|
HC LOW COST SKIN SUB T/A/L 1ST 25 SQCM
|
Facility
|
OP
|
$1,196.00
|
|
|
Service Code
|
CPT C5271
|
| Hospital Charge Code |
900101509
|
|
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 T/A/L 1ST 25 SQCM
|
Facility
|
IP
|
$1,196.00
|
|
|
Service Code
|
CPT C5271
|
| Hospital Charge Code |
900101509
|
|
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 T/A/L EACH ADD 100 SQCM
|
Facility
|
OP
|
$1,754.00
|
|
|
Service Code
|
CPT C5274
|
| Hospital Charge Code |
900101512
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3,224.00 |
| Rate for Payer: Adventist Health Commercial |
$350.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,205.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,490.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$964.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,315.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1,069.94
|
| Rate for Payer: Blue Shield of California EPN |
$855.95
|
| Rate for Payer: Cash Price |
$964.70
|
| Rate for Payer: Cash Price |
$964.70
|
| Rate for Payer: Cash Price |
$964.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,140.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,490.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,490.90
|
| Rate for Payer: Dignity Health Senior |
$1,490.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,224.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,085.73
|
| Rate for Payer: Heritage Provider Network Senior |
$1,085.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$836.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$317.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$438.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,227.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,227.80
|
| Rate for Payer: Multiplan Commercial |
$1,315.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$877.00
|
| Rate for Payer: TriValley Medical Group Senior |
$877.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$877.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$877.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,490.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,490.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1,490.90
|
|
|
HC LOW COST SKIN SUB T/A/L EACH ADD 100 SQCM
|
Facility
|
IP
|
$1,754.00
|
|
|
Service Code
|
CPT C5274
|
| Hospital Charge Code |
900101512
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$317.47 |
| Max. Negotiated Rate |
$1,315.50 |
| Rate for Payer: Adventist Health Commercial |
$350.80
|
| Rate for Payer: Cash Price |
$964.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,187.46
|
| Rate for Payer: Heritage Provider Network Senior |
$1,187.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$317.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$438.50
|
| Rate for Payer: Multiplan Commercial |
$1,315.50
|
|
|
HC LOW COST SKIN SUB T/A/L EACH ADD 25 SQCM
|
Facility
|
OP
|
$702.00
|
|
|
Service Code
|
CPT C5272
|
| Hospital Charge Code |
900101510
|
|
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 EACH ADD 25 SQCM
|
Facility
|
IP
|
$702.00
|
|
|
Service Code
|
CPT C5272
|
| Hospital Charge Code |
900101510
|
|
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 LOWER EXT ARTERIAL EXAM, BILAT
|
Facility
|
OP
|
$1,274.00
|
|
|
Service Code
|
CPT 93924
|
| Hospital Charge Code |
908100113
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$172.40 |
| Max. Negotiated Rate |
$1,077.00 |
| Rate for Payer: Adventist Health Commercial |
$254.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$680.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$875.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$298.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$218.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$198.80
|
| Rate for Payer: Blue Shield of California Commercial |
$761.28
|
| Rate for Payer: Blue Shield of California EPN |
$612.20
|
| Rate for Payer: Cash Price |
$700.70
|
| Rate for Payer: Cash Price |
$700.70
|
| Rate for Payer: Cash Price |
$700.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$828.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$298.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$218.68
|
| Rate for Payer: Dignity Health Senior |
$198.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$828.10
|
| Rate for Payer: EPIC Health Plan Medicare |
$198.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$788.61
|
| Rate for Payer: Heritage Provider Network Senior |
$788.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$172.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$198.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$607.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$230.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$228.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$318.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$250.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$250.49
|
| Rate for Payer: Multiplan Commercial |
$955.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$218.68
|
| Rate for Payer: TriValley Medical Group Senior |
$198.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,077.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$908.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$298.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$218.68
|
| Rate for Payer: Vantage Medical Group Senior |
$198.80
|
|
|
HC LOWER EXT ARTERIAL EXAM, BILAT
|
Facility
|
IP
|
$1,274.00
|
|
|
Service Code
|
CPT 93924
|
| Hospital Charge Code |
908100113
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$230.59 |
| Max. Negotiated Rate |
$955.50 |
| Rate for Payer: Adventist Health Commercial |
$254.80
|
| Rate for Payer: Cash Price |
$700.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$862.50
|
| Rate for Payer: Heritage Provider Network Senior |
$862.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$230.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$318.50
|
| Rate for Payer: Multiplan Commercial |
$955.50
|
|
|
HC LOW FREQ NON-CONTACT/THRMAL US
|
Facility
|
IP
|
$398.00
|
|
|
Service Code
|
CPT 97610
|
| Hospital Charge Code |
900803112
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$72.04 |
| Max. Negotiated Rate |
$298.50 |
| Rate for Payer: Adventist Health Commercial |
$79.60
|
| Rate for Payer: Cash Price |
$218.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$269.45
|
| Rate for Payer: Heritage Provider Network Senior |
$269.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.50
|
| Rate for Payer: Multiplan Commercial |
$298.50
|
|
|
HC LOW FREQ NON-CONTACT/THRMAL US
