|
HC LOCM (HEXABRIX) PER ML
|
Facility
|
OP
|
$4.30
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081002
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.23
|
| Rate for Payer: Blue Shield of California Commercial |
$2.62
|
| Rate for Payer: Blue Shield of California EPN |
$2.10
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.65
|
| Rate for Payer: Dignity Health Senior |
$3.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.66
|
| Rate for Payer: Heritage Provider Network Senior |
$2.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.01
|
| Rate for Payer: Multiplan Commercial |
$3.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.72
|
| Rate for Payer: TriValley Medical Group Senior |
$1.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.65
|
| Rate for Payer: Vantage Medical Group Senior |
$3.65
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 180
|
Facility
|
OP
|
$9.40
|
|
|
Service Code
|
CPT Q9965
|
| Hospital Charge Code |
909081004
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$7.99 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.05
|
| Rate for Payer: Blue Shield of California Commercial |
$5.73
|
| Rate for Payer: Blue Shield of California EPN |
$4.59
|
| Rate for Payer: Cash Price |
$5.17
|
| Rate for Payer: Cash Price |
$5.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.99
|
| Rate for Payer: Dignity Health Senior |
$7.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.82
|
| Rate for Payer: Heritage Provider Network Senior |
$5.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.58
|
| Rate for Payer: Multiplan Commercial |
$7.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.76
|
| Rate for Payer: TriValley Medical Group Senior |
$3.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.99
|
| Rate for Payer: Vantage Medical Group Senior |
$7.99
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 180
|
Facility
|
IP
|
$9.40
|
|
|
Service Code
|
CPT Q9965
|
| Hospital Charge Code |
909081004
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.05 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Cash Price |
$5.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.36
|
| Rate for Payer: Heritage Provider Network Senior |
$6.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$7.05
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 240
|
Facility
|
OP
|
$2.95
|
|
|
Service Code
|
CPT Q9966
|
| Hospital Charge Code |
909081005
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$2.51 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.21
|
| Rate for Payer: Blue Shield of California Commercial |
$1.80
|
| Rate for Payer: Blue Shield of California EPN |
$1.44
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.51
|
| Rate for Payer: Dignity Health Senior |
$2.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.83
|
| Rate for Payer: Heritage Provider Network Senior |
$1.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.06
|
| Rate for Payer: Multiplan Commercial |
$2.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.18
|
| Rate for Payer: TriValley Medical Group Senior |
$1.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.51
|
| Rate for Payer: Vantage Medical Group Senior |
$2.51
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 240
|
Facility
|
IP
|
$2.95
|
|
|
Service Code
|
CPT Q9966
|
| Hospital Charge Code |
909081005
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.00
|
| Rate for Payer: Heritage Provider Network Senior |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$2.21
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 300
|
Facility
|
OP
|
$3.38
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081006
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.54
|
| Rate for Payer: Blue Shield of California Commercial |
$2.06
|
| Rate for Payer: Blue Shield of California EPN |
$1.65
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.87
|
| Rate for Payer: Dignity Health Senior |
$2.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.09
|
| Rate for Payer: Heritage Provider Network Senior |
$2.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.37
|
| Rate for Payer: Multiplan Commercial |
$2.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.35
|
| Rate for Payer: TriValley Medical Group Senior |
$1.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.87
|
| Rate for Payer: Vantage Medical Group Senior |
$2.87
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 300
|
Facility
|
IP
|
$3.38
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081006
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.29
|
| Rate for Payer: Heritage Provider Network Senior |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$2.54
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 350-370
|
Facility
|
OP
|
$4.28
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081007
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$3.64 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.21
|
| Rate for Payer: Blue Shield of California Commercial |
$2.61
|
| Rate for Payer: Blue Shield of California EPN |
$2.09
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.64
|
| Rate for Payer: Dignity Health Senior |
$3.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.65
|
| Rate for Payer: Heritage Provider Network Senior |
$2.65
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$3.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.71
|
| Rate for Payer: TriValley Medical Group Senior |
$1.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.64
|
| Rate for Payer: Vantage Medical Group Senior |
$3.64
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 350-370
|
Facility
|
IP
|
$4.28
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081007
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$3.21 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.90
|
| Rate for Payer: Heritage Provider Network Senior |
$2.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: Multiplan Commercial |
$3.21
|
|
|
HC LOCM (VISIPAQUE) 320 PER ML
|
Facility
|
IP
|
$4.27
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081008
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Adventist Health Commercial |
$0.85
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.89
|
| Rate for Payer: Heritage Provider Network Senior |
