|
HC O2/CO2 EXHALED AIR ANALYSIS RSPC
|
Facility
|
OP
|
$846.00
|
|
|
Service Code
|
CPT 94681
|
| Hospital Charge Code |
900894681
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$132.84 |
| Max. Negotiated Rate |
$634.50 |
| Rate for Payer: Adventist Health Commercial |
$169.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$452.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$581.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$593.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$435.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$395.66
|
| Rate for Payer: Blue Shield of California Commercial |
$532.42
|
| Rate for Payer: Blue Shield of California EPN |
$428.15
|
| Rate for Payer: Cash Price |
$465.30
|
| Rate for Payer: Cash Price |
$465.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$549.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$593.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$435.23
|
| Rate for Payer: Dignity Health Senior |
$395.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$549.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$395.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$523.67
|
| Rate for Payer: Heritage Provider Network Senior |
$523.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$132.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$395.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$403.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$153.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$455.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$211.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$498.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$498.53
|
| Rate for Payer: Multiplan Commercial |
$634.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$435.23
|
| Rate for Payer: TriValley Medical Group Senior |
$395.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$423.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$423.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$593.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$435.23
|
| Rate for Payer: Vantage Medical Group Senior |
$395.66
|
|
|
HC O2/CO2 EXHALED AIR ANALYSIS RSPC
|
Facility
|
IP
|
$846.00
|
|
|
Service Code
|
CPT 94681
|
| Hospital Charge Code |
900894681
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$153.13 |
| Max. Negotiated Rate |
$634.50 |
| Rate for Payer: Adventist Health Commercial |
$169.20
|
| Rate for Payer: Cash Price |
$465.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$572.74
|
| Rate for Payer: Heritage Provider Network Senior |
$572.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$153.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$211.50
|
| Rate for Payer: Multiplan Commercial |
$634.50
|
|
|
HC O2 UPTAKE REST EXERCISE
|
Facility
|
IP
|
$476.00
|
|
|
Service Code
|
CPT 94680
|
| Hospital Charge Code |
900801032
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$86.16 |
| Max. Negotiated Rate |
$357.00 |
| Rate for Payer: Adventist Health Commercial |
$95.20
|
| Rate for Payer: Cash Price |
$261.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$322.25
|
| Rate for Payer: Heritage Provider Network Senior |
$322.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.00
|
| Rate for Payer: Multiplan Commercial |
$357.00
|
|
|
HC O2 UPTAKE REST EXERCISE
|
Facility
|
OP
|
$476.00
|
|
|
Service Code
|
CPT 94680
|
| Hospital Charge Code |
900801032
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$66.42 |
| Max. Negotiated Rate |
$374.26 |
| Rate for Payer: Adventist Health Commercial |
$95.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$254.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$327.01
|
| 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 |
$374.26
|
| Rate for Payer: Blue Shield of California EPN |
$300.96
|
| Rate for Payer: Cash Price |
$261.80
|
| Rate for Payer: Cash Price |
$261.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$309.40
|
| 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 |
$309.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$198.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$294.64
|
| Rate for Payer: Heritage Provider Network Senior |
$294.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$66.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$198.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$227.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$228.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.00
|
| 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 |
$357.00
|
| 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 |
$238.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$238.00
|
| 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 O2 UPTAKE REST INDIRECT
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
CPT 94690
|
| Hospital Charge Code |
900801015
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$24.07 |
| Max. Negotiated Rate |
$399.65 |
| Rate for Payer: Adventist Health Commercial |
$65.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$174.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$224.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$113.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$83.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$75.47
|
| Rate for Payer: Blue Shield of California Commercial |
$399.65
|
| Rate for Payer: Blue Shield of California EPN |
$321.38
|
| Rate for Payer: Cash Price |
$179.85
|
| Rate for Payer: Cash Price |
$179.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$212.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$113.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$83.02
|
| Rate for Payer: Dignity Health Senior |
$75.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$212.55
|
| Rate for Payer: EPIC Health Plan Medicare |