|
Facility
|
OP
|
$398.00
|
|
|
Service Code
|
CPT 97610
|
| Hospital Charge Code |
900803112
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$72.04 |
| Max. Negotiated Rate |
$526.00 |
| Rate for Payer: Adventist Health Commercial |
$79.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$212.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$273.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$378.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$277.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$252.47
|
| Rate for Payer: Blue Shield of California Commercial |
$242.78
|
| Rate for Payer: Blue Shield of California EPN |
$194.22
|
| Rate for Payer: Cash Price |
$218.90
|
| Rate for Payer: Cash Price |
$218.90
|
| Rate for Payer: Cash Price |
$218.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$258.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$277.72
|
| Rate for Payer: Dignity Health Senior |
$252.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$258.70
|
| Rate for Payer: EPIC Health Plan Medicare |
$252.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$246.36
|
| Rate for Payer: Heritage Provider Network Senior |
$246.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$252.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$189.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$290.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$318.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$318.11
|
| Rate for Payer: Multiplan Commercial |
$298.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$277.72
|
| Rate for Payer: TriValley Medical Group Senior |
$252.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$526.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$443.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$378.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$277.72
|
| Rate for Payer: Vantage Medical Group Senior |
$252.47
|
|
|
HC LOW MIGRAT STAGE IV CONF & ID
|
Facility
|
IP
|
$624.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900910511
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$112.94 |
| Max. Negotiated Rate |
$468.00 |
| Rate for Payer: Adventist Health Commercial |
$124.80
|
| Rate for Payer: Cash Price |
$343.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$422.45
|
| Rate for Payer: Heritage Provider Network Senior |
$422.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$112.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$156.00
|
| Rate for Payer: Multiplan Commercial |
$468.00
|
|
|
HC LOW MIGRAT STAGE IV CONF & ID
|
Facility
|
OP
|
$624.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900910511
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$62.14 |
| Max. Negotiated Rate |
$562.57 |
| Rate for Payer: Adventist Health Commercial |
$124.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$333.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$428.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$62.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$562.57
|
| Rate for Payer: Blue Shield of California Commercial |
$459.71
|
| Rate for Payer: Blue Shield of California EPN |
$368.72
|
| Rate for Payer: Cash Price |
$343.20
|
| Rate for Payer: Cash Price |
$343.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$405.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$93.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.35
|
| Rate for Payer: Dignity Health Senior |
$62.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$405.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$62.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$386.26
|
| Rate for Payer: Heritage Provider Network Senior |
$386.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$70.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$62.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$297.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$112.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$71.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$156.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$78.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78.30
|
| Rate for Payer: Multiplan Commercial |
$468.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$62.14
|
| Rate for Payer: TriValley Medical Group Senior |
$62.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$67.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$67.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: Vantage Medical Group Senior |
$62.14
|
|
|
HC LSO SAG-CORO REGID FRAME PRE
|
Facility
|
IP
|
$1,940.00
|
|
|
Service Code
|
CPT L0631
|
| Hospital Charge Code |
905350631
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$388.00 |
| Max. Negotiated Rate |
$13,277.00 |
| Rate for Payer: Adventist Health Commercial |
$388.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$931.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,277.00
|
| Rate for Payer: Blue Shield of California Commercial |
$779.88
|
| Rate for Payer: Blue Shield of California EPN |
$779.88
|
| Rate for Payer: Cash Price |
$1,067.00
|
| Rate for Payer: Cash Price |
$1,067.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$892.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,047.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$898.22
|
| Rate for Payer: Heritage Provider Network Senior |
$898.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$970.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$970.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$970.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$485.00
|
| Rate for Payer: Multiplan Commercial |
$1,455.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$700.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$642.33
|
|
|
HC LSO SAG-CORO REGID FRAME PRE
|
Facility
|
OP
|
$1,940.00
|
|
|
Service Code
|
CPT L0631
|
| Hospital Charge Code |
905350631
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$485.00 |
| Max. Negotiated Rate |
$13,240.00 |
| Rate for Payer: Adventist Health Commercial |
$795.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$931.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,332.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,649.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,067.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,455.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,240.00
|
| Rate for Payer: Blue Shield of California Commercial |
$779.88
|
| Rate for Payer: Blue Shield of California EPN |
$779.88
|
| Rate for Payer: Cash Price |
$1,067.00
|
| Rate for Payer: Cash Price |