$2.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
|
|
HC LOCM (VISIPAQUE) 320 PER ML
|
Facility
|
OP
|
$4.27
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081008
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$3.63 |
| Rate for Payer: Adventist Health Commercial |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.20
|
| Rate for Payer: Blue Shield of California Commercial |
$2.60
|
| Rate for Payer: Blue Shield of California EPN |
$2.08
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.63
|
| Rate for Payer: Dignity Health Senior |
$3.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.64
|
| Rate for Payer: Heritage Provider Network Senior |
$2.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.99
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.71
|
| Rate for Payer: TriValley Medical Group Senior |
$1.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.63
|
| Rate for Payer: Vantage Medical Group Senior |
$3.63
|
|
|
HC LOOPOGRAM (ILEAL CONDUIT)
|
Facility
|
IP
|
$445.00
|
|
|
Service Code
|
CPT 50690
|
| Hospital Charge Code |
909000207
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$80.55 |
| Max. Negotiated Rate |
$333.75 |
| Rate for Payer: Adventist Health Commercial |
$89.00
|
| Rate for Payer: Cash Price |
$244.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$301.26
|
| Rate for Payer: Heritage Provider Network Senior |
$301.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.25
|
| Rate for Payer: Multiplan Commercial |
$333.75
|
|
|
HC LOOPOGRAM (ILEAL CONDUIT)
|
Facility
|
OP
|
$445.00
|
|
|
Service Code
|
CPT 50690
|
| Hospital Charge Code |
909000207
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$89.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$305.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$378.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$244.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$333.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$244.75
|
| Rate for Payer: Cash Price |
$244.75
|
| Rate for Payer: Cash Price |
$244.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$289.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$378.25
|
| Rate for Payer: Dignity Health Senior |
$378.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$275.45
|
| Rate for Payer: Heritage Provider Network Senior |
$275.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$435.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$212.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$311.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$311.50
|
| Rate for Payer: Multiplan Commercial |
$333.75
|
| 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 |
$378.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$378.25
|
| Rate for Payer: Vantage Medical Group Senior |
$378.25
|
|
|
HC LO SAGITT RIGID PANEL PREFAB
|
Facility
|
OP
|
$710.00
|
|
|
Service Code
|
CPT L0627
|
| Hospital Charge Code |
905350627
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$177.50 |
| Max. Negotiated Rate |
$13,240.00 |
| Rate for Payer: Adventist Health Commercial |
$291.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$340.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$487.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$603.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$390.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$532.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,240.00
|
| Rate for Payer: Blue Shield of California Commercial |
$285.42
|
| Rate for Payer: Blue Shield of California EPN |
$285.42
|
| Rate for Payer: Cash Price |
$390.50
|
| Rate for Payer: Cash Price |
$390.50
|
| Rate for Payer: Cash Price |
$390.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$326.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$603.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$603.50
|
| Rate for Payer: Dignity Health Senior |
$603.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$454.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$328.73
|
| Rate for Payer: Heritage Provider Network Senior |
$328.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$418.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$355.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$355.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$355.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$177.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$497.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$497.00
|
| Rate for Payer: Multiplan Commercial |
$532.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$256.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$235.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$603.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$603.50
|
| Rate for Payer: Vantage Medical Group Senior |
$603.50
|
|
|
HC LO SAGITT RIGID PANEL PREFAB
|
Facility
|
IP
|
$710.00
|
|
|
Service Code
|
CPT L0627
|
| Hospital Charge Code |
905350627
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$142.00 |
| Max. Negotiated Rate |
$13,277.00 |
| Rate for Payer: Adventist Health Commercial |
$142.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$340.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,277.00
|
| Rate for Payer: Blue Shield of California Commercial |
$285.42
|
| Rate for Payer: Blue Shield of California EPN |
$285.42
|
| Rate for Payer: Cash Price |
$390.50
|
| Rate for Payer: Cash Price |
$390.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$326.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$383.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$328.73
|
| Rate for Payer: Heritage Provider Network Senior |
$328.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$355.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$355.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$355.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$177.50
|
| Rate for Payer: Multiplan Commercial |
$532.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$256.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$235.08
|
|
|
HC LOW COST SKIN SUB F/S/N/G/H/F 1ST 100 SQCM
|
Facility
|
OP
|
$1,196.00
|
|
|
Service Code
|
CPT C5277
|
| Hospital Charge Code |
900101515
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3,224.00 |
| Rate for Payer: Adventist Health Commercial |