$75.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$202.41
|
| Rate for Payer: Heritage Provider Network Senior |
$202.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$24.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$75.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$155.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$86.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$81.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$95.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$95.09
|
| Rate for Payer: Multiplan Commercial |
$245.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$83.02
|
| Rate for Payer: TriValley Medical Group Senior |
$75.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$163.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$163.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$113.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$83.02
|
| Rate for Payer: Vantage Medical Group Senior |
$75.47
|
|
|
HC O2 UPTAKE REST INDIRECT
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
CPT 94690
|
| Hospital Charge Code |
900801015
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$59.19 |
| Max. Negotiated Rate |
$245.25 |
| Rate for Payer: Adventist Health Commercial |
$65.40
|
| Rate for Payer: Cash Price |
$179.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$221.38
|
| Rate for Payer: Heritage Provider Network Senior |
$221.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$81.75
|
| Rate for Payer: Multiplan Commercial |
$245.25
|
|
|
HC OBSTETRIC PANEL
|
Facility
|
OP
|
$284.00
|
|
|
Service Code
|
CPT 80055
|
| Hospital Charge Code |
900913621
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$47.81 |
| Max. Negotiated Rate |
$274.70 |
| Rate for Payer: Adventist Health Commercial |
$56.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$151.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$195.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$71.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$47.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$150.34
|
| Rate for Payer: Blue Shield of California Commercial |
$274.70
|
| Rate for Payer: Blue Shield of California EPN |
$220.91
|
| Rate for Payer: Cash Price |
$156.20
|
| Rate for Payer: Cash Price |
$156.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$184.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$52.59
|
| Rate for Payer: Dignity Health Senior |
$47.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$184.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$47.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$175.80
|
| Rate for Payer: Heritage Provider Network Senior |
$175.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$58.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$47.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$135.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$51.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$54.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$71.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$60.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$60.24
|
| Rate for Payer: Multiplan Commercial |
$213.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$47.81
|
| Rate for Payer: TriValley Medical Group Senior |
$47.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$51.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$51.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$71.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$52.59
|
| Rate for Payer: Vantage Medical Group Senior |
$47.81
|
|
|
HC OBSTETRIC PANEL
|
Facility
|
IP
|
$284.00
|
|
|
Service Code
|
CPT 80055
|
| Hospital Charge Code |
900913621
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.40 |
| Max. Negotiated Rate |
$213.00 |
| Rate for Payer: Adventist Health Commercial |
$56.80
|
| Rate for Payer: Cash Price |
$156.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$192.27
|
| Rate for Payer: Heritage Provider Network Senior |
$192.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$51.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$71.00
|
| Rate for Payer: Multiplan Commercial |
$213.00
|
|
|
HC OB ULTRASOUND RPT/FOLLOW-UP ADDL FETUS
|
Facility
|
IP
|
$2,059.00
|
|
|
Service Code
|
CPT 76816 59
|
| Hospital Charge Code |
906601320
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$372.68 |
| Max. Negotiated Rate |
$1,544.25 |
| Rate for Payer: Adventist Health Commercial |
$411.80
|
| Rate for Payer: Cash Price |
$1,132.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,393.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1,393.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$372.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$514.75
|
| Rate for Payer: Multiplan Commercial |
$1,544.25
|
|
|
HC OB ULTRASOUND RPT/FOLLOW-UP ADDL FETUS
|
Facility
|
OP
|
$2,059.00
|
|
|
Service Code
|
CPT 76816 59
|
| Hospital Charge Code |
906601320
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$83.98 |
| Max. Negotiated Rate |
$1,750.15 |
| Rate for Payer: Adventist Health Commercial |
$411.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,100.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,414.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,750.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,132.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,544.25
|
| Rate for Payer: Blue Shield of California Commercial |
$234.91
|
| Rate for Payer: Blue Shield of California EPN |
$188.91
|
| Rate for Payer: Cash Price |
$1,132.45
|
| Rate for Payer: Cash Price |
$1,132.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,338.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,750.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,750.15
|
| Rate for Payer: Dignity Health Senior |
$1,750.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,338.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,274.52