$1,067.00
|
| Rate for Payer: Cash Price |
$1,067.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$892.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,649.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,649.00
|
| Rate for Payer: Dignity Health Senior |
$1,649.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,241.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$898.22
|
| Rate for Payer: Heritage Provider Network Senior |
$898.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,045.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$970.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$970.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$970.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$485.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,358.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,358.00
|
| Rate for Payer: Multiplan Commercial |
$1,455.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$700.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$642.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,649.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,649.00
|
| Rate for Payer: Vantage Medical Group Senior |
$1,649.00
|
|
|
HC LTD TAGGED WBC SCAN LIMITED
|
Facility
|
IP
|
$2,462.00
|
|
|
Service Code
|
CPT 78805
|
| Hospital Charge Code |
909301442
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$445.62 |
| Max. Negotiated Rate |
$1,846.50 |
| Rate for Payer: Adventist Health Commercial |
$492.40
|
| Rate for Payer: Cash Price |
$1,354.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,666.77
|
| Rate for Payer: Heritage Provider Network Senior |
$1,666.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$445.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$615.50
|
| Rate for Payer: Multiplan Commercial |
$1,846.50
|
|
|
HC LTD TAGGED WBC SCAN LIMITED
|
Facility
|
OP
|
$2,462.00
|
|
|
Service Code
|
CPT 78805
|
| Hospital Charge Code |
909301442
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$445.62 |
| Max. Negotiated Rate |
$2,092.70 |
| Rate for Payer: Adventist Health Commercial |
$492.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,315.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,691.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,092.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,354.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,846.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1,501.82
|
| Rate for Payer: Blue Shield of California EPN |
$1,201.46
|
| Rate for Payer: Cash Price |
$1,354.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,600.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,092.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,092.70
|
| Rate for Payer: Dignity Health Senior |
$2,092.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,600.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,523.98
|
| Rate for Payer: Heritage Provider Network Senior |
$1,523.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,174.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$445.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$615.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,723.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,723.40
|
| Rate for Payer: Multiplan Commercial |
$1,846.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,231.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,231.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,092.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,092.70
|
| Rate for Payer: Vantage Medical Group Senior |
$2,092.70
|
|
|
HC LUMBAR DISCOGRAPHY, 1 LEVEL
|
Facility
|
IP
|
$788.00
|
|
|
Service Code
|
CPT 62290
|
| Hospital Charge Code |
909000183
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$142.63 |
| Max. Negotiated Rate |
$591.00 |
| Rate for Payer: Adventist Health Commercial |
$157.60
|
| Rate for Payer: Cash Price |
$433.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$533.48
|
| Rate for Payer: Heritage Provider Network Senior |
$533.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$142.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$197.00
|
| Rate for Payer: Multiplan Commercial |
$591.00
|
|
|
HC LUMBAR DISCOGRAPHY, 1 LEVEL
|
Facility
|
OP
|
$788.00
|
|
|
Service Code
|
CPT 62290
|
| Hospital Charge Code |
909000183
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$8,962.13 |
| Rate for Payer: Adventist Health Commercial |
$157.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$541.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$669.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$433.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$591.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,959.00
|
| 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 |
$433.40
|
| Rate for Payer: Cash Price |
$433.40
|
| Rate for Payer: Cash Price |
$433.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$512.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$669.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$669.80
|
| Rate for Payer: Dignity Health Senior |
$669.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$472.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$487.77
|
| Rate for Payer: Heritage Provider Network Senior |
$487.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$206.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$375.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$142.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$197.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$551.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$551.60
|
| Rate for Payer: Multiplan Commercial |
$591.00
|
| 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 |
$669.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$669.80
|
| Rate for Payer: Vantage Medical Group Senior |
$669.80
|
|
|
HC LUMBAR PUNCTURE FOR MYELOGR
|
Facility
|
OP
|
$690.00
|
|
|
Service Code
|
CPT 62284
|
| Hospital Charge Code |
909000181
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$8,962.13 |
| Rate for Payer: Adventist Health Commercial |
$138.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$474.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$586.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$379.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$517.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,959.00
|
| 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 |
$379.50
|
| Rate for Payer: Cash Price |
$379.50
|
| Rate for Payer: Cash Price |
