|
HC SHILEY TRACHEOSOFT XLT PROXIMAL CUFF 8.0
|
Facility
|
IP
|
$377.58
|
|
|
Service Code
|
CPT A7521
|
| Hospital Charge Code |
900800847
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.34 |
| Max. Negotiated Rate |
$283.18 |
| Rate for Payer: Adventist Health Commercial |
$75.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$259.40
|
| Rate for Payer: Cash Price |
$169.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$255.62
|
| Rate for Payer: Heritage Provider Network Senior |
$255.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$94.40
|
| Rate for Payer: Multiplan Commercial |
$283.18
|
|
|
HC SHILEY TRACHEOSOFT XLT PROXIMAL CUFF 8.0
|
Facility
|
OP
|
$377.58
|
|
|
Service Code
|
CPT A7521
|
| Hospital Charge Code |
900800847
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.99 |
| Max. Negotiated Rate |
$320.94 |
| Rate for Payer: Adventist Health Commercial |
$75.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$48.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$259.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$320.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$207.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$283.18
|
| Rate for Payer: Blue Shield of California Commercial |
$234.48
|
| Rate for Payer: Blue Shield of California EPN |
$221.64
|
| Rate for Payer: Cash Price |
$169.91
|
| Rate for Payer: Cash Price |
$169.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$245.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$320.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$320.94
|
| Rate for Payer: Dignity Health Senior |
$320.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$245.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$233.72
|
| Rate for Payer: Heritage Provider Network Senior |
$233.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$181.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$94.40
|
| Rate for Payer: Multiplan Commercial |
$283.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$320.94
|
| Rate for Payer: Vantage Medical Group Senior |
$320.94
|
|
|
HC SHILEY TRACHEO SOFT XLT PROXIMAL CUFFLESS 5.0
|
Facility
|
OP
|
$377.58
|
|
|
Service Code
|
CPT A7520
|
| Hospital Charge Code |
900800852
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.42 |
| Max. Negotiated Rate |
$320.94 |
| Rate for Payer: Adventist Health Commercial |
$75.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$49.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$259.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$320.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$207.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$283.18
|
| Rate for Payer: Blue Shield of California Commercial |
$234.48
|
| Rate for Payer: Blue Shield of California EPN |
$221.64
|
| Rate for Payer: Cash Price |
$169.91
|
| Rate for Payer: Cash Price |
$169.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$245.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$320.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$320.94
|
| Rate for Payer: Dignity Health Senior |
$320.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$245.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$233.72
|
| Rate for Payer: Heritage Provider Network Senior |
$233.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$181.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$94.40
|
| Rate for Payer: Multiplan Commercial |
$283.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$320.94
|
| Rate for Payer: Vantage Medical Group Senior |
$320.94
|
|
|
HC SHILEY TRACHEO SOFT XLT PROXIMAL CUFFLESS 5.0
|
Facility
|
IP
|
$377.58
|
|
|
Service Code
|
CPT A7520
|
| Hospital Charge Code |
900800852
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.34 |
| Max. Negotiated Rate |
$283.18 |
| Rate for Payer: Adventist Health Commercial |
$75.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$259.40
|
| Rate for Payer: Cash Price |
$169.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$255.62
|
| Rate for Payer: Heritage Provider Network Senior |
$255.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$94.40
|
| Rate for Payer: Multiplan Commercial |
$283.18
|
|
|
HC SHILEY TRACHEO SOFT XLT PROXIMAL CUFFLESS 6.0
|
Facility
|
IP
|
$377.58
|
|
|
Service Code
|
CPT A7520
|
| Hospital Charge Code |
900800853
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.34 |
| Max. Negotiated Rate |
$283.18 |
| Rate for Payer: Adventist Health Commercial |
$75.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$259.40
|
| Rate for Payer: Cash Price |
$169.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$255.62
|
| Rate for Payer: Heritage Provider Network Senior |
$255.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$94.40
|
| Rate for Payer: Multiplan Commercial |
$283.18
|
|
|
HC SHILEY TRACHEO SOFT XLT PROXIMAL CUFFLESS 6.0
|
Facility
|
OP
|
$377.58
|
|
|
Service Code
|
CPT A7520
|
| Hospital Charge Code |
900800853
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.42 |
| Max. Negotiated Rate |
$320.94 |
| Rate for Payer: Adventist Health Commercial |
$75.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$49.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$259.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$320.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$207.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$283.18
|
| Rate for Payer: Blue Shield of California Commercial |
$234.48
|
| Rate for Payer: Blue Shield of California EPN |
$221.64
|
| Rate for Payer: Cash Price |
$169.91
|
| Rate for Payer: Cash Price |
$169.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$245.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$320.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$320.94