$239.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$821.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,166.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$855.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$777.77
|
| Rate for Payer: Blue Shield of California Commercial |
$729.56
|
| Rate for Payer: Blue Shield of California EPN |
$583.65
|
| Rate for Payer: Cash Price |
$657.80
|
| Rate for Payer: Cash Price |
$657.80
|
| Rate for Payer: Cash Price |
$657.80
|
| Rate for Payer: Cash Price |
$657.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$777.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,166.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$855.55
|
| Rate for Payer: Dignity Health Senior |
$777.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$777.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$740.32
|
| Rate for Payer: Heritage Provider Network Senior |
$740.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$777.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$570.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$216.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$894.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$299.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$979.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$979.99
|
| Rate for Payer: Multiplan Commercial |
$897.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$855.55
|
| Rate for Payer: TriValley Medical Group Senior |
$855.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$598.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$598.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,166.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$855.55
|
| Rate for Payer: Vantage Medical Group Senior |
$777.77
|
|
|
HC LOW COST SKIN SUB F/S/N/G/H/F 1ST 100 SQCM
|
Facility
|
IP
|
$1,196.00
|
|
|
Service Code
|
CPT C5277
|
| Hospital Charge Code |
900101515
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$216.48 |
| Max. Negotiated Rate |
$897.00 |
| Rate for Payer: Adventist Health Commercial |
$239.20
|
| Rate for Payer: Cash Price |
$657.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$809.69
|
| Rate for Payer: Heritage Provider Network Senior |
$809.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$216.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$299.00
|
| Rate for Payer: Multiplan Commercial |
$897.00
|
|
|
HC LOW COST SKIN SUB F/S/N/G/H/F 1ST 25 SQCM
|
Facility
|
OP
|
$1,196.00
|
|
|
Service Code
|
CPT C5275
|
| Hospital Charge Code |
900101513
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3,224.00 |
| Rate for Payer: Adventist Health Commercial |
$239.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$821.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,166.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$855.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$777.77
|
| Rate for Payer: Blue Shield of California Commercial |
$729.56
|
| Rate for Payer: Blue Shield of California EPN |
$583.65
|
| Rate for Payer: Cash Price |
$657.80
|
| Rate for Payer: Cash Price |
$657.80
|
| Rate for Payer: Cash Price |
$657.80
|
| Rate for Payer: Cash Price |
$657.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$777.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,166.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$855.55
|
| Rate for Payer: Dignity Health Senior |
$777.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$777.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$740.32
|
| Rate for Payer: Heritage Provider Network Senior |
$740.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$777.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$570.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$216.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$894.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$299.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$979.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$979.99
|
| Rate for Payer: Multiplan Commercial |
$897.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$855.55
|
| Rate for Payer: TriValley Medical Group Senior |
$855.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$598.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$598.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,166.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$855.55
|
| Rate for Payer: Vantage Medical Group Senior |
$777.77
|
|
|
HC LOW COST SKIN SUB F/S/N/G/H/F 1ST 25 SQCM
|
Facility
|
IP
|
$1,196.00
|
|
|
Service Code
|
CPT C5275
|
| Hospital Charge Code |
900101513
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$216.48 |
| Max. Negotiated Rate |
$897.00 |
| Rate for Payer: Adventist Health Commercial |
$239.20
|
| Rate for Payer: Cash Price |
$657.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$809.69
|
| Rate for Payer: Heritage Provider Network Senior |
$809.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$216.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$299.00
|
| Rate for Payer: Multiplan Commercial |
$897.00
|
|
|
HC LOW COST SKIN SUB F/S/N/G/H/F ADD 100 SQCM
|
Facility
|
IP
|
$702.00
|
|
|
Service Code
|
CPT C5278
|
| Hospital Charge Code |
900101516
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$127.06 |
| Max. Negotiated Rate |
$526.50 |
| Rate for Payer: Adventist Health Commercial |
$140.40
|
| Rate for Payer: Cash Price |
$386.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$475.25
|
| Rate for Payer: Heritage Provider Network Senior |
$475.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$127.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$175.50
|
| Rate for Payer: Multiplan Commercial |
$526.50
|
|
|
HC LOW COST SKIN SUB F/S/N/G/H/F ADD 100 SQCM
|
Facility
|
OP
|
$702.00
|
|
|
Service Code
|
CPT C5278
|
| Hospital Charge Code |
900101516
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3,224.00 |
| Rate for Payer: Adventist Health Commercial |
$140.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$482.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$596.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$386.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$526.50
|
| Rate for Payer: Blue Shield of California Commercial |
$428.22
|
| Rate for Payer: Blue Shield of California EPN |
$342.58
|
| Rate for Payer: Cash Price |
