
| Rate for Payer: Cash Price |
$195.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$282.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$369.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$369.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$369.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$278.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$269.26
|
| Rate for Payer: Heritage Provider Network Senior |
$269.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$207.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$78.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$304.50
|
| Rate for Payer: Multiplan Commercial |
$326.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$174.00
|
| Rate for Payer: TriValley Medical Group Senior |
$174.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$217.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$217.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$369.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$369.75
|
| Rate for Payer: Vantage Medical Group Senior |
$369.75
|
|
|
HC INITIAL OP VISIT HIGH SEVERITY
|
Facility
|
IP
|
$1,027.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
908600106
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$185.89 |
| Max. Negotiated Rate |
$770.25 |
| Rate for Payer: Adventist Health Commercial |
$205.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$661.39
|
| Rate for Payer: Cash Price |
$462.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$695.28
|
| Rate for Payer: Heritage Provider Network Senior |
$695.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$185.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$256.75
|
| Rate for Payer: Multiplan Commercial |
$770.25
|
|
|
HC INITIAL OP VISIT HIGH SEVERITY
|
Facility
|
OP
|
$1,027.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
908600106
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$171.24 |
| Max. Negotiated Rate |
$770.25 |
| Rate for Payer: Adventist Health Commercial |
$205.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$634.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$256.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$188.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$171.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$513.71
|
| Rate for Payer: Blue Shield of California Commercial |
$626.47
|
| Rate for Payer: Blue Shield of California EPN |
$501.18
|
| Rate for Payer: Cash Price |
$462.15
|
| Rate for Payer: Cash Price |
$462.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$256.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$188.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$171.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$605.93
|
| Rate for Payer: EPIC Health Plan Medicare |
$171.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$635.71
|
| Rate for Payer: Heritage Provider Network Senior |
$635.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$171.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$489.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$185.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$196.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$256.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$229.46
|
| Rate for Payer: Multiplan Commercial |
$770.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$513.50
|
| Rate for Payer: TriValley Medical Group Senior |
$513.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$513.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$513.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$256.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$188.36
|
| Rate for Payer: Vantage Medical Group Senior |
$171.24
|
|
|
HC INITIAL OP VISIT LOW TO MOD
|
Facility
|
IP
|
$366.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
908600103
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.25 |
| Max. Negotiated Rate |
$274.50 |
| Rate for Payer: Adventist Health Commercial |
$73.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$235.70
|
| Rate for Payer: Cash Price |
$164.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$247.78
|
| Rate for Payer: Heritage Provider Network Senior |
$247.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$66.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.50
|
| Rate for Payer: Multiplan Commercial |
$274.50
|
|
|
HC INITIAL OP VISIT LOW TO MOD
|
Facility
|
OP
|
$366.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
908600103
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.25 |
| Max. Negotiated Rate |
$274.50 |
| Rate for Payer: Adventist Health Commercial |
$73.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$226.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$256.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$188.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$171.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$183.07
|
| Rate for Payer: Blue Shield of California Commercial |
$223.26
|
| Rate for Payer: Blue Shield of California EPN |
$178.61
|
| Rate for Payer: Cash Price |
$164.70
|
| Rate for Payer: Cash Price |
$164.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$256.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$188.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$171.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$215.94
|
| Rate for Payer: EPIC Health Plan Medicare |
$171.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$226.55
|
| Rate for Payer: Heritage Provider Network Senior |
$226.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$171.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$174.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$66.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$196.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$229.46
|
| Rate for Payer: Multiplan Commercial |
$274.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$183.00
|
| Rate for Payer: TriValley Medical Group Senior |
$183.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$183.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$183.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$256.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$188.36
|
| Rate for Payer: Vantage Medical Group Senior |
$171.24
|
|
|
HC INITIAL OP VISIT MINOR
|
Facility
|
IP
|
$277.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
908600102
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$50.14 |
| Max. Negotiated Rate |
$207.75 |
| Rate for Payer: Adventist Health Commercial |
$55.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$178.39
|
| Rate for Payer: Cash Price |
$124.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$187.53
|
| Rate for Payer: Heritage Provider Network Senior |
$187.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.25
|
| Rate for Payer: Multiplan Commercial |