|
| Rate for Payer: Dignity Health Senior |
$320.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$245.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$233.72
|
| Rate for Payer: Heritage Provider Network Senior |
$233.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$181.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$94.40
|
| Rate for Payer: Multiplan Commercial |
$283.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$320.94
|
| Rate for Payer: Vantage Medical Group Senior |
$320.94
|
|
|
HC SHILEY TRACHEO SOFT XLT PROXIMAL CUFFLESS 7.0
|
Facility
|
OP
|
$377.58
|
|
|
Service Code
|
CPT A7520
|
| Hospital Charge Code |
900800854
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.42 |
| Max. Negotiated Rate |
$320.94 |
| Rate for Payer: Adventist Health Commercial |
$75.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$49.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$259.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$320.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$207.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$283.18
|
| Rate for Payer: Blue Shield of California Commercial |
$234.48
|
| Rate for Payer: Blue Shield of California EPN |
$221.64
|
| Rate for Payer: Cash Price |
$169.91
|
| Rate for Payer: Cash Price |
$169.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$245.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$320.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$320.94
|
| Rate for Payer: Dignity Health Senior |
$320.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$245.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$233.72
|
| Rate for Payer: Heritage Provider Network Senior |
$233.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$181.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$94.40
|
| Rate for Payer: Multiplan Commercial |
$283.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$320.94
|
| Rate for Payer: Vantage Medical Group Senior |
$320.94
|
|
|
HC SHILEY TRACHEO SOFT XLT PROXIMAL CUFFLESS 7.0
|
Facility
|
IP
|
$377.58
|
|
|
Service Code
|
CPT A7520
|
| Hospital Charge Code |
900800854
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.34 |
| Max. Negotiated Rate |
$283.18 |
| Rate for Payer: Adventist Health Commercial |
$75.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$259.40
|
| Rate for Payer: Cash Price |
$169.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$255.62
|
| Rate for Payer: Heritage Provider Network Senior |
$255.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$94.40
|
| Rate for Payer: Multiplan Commercial |
$283.18
|
|
|
HC SHILEY TRACHEO SOFT XLT PROXIMAL CUFFLESS 8.0
|
Facility
|
OP
|
$377.58
|
|
|
Service Code
|
CPT A7520
|
| Hospital Charge Code |
900800855
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.42 |
| Max. Negotiated Rate |
$320.94 |
| Rate for Payer: Adventist Health Commercial |
$75.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$49.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$259.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$320.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$207.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$283.18
|
| Rate for Payer: Blue Shield of California Commercial |
$234.48
|
| Rate for Payer: Blue Shield of California EPN |
$221.64
|
| Rate for Payer: Cash Price |
$169.91
|
| Rate for Payer: Cash Price |
$169.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$245.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$320.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$320.94
|
| Rate for Payer: Dignity Health Senior |
$320.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$245.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$233.72
|
| Rate for Payer: Heritage Provider Network Senior |
$233.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$181.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$94.40
|
| Rate for Payer: Multiplan Commercial |
$283.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$320.94
|
| Rate for Payer: Vantage Medical Group Senior |
$320.94
|
|
|
HC SHILEY TRACHEO SOFT XLT PROXIMAL CUFFLESS 8.0
|
Facility
|
IP
|
$377.58
|
|
|
Service Code
|
CPT A7520
|
| Hospital Charge Code |
900800855
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.34 |
| Max. Negotiated Rate |
$283.18 |
| Rate for Payer: Adventist Health Commercial |
$75.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$259.40
|
| Rate for Payer: Cash Price |
$169.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$255.62
|
| Rate for Payer: Heritage Provider Network Senior |
$255.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$94.40
|
| Rate for Payer: Multiplan Commercial |
$283.18
|
|
|
HC SHILEY TRACH TUBE
|
Facility
|
OP
|
$270.00
|
|
| Hospital Charge Code |
900800703
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.87 |
| Max. Negotiated Rate |
$229.50 |
| Rate for Payer: Adventist Health Commercial |
$54.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$144.32
|
| 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: Blue Shield of California Commercial |
$167.67
|
| Rate for Payer: Blue Shield of California EPN |
$158.49
|
| Rate for Payer: Cash Price |
$121.50
|
| 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 |
$130.14
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$229.50
|
| Rate for Payer: Vantage Medical Group Senior |
$229.50
|
|
|
HC SHILEY TRACH TUBE
|
Facility
|
IP
|
$270.00
|
|
| Hospital Charge Code |
900800703
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.87 |
| Max. Negotiated Rate |
$202.50 |
| Rate for Payer: Adventist Health Commercial |