|
| Rate for Payer: Heritage Provider Network Senior |
$1,274.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$83.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$982.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$372.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$514.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,441.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,441.30
|
| Rate for Payer: Multiplan Commercial |
$1,544.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$100.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$100.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,750.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,750.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1,750.15
|
|
|
HC OB ULTRASOUND RPT/FOLLOW-UP SINGLE FETUS
|
Facility
|
IP
|
$2,059.00
|
|
|
Service Code
|
CPT 76816
|
| Hospital Charge Code |
906601311
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$372.68 |
| Max. Negotiated Rate |
$1,544.25 |
| Rate for Payer: Adventist Health Commercial |
$411.80
|
| Rate for Payer: Cash Price |
$1,132.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,393.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1,393.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$372.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$514.75
|
| Rate for Payer: Multiplan Commercial |
$1,544.25
|
|
|
HC OB ULTRASOUND RPT/FOLLOW-UP SINGLE FETUS
|
Facility
|
OP
|
$2,059.00
|
|
|
Service Code
|
CPT 76816
|
| Hospital Charge Code |
906601311
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$100.67 |
| Max. Negotiated Rate |
$1,544.25 |
| Rate for Payer: Adventist Health Commercial |
$411.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,100.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,414.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$135.12
|
| Rate for Payer: Blue Shield of California Commercial |
$234.91
|
| Rate for Payer: Blue Shield of California EPN |
$188.91
|
| Rate for Payer: Cash Price |
$1,132.45
|
| Rate for Payer: Cash Price |
$1,132.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,338.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$202.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$148.63
|
| Rate for Payer: Dignity Health Senior |
$135.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,338.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$135.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,274.52
|
| Rate for Payer: Heritage Provider Network Senior |
$1,274.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$167.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$135.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$982.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$372.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$155.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$514.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$170.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$170.25
|
| Rate for Payer: Multiplan Commercial |
$1,544.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$135.12
|
| Rate for Payer: TriValley Medical Group Senior |
$135.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$100.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$100.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Vantage Medical Group Senior |
$135.12
|
|
|
HC OB US AFI LMTD 1 OR MORE FETUS
|
Facility
|
OP
|
$1,032.00
|
|
|
Service Code
|
CPT 76815
|
| Hospital Charge Code |
910400110
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$100.67 |
| Max. Negotiated Rate |
$774.00 |
| Rate for Payer: Adventist Health Commercial |
$206.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$551.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$708.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$135.12
|
| Rate for Payer: Blue Shield of California Commercial |
$300.43
|
| Rate for Payer: Blue Shield of California EPN |
$241.60
|
| Rate for Payer: Cash Price |
$567.60
|
| Rate for Payer: Cash Price |
$567.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$670.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$202.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$148.63
|
| Rate for Payer: Dignity Health Senior |
$135.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$670.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$135.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$638.81
|
| Rate for Payer: Heritage Provider Network Senior |
$638.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$101.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$135.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$492.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$186.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$155.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$258.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$170.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$170.25
|
| Rate for Payer: Multiplan Commercial |
$774.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$135.12
|
| Rate for Payer: TriValley Medical Group Senior |
$135.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$100.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$100.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Vantage Medical Group Senior |
$135.12
|
|
|
HC OB US AFI LMTD 1 OR MORE FETUS
|
Facility
|
IP
|
$1,032.00
|
|
|
Service Code
|
CPT 76815
|
| Hospital Charge Code |
910400110
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$186.79 |
| Max. Negotiated Rate |
$774.00 |
| Rate for Payer: Adventist Health Commercial |
$206.40
|
| Rate for Payer: Cash Price |
$567.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$698.66
|
| Rate for Payer: Heritage Provider Network Senior |
$698.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$186.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$258.00