$207.75
|
|
|
HC INITIAL OP VISIT MINOR
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
908600102
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$50.14 |
| Max. Negotiated Rate |
$256.86 |
| Rate for Payer: Adventist Health Commercial |
$55.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$171.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$256.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$188.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$171.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$138.56
|
| Rate for Payer: Blue Shield of California Commercial |
$168.97
|
| Rate for Payer: Blue Shield of California EPN |
$135.18
|
| Rate for Payer: Cash Price |
$124.65
|
| Rate for Payer: Cash Price |
$124.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$256.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$188.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$171.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$163.43
|
| Rate for Payer: EPIC Health Plan Medicare |
$171.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$171.46
|
| Rate for Payer: Heritage Provider Network Senior |
$171.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$171.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$132.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$196.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$229.46
|
| Rate for Payer: Multiplan Commercial |
$207.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$138.50
|
| Rate for Payer: TriValley Medical Group Senior |
$138.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$138.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$138.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$256.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$188.36
|
| Rate for Payer: Vantage Medical Group Senior |
$171.24
|
|
|
HC INITIAL OP VISIT MODERATE
|
Facility
|
OP
|
$539.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
908600104
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$97.56 |
| Max. Negotiated Rate |
$404.25 |
| Rate for Payer: Adventist Health Commercial |
$107.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$333.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$256.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$188.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$171.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$269.61
|
| Rate for Payer: Blue Shield of California Commercial |
$328.79
|
| Rate for Payer: Blue Shield of California EPN |
$263.03
|
| Rate for Payer: Cash Price |
$242.55
|
| Rate for Payer: Cash Price |
$242.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$256.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$188.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$171.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$318.01
|
| Rate for Payer: EPIC Health Plan Medicare |
$171.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$333.64
|
| Rate for Payer: Heritage Provider Network Senior |
$333.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$171.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$257.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$97.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$196.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$229.46
|
| Rate for Payer: Multiplan Commercial |
$404.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$269.50
|
| Rate for Payer: TriValley Medical Group Senior |
$269.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$269.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$269.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$256.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$188.36
|
| Rate for Payer: Vantage Medical Group Senior |
$171.24
|
|
|
HC INITIAL OP VISIT MODERATE
|
Facility
|
IP
|
$539.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
908600104
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$97.56 |
| Max. Negotiated Rate |
$404.25 |
| Rate for Payer: Adventist Health Commercial |
$107.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$347.12
|
| Rate for Payer: Cash Price |
$242.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$364.90
|
| Rate for Payer: Heritage Provider Network Senior |
$364.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$97.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.75
|
| Rate for Payer: Multiplan Commercial |
$404.25
|
|
|
HC INITIAL OP VISIT MOD TO HIGH
|
Facility
|
IP
|
$826.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
908600105
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$149.51 |
| Max. Negotiated Rate |
$619.50 |
| Rate for Payer: Adventist Health Commercial |
$165.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$531.94
|
| Rate for Payer: Cash Price |
$371.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$559.20
|
| Rate for Payer: Heritage Provider Network Senior |
$559.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.50
|
| Rate for Payer: Multiplan Commercial |
$619.50
|
|
|
HC INITIAL OP VISIT MOD TO HIGH
|
Facility
|
OP
|
$826.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
908600105
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$149.51 |
| Max. Negotiated Rate |
$619.50 |
| Rate for Payer: Adventist Health Commercial |
$165.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$510.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$256.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$188.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$171.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$413.17
|
| Rate for Payer: Blue Shield of California Commercial |
$503.86
|
| Rate for Payer: Blue Shield of California EPN |
$403.09
|
| Rate for Payer: Cash Price |
$371.70
|
| Rate for Payer: Cash Price |
$371.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$256.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$188.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$171.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$487.34
|
| Rate for Payer: EPIC Health Plan Medicare |
$171.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$511.29
|
| Rate for Payer: Heritage Provider Network Senior |
$511.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$171.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$394.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$196.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$229.46
|
| Rate for Payer: Multiplan Commercial |
$619.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$413.00
|
| Rate for Payer: TriValley Medical Group Senior |
$413.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$413.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$413.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$256.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$188.36
|
| Rate for Payer: Vantage Medical Group Senior |
$171.24
|
|
