|
HC SEDATION EA ADDL 15 MIN
|
Facility
|
IP
|
$481.00
|
|
| Hospital Charge Code |
906820142
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$87.06 |
| Max. Negotiated Rate |
$360.75 |
| Rate for Payer: Adventist Health Commercial |
$96.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$330.45
|
| Rate for Payer: Cash Price |
$216.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$325.64
|
| Rate for Payer: Heritage Provider Network Senior |
$325.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$87.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.25
|
| Rate for Payer: Multiplan Commercial |
$360.75
|
|
|
HC SEDATION EA ADDL 15 MIN
|
Facility
|
OP
|
$477.00
|
|
| Hospital Charge Code |
907201215
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$86.34 |
| Max. Negotiated Rate |
$405.45 |
| Rate for Payer: Adventist Health Commercial |
$95.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$254.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$327.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$405.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$262.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$357.75
|
| Rate for Payer: Blue Shield of California Commercial |
$296.22
|
| Rate for Payer: Blue Shield of California EPN |
$280.00
|
| Rate for Payer: Cash Price |
$214.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$310.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$405.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$405.45
|
| Rate for Payer: Dignity Health Senior |
$405.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$310.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$295.26
|
| Rate for Payer: Heritage Provider Network Senior |
$295.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$229.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.25
|
| Rate for Payer: Multiplan Commercial |
$357.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$405.45
|
| Rate for Payer: Vantage Medical Group Senior |
$405.45
|
|
|
HC SEDATION EA ADDL 15 MIN
|
Facility
|
OP
|
$481.00
|
|
| Hospital Charge Code |
906820142
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$87.06 |
| Max. Negotiated Rate |
$408.85 |
| Rate for Payer: Adventist Health Commercial |
$96.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$257.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$330.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$408.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$264.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$360.75
|
| Rate for Payer: Blue Shield of California Commercial |
$298.70
|
| Rate for Payer: Blue Shield of California EPN |
$282.35
|
| Rate for Payer: Cash Price |
$216.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$312.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$408.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$408.85
|
| Rate for Payer: Dignity Health Senior |
$408.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$312.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$297.74
|
| Rate for Payer: Heritage Provider Network Senior |
$297.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$231.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$87.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.25
|
| Rate for Payer: Multiplan Commercial |
$360.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$408.85
|
| Rate for Payer: Vantage Medical Group Senior |
$408.85
|
|
|
HC SEDATION EA ADDL 15 MIN
|
Facility
|
IP
|
$477.00
|
|
| Hospital Charge Code |
907201215
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$86.34 |
| Max. Negotiated Rate |
$357.75 |
| Rate for Payer: Adventist Health Commercial |
$95.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$327.70
|
| Rate for Payer: Cash Price |
$214.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$322.93
|
| Rate for Payer: Heritage Provider Network Senior |
$322.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.25
|
| Rate for Payer: Multiplan Commercial |
$357.75
|
|
|
HC SEDATION GT 5 YRS FIRST 30 MIN
|
Facility
|
IP
|
$869.00
|
|
| Hospital Charge Code |
906820141
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$157.29 |
| Max. Negotiated Rate |
$651.75 |
| Rate for Payer: Adventist Health Commercial |
$173.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$597.00
|
| Rate for Payer: Cash Price |
$391.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$588.31
|
| Rate for Payer: Heritage Provider Network Senior |
$588.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$157.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$217.25
|
| Rate for Payer: Multiplan Commercial |
$651.75
|
|
|
HC SEDATION GT 5 YRS FIRST 30 MIN
|
Facility
|
OP
|
$869.00
|
|
| Hospital Charge Code |
906820141
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$157.29 |
| Max. Negotiated Rate |
$738.65 |
| Rate for Payer: Adventist Health Commercial |
$173.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$464.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$597.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$738.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$477.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$651.75
|
| Rate for Payer: Blue Shield of California Commercial |
$539.65
|
| Rate for Payer: Blue Shield of California EPN |
$510.10
|
| Rate for Payer: Cash Price |
$391.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$564.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$738.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$738.65
|
| Rate for Payer: Dignity Health Senior |
$738.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$564.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$537.91
|
| Rate for Payer: Heritage Provider Network Senior |
$537.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$418.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$157.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$217.25
|
| Rate for Payer: Multiplan Commercial |
$651.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$738.65
|
| Rate for Payer: Vantage Medical Group Senior |
$738.65
|
|
|
HC SEDATION GT 5 YRS FIRST 30 MIN
|
Facility
|
OP
|
$1,254.00
|
|
| Hospital Charge Code |
907201214