|
| Rate for Payer: Multiplan Commercial |
$774.00
|
|
|
HC OCCLUSION CATHETER
|
Facility
|
IP
|
$595.00
|
|
|
Service Code
|
CPT C2628
|
| Hospital Charge Code |
909081214
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$107.69 |
| Max. Negotiated Rate |
$446.25 |
| Rate for Payer: Adventist Health Commercial |
$119.00
|
| Rate for Payer: Cash Price |
$327.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$402.81
|
| Rate for Payer: Heritage Provider Network Senior |
$402.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$148.75
|
| Rate for Payer: Multiplan Commercial |
$446.25
|
|
|
HC OCCLUSION CATHETER
|
Facility
|
OP
|
$595.00
|
|
|
Service Code
|
CPT C2628
|
| Hospital Charge Code |
909081214
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$107.69 |
| Max. Negotiated Rate |
$505.75 |
| Rate for Payer: Adventist Health Commercial |
$119.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$318.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$408.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$505.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$327.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$446.25
|
| Rate for Payer: Blue Shield of California Commercial |
$362.95
|
| Rate for Payer: Blue Shield of California EPN |
$290.36
|
| Rate for Payer: Cash Price |
$327.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$386.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$505.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$505.75
|
| Rate for Payer: Dignity Health Senior |
$505.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$386.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$368.31
|
| Rate for Payer: Heritage Provider Network Senior |
$368.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$283.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$148.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$416.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$416.50
|
| Rate for Payer: Multiplan Commercial |
$446.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$297.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$297.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$505.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$505.75
|
| Rate for Payer: Vantage Medical Group Senior |
$505.75
|
|
|
HC OCCLUSIVE DEVICE IN VEIN ART
|
Facility
|
IP
|
$981.00
|
|
|
Service Code
|
CPT G0269
|
| Hospital Charge Code |
906811384
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$177.56 |
| Max. Negotiated Rate |
$735.75 |
| Rate for Payer: Adventist Health Commercial |
$196.20
|
| Rate for Payer: Cash Price |
$539.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$664.14
|
| Rate for Payer: Heritage Provider Network Senior |
$664.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$177.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$245.25
|
| Rate for Payer: Multiplan Commercial |
$735.75
|
|
|
HC OCCLUSIVE DEVICE IN VEIN ART
|
Facility
|
OP
|
$1,020.00
|
|
|
Service Code
|
CPT G0269
|
| Hospital Charge Code |
906820128
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$184.62 |
| Max. Negotiated Rate |
$12,620.00 |
| Rate for Payer: Adventist Health Commercial |
$204.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12,620.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$700.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$867.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$561.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$765.00
|
| 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 |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$663.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$867.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$867.00
|
| Rate for Payer: Dignity Health Senior |
$867.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$612.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$631.38
|
| Rate for Payer: Heritage Provider Network Senior |
$631.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$486.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$184.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$255.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$714.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$714.00
|
| Rate for Payer: Multiplan Commercial |
$765.00
|
| 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 |
$867.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$867.00
|
| Rate for Payer: Vantage Medical Group Senior |
$867.00
|
|
|
HC OCCLUSIVE DEVICE IN VEIN ART
|
Facility
|
IP
|
$1,020.00
|
|
|
Service Code
|
CPT G0269
|
| Hospital Charge Code |
906820128
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$184.62 |
| Max. Negotiated Rate |
$765.00 |
| Rate for Payer: Adventist Health Commercial |
$204.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$690.54
|
| Rate for Payer: Heritage Provider Network Senior |
$690.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$184.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$255.00
|
| Rate for Payer: Multiplan Commercial |
$765.00
|
|
|
HC OCCLUSIVE DEVICE IN VEIN ART
|
Facility
|
OP
|
$981.00
|
|
|
Service Code
|
CPT G0269
|
| Hospital Charge Code |
906811384
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$177.56 |
| Max. Negotiated Rate |
$12,620.00 |
| Rate for Payer: Adventist Health Commercial |
$196.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12,620.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$673.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$833.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$539.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$735.75
|
| 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 |
$539.55
|
| Rate for Payer: Cash Price |
$539.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$637.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$833.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$833.85
