|
HC MRI CHEST, W/O CONT
|
Facility
|
IP
|
$3,497.00
|
|
|
Service Code
|
CPT 71550
|
| Hospital Charge Code |
908801200
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$632.96 |
| Max. Negotiated Rate |
$2,622.75 |
| Rate for Payer: Adventist Health Commercial |
$699.40
|
| Rate for Payer: Cash Price |
$1,923.35
|
| Rate for Payer: Cash Price |
$1,923.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,367.47
|
| Rate for Payer: Heritage Provider Network Senior |
$2,367.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$632.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$874.25
|
| Rate for Payer: Multiplan Commercial |
$2,622.75
|
|
|
HC MRI CHEST, W/O CONT
|
Facility
|
OP
|
$3,497.00
|
|
|
Service Code
|
CPT 71550
|
| Hospital Charge Code |
908801200
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$307.13 |
| Max. Negotiated Rate |
$2,622.75 |
| Rate for Payer: Adventist Health Commercial |
$699.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,574.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,402.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$460.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$337.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$307.13
|
| Rate for Payer: Blue Shield of California Commercial |
$2,335.44
|
| Rate for Payer: Blue Shield of California EPN |
$1,878.08
|
| Rate for Payer: Cash Price |
$1,923.35
|
| Rate for Payer: Cash Price |
$1,923.35
|
| Rate for Payer: Cash Price |
$1,923.35
|
| Rate for Payer: Cash Price |
$1,923.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$460.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$337.84
|
| Rate for Payer: Dignity Health Senior |
$307.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$307.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$548.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$307.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,668.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$632.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$353.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$874.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$386.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$386.98
|
| Rate for Payer: Multiplan Commercial |
$2,622.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$541.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$541.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$460.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$337.84
|
| Rate for Payer: Vantage Medical Group Senior |
$307.13
|
|
|
HC MRI CHEST W WO CONTRAST
|
Facility
|
OP
|
$5,578.00
|
|
|
Service Code
|
CPT 71552
|
| Hospital Charge Code |
908801202
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$5,144.06 |
| Rate for Payer: Adventist Health Commercial |
$1,115.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,574.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,832.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$680.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$499.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$453.77
|
| Rate for Payer: Blue Shield of California Commercial |
$5,144.06
|
| Rate for Payer: Blue Shield of California EPN |
$4,136.68
|
| Rate for Payer: Cash Price |
$3,067.90
|
| Rate for Payer: Cash Price |
$3,067.90
|
| Rate for Payer: Cash Price |
$3,067.90
|
| Rate for Payer: Cash Price |
$3,067.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$680.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$499.15
|
| Rate for Payer: Dignity Health Senior |
$453.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$453.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$765.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$453.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,660.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,009.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$521.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,394.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$571.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$571.75
|
| Rate for Payer: Multiplan Commercial |
$4,183.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$854.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$854.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$680.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$499.15
|
| Rate for Payer: Vantage Medical Group Senior |
$453.77
|
|
|
HC MRI CHEST W WO CONTRAST
|
Facility
|
IP
|
$5,578.00
|
|
|
Service Code
|
CPT 71552
|
| Hospital Charge Code |
908801202
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$929.00 |
| Max. Negotiated Rate |
$4,183.50 |
| Rate for Payer: Adventist Health Commercial |
$1,115.60
|
| Rate for Payer: Cash Price |
$3,067.90
|
| Rate for Payer: Cash Price |
$3,067.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,776.31
|
| Rate for Payer: Heritage Provider Network Senior |
$3,776.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,009.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,394.50
|
| Rate for Payer: Multiplan Commercial |
$4,183.50
|
|
|
HC MRI FETAL PELVIC IMG 1ST FETUS
|
Facility
|
IP
|
$1,551.00
|
|
|
Service Code
|
CPT 74712
|
| Hospital Charge Code |
908874712
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$280.73 |
| Max. Negotiated Rate |
$1,163.25 |
| Rate for Payer: Adventist Health Commercial |
$310.20
|
| Rate for Payer: Cash Price |
$853.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,050.03
|
| Rate for Payer: Heritage Provider Network Senior |
$1,050.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$280.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$387.75
|
| Rate for Payer: Multiplan Commercial |
$1,163.25
|
|
|
HC MRI FETAL PELVIC IMG 1ST FETUS
|
Facility
|
OP
|
$1,551.00
|
|
|
Service Code
|
CPT 74712
|
| Hospital Charge Code |
908874712
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$280.73 |
| Max. Negotiated Rate |
$5,314.34 |
| Rate for Payer: Adventist Health Commercial |
$310.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$829.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,065.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$460.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$337.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$307.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,314.34
|
| Rate for Payer: Blue Shield of California Commercial |
$1,865.23
|
| Rate for Payer: Blue Shield of California EPN |
$1,499.96
|
| Rate for Payer: Cash Price |
$853.05
|
| Rate for Payer: Cash Price |