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$226.97 |
| Max. Negotiated Rate |
$1,065.90 |
| Rate for Payer: Adventist Health Commercial |
$250.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$670.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$861.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,065.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$689.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$940.50
|
| Rate for Payer: Blue Shield of California Commercial |
$778.73
|
| Rate for Payer: Blue Shield of California EPN |
$736.10
|
| Rate for Payer: Cash Price |
$564.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$815.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,065.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,065.90
|
| Rate for Payer: Dignity Health Senior |
$1,065.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$815.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$776.23
|
| Rate for Payer: Heritage Provider Network Senior |
$776.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$604.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$226.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$313.50
|
| Rate for Payer: Multiplan Commercial |
$940.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,065.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1,065.90
|
|
|
HC SEDATION GT 5 YRS FIRST 30 MIN
|
Facility
|
IP
|
$1,254.00
|
|
| Hospital Charge Code |
907201214
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$226.97 |
| Max. Negotiated Rate |
$940.50 |
| Rate for Payer: Adventist Health Commercial |
$250.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$861.50
|
| Rate for Payer: Cash Price |
$564.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$848.96
|
| Rate for Payer: Heritage Provider Network Senior |
$848.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$226.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$313.50
|
| Rate for Payer: Multiplan Commercial |
$940.50
|
|
|
HC SEDATION LT 5 YRS FIRST 30 MIN
|
Facility
|
OP
|
$1,136.00
|
|
| Hospital Charge Code |
909201305
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$205.62 |
| Max. Negotiated Rate |
$965.60 |
| Rate for Payer: Adventist Health Commercial |
$227.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$607.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$780.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$965.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$624.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$852.00
|
| Rate for Payer: Blue Shield of California Commercial |
$705.46
|
| Rate for Payer: Blue Shield of California EPN |
$666.83
|
| Rate for Payer: Cash Price |
$511.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$738.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$965.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$965.60
|
| Rate for Payer: Dignity Health Senior |
$965.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$738.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$703.18
|
| Rate for Payer: Heritage Provider Network Senior |
$703.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$547.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$205.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$284.00
|
| Rate for Payer: Multiplan Commercial |
$852.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$965.60
|
| Rate for Payer: Vantage Medical Group Senior |
$965.60
|
|
|
HC SEDATION LT 5 YRS FIRST 30 MIN
|
Facility
|
OP
|
$1,254.00
|
|
| Hospital Charge Code |
907201213
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$226.97 |
| Max. Negotiated Rate |
$1,065.90 |
| Rate for Payer: Adventist Health Commercial |
$250.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$670.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$861.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,065.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$689.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$940.50
|
| Rate for Payer: Blue Shield of California Commercial |
$778.73
|
| Rate for Payer: Blue Shield of California EPN |
$736.10
|
| Rate for Payer: Cash Price |
$564.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$815.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,065.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,065.90
|
| Rate for Payer: Dignity Health Senior |
$1,065.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$815.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$776.23
|
| Rate for Payer: Heritage Provider Network Senior |
$776.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$604.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$226.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$313.50
|
| Rate for Payer: Multiplan Commercial |
$940.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,065.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1,065.90
|
|
|
HC SEDATION LT 5 YRS FIRST 30 MIN
|
Facility
|
OP
|
$996.00
|
|
| Hospital Charge Code |
906820140
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$180.28 |
| Max. Negotiated Rate |
$846.60 |
| Rate for Payer: Adventist Health Commercial |
$199.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$532.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$684.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$846.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$547.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$747.00
|
| Rate for Payer: Blue Shield of California Commercial |
$618.52
|
| Rate for Payer: Blue Shield of California EPN |
$584.65
|
| Rate for Payer: Cash Price |
$448.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$647.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$846.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$846.60
|
| Rate for Payer: Dignity Health Senior |
$846.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$647.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$616.52
|
| Rate for Payer: Heritage Provider Network Senior |
$616.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$480.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$180.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$249.00
|
| Rate for Payer: Multiplan Commercial |