|
| Rate for Payer: Dignity Health Senior |
$833.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$588.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$607.24
|
| Rate for Payer: Heritage Provider Network Senior |
$607.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$467.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$177.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$245.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$686.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$686.70
|
| Rate for Payer: Multiplan Commercial |
$735.75
|
| 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 |
$833.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$833.85
|
| Rate for Payer: Vantage Medical Group Senior |
$833.85
|
|
|
HC OCC THER APP OF SURFACE NEUROSTIMULATOR
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
CPT 64550
|
| Hospital Charge Code |
901307015
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$48.87 |
| Max. Negotiated Rate |
$354.00 |
| Rate for Payer: Adventist Health Commercial |
$110.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$144.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$185.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$229.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$148.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$202.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$334.00
|
| Rate for Payer: Blue Shield of California Commercial |
$354.00
|
| Rate for Payer: Blue Shield of California EPN |
$284.00
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$175.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$229.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$229.50
|
| Rate for Payer: Dignity Health Senior |
$229.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$175.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$167.13
|
| Rate for Payer: Heritage Provider Network Senior |
$167.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$128.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$189.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$189.00
|
| Rate for Payer: Multiplan Commercial |
$202.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$261.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$220.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$229.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$229.50
|
| Rate for Payer: Vantage Medical Group Senior |
$229.50
|
|
|
HC OCC THER APP OF SURFACE NEUROSTIMULATOR
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
CPT 64550
|
| Hospital Charge Code |
901307015
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$48.87 |
| Max. Negotiated Rate |
$202.50 |
| Rate for Payer: Adventist Health Commercial |
$54.00
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$182.79
|
| Rate for Payer: Heritage Provider Network Senior |
$182.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.50
|
| Rate for Payer: Multiplan Commercial |
$202.50
|
|
|
HC OCC THER EVALUATION INITIAL 15MIN
|
Facility
|
IP
|
$214.00
|
|
| Hospital Charge Code |
901309051
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$38.73 |
| Max. Negotiated Rate |
$160.50 |
| Rate for Payer: Adventist Health Commercial |
$42.80
|
| Rate for Payer: Cash Price |
$117.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$144.88
|
| Rate for Payer: Heritage Provider Network Senior |
$144.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.50
|
| Rate for Payer: Multiplan Commercial |
$160.50
|
|
|
HC OCC THER EVALUATION INITIAL 15MIN
|
Facility
|
OP
|
$214.00
|
|
| Hospital Charge Code |
901309051
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$38.73 |
| Max. Negotiated Rate |
$354.00 |
| Rate for Payer: Adventist Health Commercial |
$87.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$114.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$147.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$181.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$117.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$160.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$334.00
|
| Rate for Payer: Blue Shield of California Commercial |
$354.00
|
| Rate for Payer: Blue Shield of California EPN |
$284.00
|
| Rate for Payer: Cash Price |
$117.70
|
| Rate for Payer: Cash Price |
$117.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$139.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$181.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$181.90
|
| Rate for Payer: Dignity Health Senior |
$181.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$139.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$132.47
|
| Rate for Payer: Heritage Provider Network Senior |
$132.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$102.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$149.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$149.80
|
| Rate for Payer: Multiplan Commercial |
$160.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$261.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$220.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$181.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$181.90
|
| Rate for Payer: Vantage Medical Group Senior |
$181.90
|
|
|
HC OCC THER EVALUATION INITIAL 30MIN
|
Facility
|
IP
|
$757.00
|
|
| Hospital Charge Code |
901309050
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$137.02 |
| Max. Negotiated Rate |
$567.75 |
| Rate for Payer: Adventist Health Commercial |
$151.40
|
| Rate for Payer: Cash Price |
$416.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$512.49
|
| Rate for Payer: Heritage Provider Network Senior |
$512.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$137.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.25
|
| Rate for Payer: Multiplan Commercial |
$567.75
|
|