$853.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,008.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$460.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$337.84
|
| Rate for Payer: Dignity Health Senior |
$307.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,008.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$307.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$960.07
|
| Rate for Payer: Heritage Provider Network Senior |
$960.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$649.91
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$307.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$739.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$280.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$353.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$387.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$386.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$386.98
|
| Rate for Payer: Multiplan Commercial |
$1,163.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$307.13
|
| Rate for Payer: TriValley Medical Group Senior |
$307.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$437.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$437.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$460.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$337.84
|
| Rate for Payer: Vantage Medical Group Senior |
$307.13
|
|
|
HC MRI FETAL PELVIC IMG ADD FETUS
|
Facility
|
IP
|
$741.00
|
|
|
Service Code
|
CPT 74713
|
| Hospital Charge Code |
908874713
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$134.12 |
| Max. Negotiated Rate |
$555.75 |
| Rate for Payer: Adventist Health Commercial |
$148.20
|
| Rate for Payer: Cash Price |
$407.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$501.66
|
| Rate for Payer: Heritage Provider Network Senior |
$501.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$134.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$185.25
|
| Rate for Payer: Multiplan Commercial |
$555.75
|
|
|
HC MRI FETAL PELVIC IMG ADD FETUS
|
Facility
|
OP
|
$741.00
|
|
|
Service Code
|
CPT 74713
|
| Hospital Charge Code |
908874713
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$134.12 |
| Max. Negotiated Rate |
$2,277.08 |
| Rate for Payer: Adventist Health Commercial |
$148.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$396.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$509.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$629.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$407.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$555.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,277.08
|
| Rate for Payer: Blue Shield of California Commercial |
$799.30
|
| Rate for Payer: Blue Shield of California EPN |
$642.77
|
| Rate for Payer: Cash Price |
$407.55
|
| Rate for Payer: Cash Price |
$407.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$481.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$629.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$629.85
|
| Rate for Payer: Dignity Health Senior |
$629.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$481.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$458.68
|
| Rate for Payer: Heritage Provider Network Senior |
$458.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$313.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$353.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$134.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$185.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$518.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$518.70
|
| Rate for Payer: Multiplan Commercial |
$555.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$370.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$370.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$629.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$629.85
|
| Rate for Payer: Vantage Medical Group Senior |
$629.85
|
|
|
HC MRI GUID BX/NEEDLE LOC/ASPIR
|
Facility
|
IP
|
$2,993.00
|
|
|
Service Code
|
CPT 77021
|
| Hospital Charge Code |
909002020
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$541.73 |
| Max. Negotiated Rate |
$2,244.75 |
| Rate for Payer: Adventist Health Commercial |
$598.60
|
| Rate for Payer: Cash Price |
$1,646.15
|
| Rate for Payer: Cash Price |
$1,646.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,026.26
|
| Rate for Payer: Heritage Provider Network Senior |
$2,026.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$541.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$748.25
|
| Rate for Payer: Multiplan Commercial |
$2,244.75
|
|
|
HC MRI GUID BX/NEEDLE LOC/ASPIR
|
Facility
|
OP
|
$2,993.00
|
|
|
Service Code
|
CPT 77021
|
| Hospital Charge Code |
909002020
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$2,544.05 |
| Rate for Payer: Adventist Health Commercial |
$598.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,599.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,056.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,544.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,646.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,244.75
|
| Rate for Payer: Blue Shield of California Commercial |
$1,848.96
|
| Rate for Payer: Blue Shield of California EPN |
$1,486.87
|
| Rate for Payer: Cash Price |
$1,646.15
|
| Rate for Payer: Cash Price |
$1,646.15
|
| Rate for Payer: Cash Price |
$1,646.15
|
| Rate for Payer: Cash Price |
$1,646.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,544.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,544.05
|
| Rate for Payer: Dignity Health Senior |
$2,544.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$594.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,427.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$541.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$748.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,095.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,095.10
|
| Rate for Payer: Multiplan Commercial |
$2,244.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,496.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,496.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,544.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,544.05
|
| Rate for Payer: Vantage Medical Group Senior |
$2,544.05
|
|
|
HC MRI INSERTABLE IMAGING COIL
|
Facility
|
OP
|
$525.00
|
|
|
Service Code
|
CPT C1770
|
| Hospital Charge Code |
908801710
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$13,240.00 |
| Rate for Payer: Adventist Health Commercial |