$747.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$846.60
|
| Rate for Payer: Vantage Medical Group Senior |
$846.60
|
|
|
HC SEDATION LT 5 YRS FIRST 30 MIN
|
Facility
|
IP
|
$1,136.00
|
|
| Hospital Charge Code |
909201305
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$205.62 |
| Max. Negotiated Rate |
$852.00 |
| Rate for Payer: Adventist Health Commercial |
$227.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$780.43
|
| Rate for Payer: Cash Price |
$511.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$769.07
|
| Rate for Payer: Heritage Provider Network Senior |
$769.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$205.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$284.00
|
| Rate for Payer: Multiplan Commercial |
$852.00
|
|
|
HC SEDATION LT 5 YRS FIRST 30 MIN
|
Facility
|
IP
|
$1,254.00
|
|
| Hospital Charge Code |
907201213
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$226.97 |
| Max. Negotiated Rate |
$940.50 |
| Rate for Payer: Adventist Health Commercial |
$250.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$861.50
|
| Rate for Payer: Cash Price |
$564.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$848.96
|
| Rate for Payer: Heritage Provider Network Senior |
$848.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$226.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$313.50
|
| Rate for Payer: Multiplan Commercial |
$940.50
|
|
|
HC SEDATION LT 5 YRS FIRST 30 MIN
|
Facility
|
IP
|
$996.00
|
|
| Hospital Charge Code |
906820140
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$180.28 |
| Max. Negotiated Rate |
$747.00 |
| Rate for Payer: Adventist Health Commercial |
$199.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$684.25
|
| Rate for Payer: Cash Price |
$448.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$674.29
|
| Rate for Payer: Heritage Provider Network Senior |
$674.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$180.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$249.00
|
| Rate for Payer: Multiplan Commercial |
$747.00
|
|
|
HC SED RATE WESTERGREN MANUAL
|
Facility
|
IP
|
$156.00
|
|
|
Service Code
|
CPT 85651
|
| Hospital Charge Code |
900912022
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$28.24 |
| Max. Negotiated Rate |
$117.00 |
| Rate for Payer: Adventist Health Commercial |
$31.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$107.17
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$105.61
|
| Rate for Payer: Heritage Provider Network Senior |
$105.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.00
|
| Rate for Payer: Multiplan Commercial |
$117.00
|
|
|
HC SED RATE WESTERGREN MANUAL
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
CPT 85651
|
| Hospital Charge Code |
900912022
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$29.70 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$29.70
|
| Rate for Payer: Blue Shield of California Commercial |
$27.73
|
| Rate for Payer: Blue Shield of California EPN |
$21.68
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.70
|
| Rate for Payer: Dignity Health Senior |
$4.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.43
|
| Rate for Payer: Heritage Provider Network Senior |
$7.43
|
| Rate for Payer: Humana Medicare |
$4.27
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.38
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.27
|
| Rate for Payer: TriValley Medical Group Senior |
$4.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.70
|
| Rate for Payer: Vantage Medical Group Senior |
$4.27
|
|
|
HC SED RATE WESTERGRN AUTOMATED
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
CPT 85652
|
| Hospital Charge Code |
900910025
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$21.86 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.86
|
| Rate for Payer: Blue Shield of California Commercial |
$21.07
|
| Rate for Payer: Blue Shield of California EPN |
$16.47
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.97
|
| Rate for Payer: Dignity Health Senior |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$2.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.43
|
| Rate for Payer: Heritage Provider Network Senior |
$7.43
|
| Rate for Payer: Humana Medicare |
$2.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.40
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.70
|
| Rate for Payer: TriValley Medical Group Senior |
$2.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.97
|
| Rate for Payer: Vantage Medical Group Senior |
$2.70
|
|
|
HC SED RATE WESTERGRN AUTOMATED
|
Facility
|
IP
|
$132.00
|
|
|
Service Code
|
CPT 85652
|
| Hospital Charge Code |
900910025
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$23.89 |
| Max. Negotiated Rate |
$99.00 |
| Rate for Payer: Adventist Health Commercial |
$26.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$90.68
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$89.36
|
| Rate for Payer: Heritage Provider Network Senior |
$89.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$99.00
|
|
|
HC SEGURA-RETRIVAL BASKET
|
Facility
|
IP
|
$830.00
|
|
| Hospital Charge Code |
909001079
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$150.23 |
| Max. Negotiated Rate |
$622.50 |
| Rate for Payer: Adventist Health Commercial |
$166.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$570.21
|
| Rate for Payer: Cash Price |
$373.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$561.91
|
| Rate for Payer: Heritage Provider Network Senior |
$561.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$150.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$207.50
|
| Rate for Payer: Multiplan Commercial |
$622.50
|
|
|
HC SEGURA-RETRIVAL BASKET
|
Facility
|
OP
|
$830.00
|
|
| Hospital Charge Code |
909001079
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$150.23 |
| Max. Negotiated Rate |
$705.50 |
| Rate for Payer: Adventist Health Commercial |
$166.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$443.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$570.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$705.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$456.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$622.50
|