$379.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$448.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$586.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$586.50
|
| Rate for Payer: Dignity Health Senior |
$586.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$414.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$427.11
|
| Rate for Payer: Heritage Provider Network Senior |
$427.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$143.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$329.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$124.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$172.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$483.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$483.00
|
| Rate for Payer: Multiplan Commercial |
$517.50
|
| 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 |
$586.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$586.50
|
| Rate for Payer: Vantage Medical Group Senior |
$586.50
|
|
|
HC LUMBAR PUNCTURE FOR MYELOGR
|
Facility
|
IP
|
$690.00
|
|
|
Service Code
|
CPT 62284
|
| Hospital Charge Code |
909000181
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$124.89 |
| Max. Negotiated Rate |
$517.50 |
| Rate for Payer: Adventist Health Commercial |
$138.00
|
| Rate for Payer: Cash Price |
$379.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$467.13
|
| Rate for Payer: Heritage Provider Network Senior |
$467.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$124.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$172.50
|
| Rate for Payer: Multiplan Commercial |
$517.50
|
|
|
HC LUMBAR/SACRAL FACET INJ 3RD EA
|
Facility
|
IP
|
$745.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
909020044
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$134.84 |
| Max. Negotiated Rate |
$558.75 |
| Rate for Payer: Adventist Health Commercial |
$149.00
|
| Rate for Payer: Cash Price |
$409.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$504.37
|
| Rate for Payer: Heritage Provider Network Senior |
$504.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$134.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$186.25
|
| Rate for Payer: Multiplan Commercial |
$558.75
|
|
|
HC LUMBAR/SACRAL FACET INJ 3RD EA
|
Facility
|
OP
|
$745.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
909020044
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$8,962.13 |
| Rate for Payer: Adventist Health Commercial |
$149.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$511.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$633.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$409.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$558.75
|
| 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 |
$409.75
|
| Rate for Payer: Cash Price |
$409.75
|
| Rate for Payer: Cash Price |
$409.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$484.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$633.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$633.25
|
| Rate for Payer: Dignity Health Senior |
$633.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$447.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$461.15
|
| Rate for Payer: Heritage Provider Network Senior |
$461.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$120.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$355.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$134.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$186.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$521.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$521.50
|
| Rate for Payer: Multiplan Commercial |
$558.75
|
| 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 |
$633.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$633.25
|
| Rate for Payer: Vantage Medical Group Senior |
$633.25
|
|
|
HC LUMBAR/SACRAL FACET INJECT/ADD
|
Facility
|
IP
|
$1,634.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
909000186
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$295.75 |
| Max. Negotiated Rate |
$1,225.50 |
| Rate for Payer: Adventist Health Commercial |
$326.80
|
| Rate for Payer: Cash Price |
$898.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,106.22
|
| Rate for Payer: Heritage Provider Network Senior |
$1,106.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$295.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$408.50
|
| Rate for Payer: Multiplan Commercial |
$1,225.50
|
|
|
HC LUMBAR/SACRAL FACET INJECT/ADD
|
Facility
|
OP
|
$1,634.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
909000186
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$8,962.13 |
| Rate for Payer: Adventist Health Commercial |
$326.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,122.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,388.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$898.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,225.50
|
| 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 |
$898.70
|
| Rate for Payer: Cash Price |
$898.70
|
| Rate for Payer: Cash Price |
$898.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,062.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,388.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,388.90
|
| Rate for Payer: Dignity Health Senior |
$1,388.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$980.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,011.45
|
| Rate for Payer: Heritage Provider Network Senior |
$1,011.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$118.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$779.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$295.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$408.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,143.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,143.80
|
| Rate for Payer: Multiplan Commercial |
$1,225.50
|
| 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 |
$1,388.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,388.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1,388.90
|
|
|
HC LUMBAR/SACRAL FACET INJECT/INT
|
Facility
|
IP
|
$2,858.00
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
909000185
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$517.30 |
| Max. Negotiated Rate |
$2,143.50 |
| Rate for Payer: Adventist Health Commercial |
$571.60
|
| Rate for Payer: Cash Price |
$1,571.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,934.87
|
| Rate for Payer: Heritage Provider Network Senior |
$1,934.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$517.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$714.50
|
| Rate for Payer: Multiplan Commercial |
$2,143.50
|
|