$105.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$252.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$360.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$446.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$288.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$393.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,240.00
|
| Rate for Payer: Blue Shield of California Commercial |
$211.05
|
| Rate for Payer: Blue Shield of California EPN |
$211.05
|
| Rate for Payer: Cash Price |
$288.75
|
| Rate for Payer: Cash Price |
$288.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$241.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$446.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$446.25
|
| Rate for Payer: Dignity Health Senior |
$446.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$336.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$243.07
|
| Rate for Payer: Heritage Provider Network Senior |
$243.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$262.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$262.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$262.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$367.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$367.50
|
| Rate for Payer: Multiplan Commercial |
$393.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$189.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$173.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$446.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$446.25
|
| Rate for Payer: Vantage Medical Group Senior |
$446.25
|
|
|
HC MRI INSERTABLE IMAGING COIL
|
Facility
|
IP
|
$525.00
|
|
|
Service Code
|
CPT C1770
|
| Hospital Charge Code |
908801710
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$13,277.00 |
| Rate for Payer: Adventist Health Commercial |
$105.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$252.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,277.00
|
| Rate for Payer: Blue Shield of California Commercial |
$211.05
|
| Rate for Payer: Blue Shield of California EPN |
$211.05
|
| Rate for Payer: Cash Price |
$288.75
|
| Rate for Payer: Cash Price |
$288.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$241.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$283.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$243.07
|
| Rate for Payer: Heritage Provider Network Senior |
$243.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$262.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$262.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$262.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.25
|
| Rate for Payer: Multiplan Commercial |
$393.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$189.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$173.83
|
|
|
HC MRI LOWER EXTREMITY W/O CON
|
Facility
|
OP
|
$3,650.00
|
|
|
Service Code
|
CPT 73718
|
| Hospital Charge Code |
908801402
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$307.13 |
| Max. Negotiated Rate |
$2,737.50 |
| Rate for Payer: Adventist Health Commercial |
$730.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,574.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,507.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$460.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$337.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$307.13
|
| Rate for Payer: Blue Shield of California Commercial |
$2,326.75
|
| Rate for Payer: Blue Shield of California EPN |
$1,871.10
|
| Rate for Payer: Cash Price |
$2,007.50
|
| Rate for Payer: Cash Price |
$2,007.50
|
| Rate for Payer: Cash Price |
$2,007.50
|
| Rate for Payer: Cash Price |
$2,007.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$460.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$337.84
|
| Rate for Payer: Dignity Health Senior |
$307.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$307.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$356.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$307.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,741.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$660.65
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$353.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$912.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$386.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$386.98
|
| Rate for Payer: Multiplan Commercial |
$2,737.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$541.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$541.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$460.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$337.84
|
| Rate for Payer: Vantage Medical Group Senior |
$307.13
|
|
|
HC MRI LOWER EXTREMITY W/O CON
|
Facility
|
IP
|
$3,650.00
|
|
|
Service Code
|
CPT 73718
|
| Hospital Charge Code |
908801402
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$660.65 |
| Max. Negotiated Rate |
$2,737.50 |
| Rate for Payer: Adventist Health Commercial |
$730.00
|
| Rate for Payer: Cash Price |
$2,007.50
|
| Rate for Payer: Cash Price |
$2,007.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,471.05
|
| Rate for Payer: Heritage Provider Network Senior |
$2,471.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$660.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$912.50
|
| Rate for Payer: Multiplan Commercial |
$2,737.50
|
|
|
HC MRI LOWER EXTREM WO CONT
|
Facility
|
OP
|
$4,388.00
|
|
|
Service Code
|
CPT 73720
|
| Hospital Charge Code |
908801399
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$5,167.15 |
| Rate for Payer: Adventist Health Commercial |
$877.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,574.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,014.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$680.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$499.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$453.77
|
| Rate for Payer: Blue Shield of California Commercial |
$5,167.15
|
| Rate for Payer: Blue Shield of California EPN |
$4,155.25
|
| Rate for Payer: Cash Price |
$2,413.40
|
| Rate for Payer: Cash Price |
$2,413.40
|
| Rate for Payer: Cash Price |
$2,413.40
|
| Rate for Payer: Cash Price |
$2,413.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$680.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$499.15
|
| Rate for Payer: Dignity Health Senior |
$453.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$453.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$539.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$453.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,093.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$794.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$521.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,097.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$571.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$571.75