| Rate for Payer: Blue Shield of California Commercial |
$515.43
|
| Rate for Payer: Blue Shield of California EPN |
$487.21
|
| Rate for Payer: Cash Price |
$373.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$539.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$705.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$705.50
|
| Rate for Payer: Dignity Health Senior |
$705.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$539.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$513.77
|
| Rate for Payer: Heritage Provider Network Senior |
$513.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$400.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$150.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$207.50
|
| Rate for Payer: Multiplan Commercial |
$622.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$705.50
|
| Rate for Payer: Vantage Medical Group Senior |
$705.50
|
|
|
HC SELECT CATH L/R PULMONARY ART
|
Facility
|
IP
|
$1,926.00
|
|
|
Service Code
|
CPT 36014
|
| Hospital Charge Code |
909081312
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$348.61 |
| Max. Negotiated Rate |
$1,444.50 |
| Rate for Payer: Adventist Health Commercial |
$385.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,323.16
|
| Rate for Payer: Cash Price |
$866.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,303.90
|
| Rate for Payer: Heritage Provider Network Senior |
$1,303.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$348.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$481.50
|
| Rate for Payer: Multiplan Commercial |
$1,444.50
|
|
|
HC SELECT CATH L/R PULMONARY ART
|
Facility
|
OP
|
$584.00
|
|
|
Service Code
|
CPT 36014
|
| Hospital Charge Code |
906820171
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$105.70 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$116.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6,699.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$401.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$496.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$321.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$438.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,689.75
|
| Rate for Payer: Blue Shield of California EPN |
$7,468.44
|
| Rate for Payer: Cash Price |
$262.80
|
| Rate for Payer: Cash Price |
$262.80
|
| Rate for Payer: Cash Price |
$262.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$379.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$496.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$496.40
|
| Rate for Payer: Dignity Health Senior |
$496.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$361.50
|
| Rate for Payer: Heritage Provider Network Senior |
$361.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$151.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$281.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$105.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$146.00
|
| Rate for Payer: Multiplan Commercial |
$438.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,040.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$874.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$496.40
|
| Rate for Payer: Vantage Medical Group Senior |
$496.40
|
|
|
HC SELECT CATH L/R PULMONARY ART
|
Facility
|
IP
|
$584.00
|
|
|
Service Code
|
CPT 36014
|
| Hospital Charge Code |
906820171
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$105.70 |
| Max. Negotiated Rate |
$438.00 |
| Rate for Payer: Adventist Health Commercial |
$116.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$401.21
|
| Rate for Payer: Cash Price |
$262.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$395.37
|
| Rate for Payer: Heritage Provider Network Senior |
$395.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$105.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$146.00
|
| Rate for Payer: Multiplan Commercial |
$438.00
|
|
|
HC SELECT CATH L/R PULMONARY ART
|
Facility
|
OP
|
$1,926.00
|
|
|
Service Code
|
CPT 36014
|
| Hospital Charge Code |
909081312
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$151.59 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$385.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6,699.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,323.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,637.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,059.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,444.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,689.75
|
| Rate for Payer: Blue Shield of California EPN |
$7,468.44
|
| Rate for Payer: Cash Price |
$866.70
|
| Rate for Payer: Cash Price |
$866.70
|
| Rate for Payer: Cash Price |
$866.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,251.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,637.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,637.10
|
| Rate for Payer: Dignity Health Senior |
$1,637.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,192.19
|
| Rate for Payer: Heritage Provider Network Senior |
$1,192.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$151.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$928.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$348.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$481.50
|
| Rate for Payer: Multiplan Commercial |
$1,444.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,040.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$874.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,637.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1,637.10
|
|
|
HC SELECT CATH PULMON. ART SEGMENTAL
|
Facility
|
IP
|
$3,048.00
|
|
|
Service Code
|
CPT 36015
|
| Hospital Charge Code |
909081313
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$551.69 |
| Max. Negotiated Rate |
$2,286.00 |
| Rate for Payer: Adventist Health Commercial |
$609.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,093.98
|
| Rate for Payer: Cash Price |
$1,371.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,063.50
|
| Rate for Payer: Heritage Provider Network Senior |
$2,063.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$551.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$762.00
|
| Rate for Payer: Multiplan Commercial |
$2,286.00
|
|