$386.10
|
| Rate for Payer: Cash Price |
$386.10
|
| Rate for Payer: Cash Price |
$386.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$456.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$596.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$596.70
|
| Rate for Payer: Dignity Health Senior |
$596.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$434.54
|
| Rate for Payer: Heritage Provider Network Senior |
$434.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$334.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$127.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$175.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$491.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$491.40
|
| Rate for Payer: Multiplan Commercial |
$526.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$351.00
|
| Rate for Payer: TriValley Medical Group Senior |
$351.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$351.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$351.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$596.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$596.70
|
| Rate for Payer: Vantage Medical Group Senior |
$596.70
|
|
|
HC LOW COST SKIN SUB F/S/N/G/H/F ADD 25 SQCM
|
Facility
|
IP
|
$702.00
|
|
|
Service Code
|
CPT C5276
|
| Hospital Charge Code |
900101514
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$127.06 |
| Max. Negotiated Rate |
$526.50 |
| Rate for Payer: Adventist Health Commercial |
$140.40
|
| Rate for Payer: Cash Price |
$386.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$475.25
|
| Rate for Payer: Heritage Provider Network Senior |
$475.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$127.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$175.50
|
| Rate for Payer: Multiplan Commercial |
$526.50
|
|
|
HC LOW COST SKIN SUB F/S/N/G/H/F ADD 25 SQCM
|
Facility
|
OP
|
$702.00
|
|
|
Service Code
|
CPT C5276
|
| Hospital Charge Code |
900101514
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3,224.00 |
| Rate for Payer: Adventist Health Commercial |
$140.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$482.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$596.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$386.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$526.50
|
| Rate for Payer: Blue Shield of California Commercial |
$428.22
|
| Rate for Payer: Blue Shield of California EPN |
$342.58
|
| Rate for Payer: Cash Price |
$386.10
|
| Rate for Payer: Cash Price |
$386.10
|
| Rate for Payer: Cash Price |
$386.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$456.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$596.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$596.70
|
| Rate for Payer: Dignity Health Senior |
$596.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$434.54
|
| Rate for Payer: Heritage Provider Network Senior |
$434.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$334.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$127.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$175.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$491.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$491.40
|
| Rate for Payer: Multiplan Commercial |
$526.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$351.00
|
| Rate for Payer: TriValley Medical Group Senior |
$351.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$351.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$351.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$596.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$596.70
|
| Rate for Payer: Vantage Medical Group Senior |
$596.70
|
|
|
HC LOW COST SKIN SUB T/A/L 1ST 100 SQCM
|
Facility
|
OP
|
$4,007.00
|
|
|
Service Code
|
CPT C5273
|
| Hospital Charge Code |
900101511
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3,486.33 |
| Rate for Payer: Adventist Health Commercial |
$801.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,752.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,486.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,556.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,324.22
|
| Rate for Payer: Blue Shield of California Commercial |
$2,444.27
|
| Rate for Payer: Blue Shield of California EPN |
$1,955.42
|
| Rate for Payer: Cash Price |
$2,203.85
|
| Rate for Payer: Cash Price |
$2,203.85
|
| Rate for Payer: Cash Price |
$2,203.85
|
| Rate for Payer: Cash Price |
$2,203.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,604.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,486.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,556.64
|
| Rate for Payer: Dignity Health Senior |
$2,324.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,324.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,480.33
|
| Rate for Payer: Heritage Provider Network Senior |
$2,480.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,324.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,911.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$725.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,672.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,001.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,928.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,928.52
|
| Rate for Payer: Multiplan Commercial |
$3,005.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,556.64
|
| Rate for Payer: TriValley Medical Group Senior |
$2,556.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,003.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,003.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,486.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,556.64
|
| Rate for Payer: Vantage Medical Group Senior |
$2,324.22
|
|
|
HC LOW COST SKIN SUB T/A/L 1ST 100 SQCM
|
Facility
|
IP
|
$4,007.00
|
|
|
Service Code
|
CPT C5273
|
| Hospital Charge Code |
900101511
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$725.27 |
| Max. Negotiated Rate |
$3,005.25 |
| Rate for Payer: Adventist Health Commercial |
$801.40
|
| Rate for Payer: Cash Price |
$2,203.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,712.74
|
| Rate for Payer: Heritage Provider Network Senior |
$2,712.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$725.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,001.75
|
| Rate for Payer: Multiplan Commercial |
$3,005.25
|
|