|
| Rate for Payer: Multiplan Commercial |
$3,291.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$854.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$854.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$680.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$499.15
|
| Rate for Payer: Vantage Medical Group Senior |
$453.77
|
|
|
HC MRI LOWER EXTREM WO CONT
|
Facility
|
IP
|
$4,388.00
|
|
|
Service Code
|
CPT 73720
|
| Hospital Charge Code |
908801399
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$794.23 |
| Max. Negotiated Rate |
$3,291.00 |
| Rate for Payer: Adventist Health Commercial |
$877.60
|
| Rate for Payer: Cash Price |
$2,413.40
|
| Rate for Payer: Cash Price |
$2,413.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,970.68
|
| Rate for Payer: Heritage Provider Network Senior |
$2,970.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$794.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,097.00
|
| Rate for Payer: Multiplan Commercial |
$3,291.00
|
|
|
HC MRI L-SPINE W & WO CONTRAST
|
Facility
|
OP
|
$6,052.00
|
|
|
Service Code
|
CPT 72158
|
| Hospital Charge Code |
908801124
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$5,235.12 |
| Rate for Payer: Adventist Health Commercial |
$1,210.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,574.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,157.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$680.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$499.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$453.77
|
| Rate for Payer: Blue Shield of California Commercial |
$5,235.12
|
| Rate for Payer: Blue Shield of California EPN |
$4,209.91
|
| Rate for Payer: Cash Price |
$3,328.60
|
| Rate for Payer: Cash Price |
$3,328.60
|
| Rate for Payer: Cash Price |
$3,328.60
|
| Rate for Payer: Cash Price |
$3,328.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$680.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$499.15
|
| Rate for Payer: Dignity Health Senior |
$453.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$453.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$505.91
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$453.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,886.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,095.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$521.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,513.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$571.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$571.75
|
| Rate for Payer: Multiplan Commercial |
$4,539.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$854.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$854.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$680.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$499.15
|
| Rate for Payer: Vantage Medical Group Senior |
$453.77
|
|
|
HC MRI L-SPINE W & WO CONTRAST
|
Facility
|
IP
|
$6,052.00
|
|
|
Service Code
|
CPT 72158
|
| Hospital Charge Code |
908801124
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$929.00 |
| Max. Negotiated Rate |
$4,539.00 |
| Rate for Payer: Adventist Health Commercial |
$1,210.40
|
| Rate for Payer: Cash Price |
$3,328.60
|
| Rate for Payer: Cash Price |
$3,328.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,097.20
|
| Rate for Payer: Heritage Provider Network Senior |
$4,097.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,095.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,513.00
|
| Rate for Payer: Multiplan Commercial |
$4,539.00
|
|
|
HC MRI LUMBAR SPINE W CONTRAST
|
Facility
|
OP
|
$4,990.00
|
|
|
Service Code
|
CPT 72149
|
| Hospital Charge Code |
908801122
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$3,742.50 |
| Rate for Payer: Adventist Health Commercial |
$998.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,574.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,428.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$680.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$499.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$453.77
|
| Rate for Payer: Blue Shield of California Commercial |
$2,826.05
|
| Rate for Payer: Blue Shield of California EPN |
$2,272.61
|
| Rate for Payer: Cash Price |
$2,744.50
|
| Rate for Payer: Cash Price |
$2,744.50
|
| Rate for Payer: Cash Price |
$2,744.50
|
| Rate for Payer: Cash Price |
$2,744.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$680.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$499.15
|
| Rate for Payer: Dignity Health Senior |
$453.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$453.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$430.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$453.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,380.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$903.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$521.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,247.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$571.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$571.75
|
| Rate for Payer: Multiplan Commercial |
$3,742.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$697.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$697.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$680.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$499.15
|
| Rate for Payer: Vantage Medical Group Senior |
$453.77
|
|
|
HC MRI LUMBAR SPINE W CONTRAST
|
Facility
|
IP
|
$4,990.00
|
|
|
Service Code
|
CPT 72149
|
| Hospital Charge Code |
908801122
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$903.19 |
| Max. Negotiated Rate |
$3,742.50 |
| Rate for Payer: Adventist Health Commercial |
$998.00
|
| Rate for Payer: Cash Price |
$2,744.50
|
| Rate for Payer: Cash Price |
$2,744.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,378.23
|
| Rate for Payer: Heritage Provider Network Senior |
$3,378.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$903.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,247.50
|
| Rate for Payer: Multiplan Commercial |
$3,742.50
|
|
|
HC MRI PELVIS W/CONTRAST
|
Facility
|
IP
|
$3,705.00
|
|
|
Service Code
|
CPT 72196
|
| Hospital Charge Code |
908801350
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$670.61 |
| Max. Negotiated Rate |
$2,778.75 |
| Rate for Payer: Adventist Health Commercial |
$741.00
|
| Rate for Payer: Cash Price |
$2,037.75
|
| Rate for Payer: Cash Price |
$2,037.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,508.28
|
| Rate for Payer: Heritage Provider Network Senior |
$2,508.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$670.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$926.25
|
| Rate for Payer: Multiplan Commercial |
$2,778.75
|
|
|
HC MRI PELVIS W/CONTRAST
|
Facility
|
OP
|
$3,705.00
|
|
|
Service Code
|
CPT 72196
|
| Hospital Charge Code |
908801350
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$2,800.03 |
| Rate for Payer: Adventist Health Commercial |
$741.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,574.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,545.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$680.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$499.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$453.77
|
| Rate for Payer: Blue Shield of California Commercial |
$2,800.03
|
| Rate for Payer: Blue Shield of California EPN |
$2,251.69
|
| Rate for Payer: Cash Price |
$2,037.75
|
| Rate for Payer: Cash Price |
$2,037.75
|
| Rate for Payer: Cash Price |
$2,037.75
|
| Rate for Payer: Cash Price |
$2,037.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$680.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$499.15
|
| Rate for Payer: Dignity Health Senior |
$453.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$453.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$429.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$453.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,767.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$670.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$521.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$926.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$571.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$571.75
|
| Rate for Payer: Multiplan Commercial |
$2,778.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$697.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$697.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$680.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$499.15
|
| Rate for Payer: Vantage Medical Group Senior |
$453.77
|
|
|
HC MRI PELVIS W/O CONTRAST
|
Facility
|
OP
|
$3,705.00
|
|
|
Service Code
|
CPT 72195
|
| Hospital Charge Code |
908801351
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$307.13 |
| Max. Negotiated Rate |
$2,778.75 |
| Rate for Payer: Adventist Health Commercial |
$741.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,574.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,545.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$460.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$337.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$307.13
|
| Rate for Payer: Blue Shield of California Commercial |
$2,335.44
|
| Rate for Payer: Blue Shield of California EPN |
$1,878.08
|
| Rate for Payer: Cash Price |
$2,037.75
|
| Rate for Payer: Cash Price |
$2,037.75
|
| Rate for Payer: Cash Price |
$2,037.75
|
| Rate for Payer: Cash Price |
$2,037.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$460.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$337.84
|
| Rate for Payer: Dignity Health Senior |
$307.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$307.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$366.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$307.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,767.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$670.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$353.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$926.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$386.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$386.98
|
| Rate for Payer: Multiplan Commercial |
$2,778.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$541.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$541.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$460.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$337.84
|
| Rate for Payer: Vantage Medical Group Senior |
$307.13
|
|
|
HC MRI PELVIS W/O CONTRAST
|
Facility
|
IP
|
$3,705.00
|
|
|
Service Code
|
CPT 72195
|
| Hospital Charge Code |
908801351
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$670.61 |
| Max. Negotiated Rate |
$2,778.75 |
| Rate for Payer: Adventist Health Commercial |
$741.00
|
| Rate for Payer: Cash Price |
$2,037.75
|
| Rate for Payer: Cash Price |
$2,037.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,508.28
|
| Rate for Payer: Heritage Provider Network Senior |
$2,508.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$670.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$926.25
|
| Rate for Payer: Multiplan Commercial |
$2,778.75
|
|
|
HC MRI PELVIS W & WO CONTRAST
|
Facility
|
OP
|
$5,607.00
|
|
|
Service Code
|
CPT 72197
|
| Hospital Charge Code |
908801352
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$5,178.72 |
| Rate for Payer: Adventist Health Commercial |
$1,121.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,574.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,852.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$680.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$499.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$453.77
|
| Rate for Payer: Blue Shield of California Commercial |
$5,178.72
|
| Rate for Payer: Blue Shield of California EPN |
$4,164.55
|
| Rate for Payer: Cash Price |
$3,083.85
|
| Rate for Payer: Cash Price |
$3,083.85
|
| Rate for Payer: Cash Price |
$3,083.85
|
| Rate for Payer: Cash Price |
$3,083.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$680.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$499.15
|
| Rate for Payer: Dignity Health Senior |
$453.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$453.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$539.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$453.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,674.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,014.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$521.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,401.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$571.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$571.75
|
| Rate for Payer: Multiplan Commercial |
$4,205.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$854.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$854.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$680.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$499.15
|
| Rate for Payer: Vantage Medical Group Senior |
$453.77
|
|