$54.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$185.49
|
| Rate for Payer: Cash Price |
$121.50
|
| 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 SHOULDER ARTHROGRAPHY INJ
|
Facility
|
IP
|
$664.00
|
|
|
Service Code
|
CPT 23350
|
| Hospital Charge Code |
909000113
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$120.18 |
| Max. Negotiated Rate |
$498.00 |
| Rate for Payer: Adventist Health Commercial |
$132.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$456.17
|
| Rate for Payer: Cash Price |
$298.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$449.53
|
| Rate for Payer: Heritage Provider Network Senior |
$449.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$120.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$166.00
|
| Rate for Payer: Multiplan Commercial |
$498.00
|
|
|
HC SHOULDER ARTHROGRAPHY INJ
|
Facility
|
OP
|
$664.00
|
|
|
Service Code
|
CPT 23350
|
| Hospital Charge Code |
909000113
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$120.18 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$132.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$456.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$564.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$365.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$498.00
|
| 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 |
$298.80
|
| Rate for Payer: Cash Price |
$298.80
|
| Rate for Payer: Cash Price |
$298.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$431.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$564.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$564.40
|
| Rate for Payer: Dignity Health Senior |
$564.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$411.02
|
| Rate for Payer: Heritage Provider Network Senior |
$411.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$268.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$320.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$120.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$166.00
|
| Rate for Payer: Multiplan Commercial |
$498.00
|
| 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 |
$564.40
|
| Rate for Payer: Vantage Medical Group Senior |
$564.40
|
|
|
HC SHOULDER COMPLETE UNILAT
|
Facility
|
OP
|
$1,266.00
|
|
|
Service Code
|
CPT 73030
|
| Hospital Charge Code |
909001504
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$40.34 |
| Max. Negotiated Rate |
$949.50 |
| Rate for Payer: Adventist Health Commercial |
$253.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$46.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$869.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$113.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$136.59
|
| Rate for Payer: Blue Shield of California Commercial |
$117.39
|
| Rate for Payer: Blue Shield of California EPN |
$66.75
|
| Rate for Payer: Cash Price |
$569.70
|
| Rate for Payer: Cash Price |
$569.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$822.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.89
|
| Rate for Payer: Dignity Health Senior |
$113.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$822.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$783.65
|
| Rate for Payer: Heritage Provider Network Senior |
$783.65
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$40.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$113.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$229.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$316.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$143.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$143.06
|
| Rate for Payer: Multiplan Commercial |
$949.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$113.54
|
| Rate for Payer: TriValley Medical Group Senior |
$113.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Vantage Medical Group Senior |
$113.54
|
|
|
HC SHOULDER COMPLETE UNILAT
|
Facility
|
IP
|
$1,266.00
|
|
|
Service Code
|
CPT 73030
|
| Hospital Charge Code |
909001504
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$229.15 |
| Max. Negotiated Rate |
$949.50 |
| Rate for Payer: Adventist Health Commercial |
$253.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$869.74
|
| Rate for Payer: Cash Price |
$569.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$857.08
|
| Rate for Payer: Heritage Provider Network Senior |
$857.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$229.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$316.50
|
| Rate for Payer: Multiplan Commercial |
$949.50
|
|
|
HC SHOULDER LIMITED
|
Facility
|
IP
|
$505.00
|
|
|
Service Code
|
CPT 73020
|
| Hospital Charge Code |
909001505
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$91.40 |
| Max. Negotiated Rate |
$378.75 |
| Rate for Payer: Adventist Health Commercial |
$101.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$346.94
|
| Rate for Payer: Cash Price |
$227.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$341.88
|
| Rate for Payer: Heritage Provider Network Senior |
$341.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$126.25
|
| Rate for Payer: Multiplan Commercial |
$378.75
|
|
|
HC SHOULDER LIMITED
|
Facility
|
OP
|
$505.00
|
|
|
Service Code
|
CPT 73020
|
| Hospital Charge Code |
909001505
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$26.99 |
| Max. Negotiated Rate |
$378.75 |
| Rate for Payer: Adventist Health Commercial |
$101.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$35.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$346.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$113.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$113.38
|
| Rate for Payer: Blue Shield of California Commercial |
$94.97
|
| Rate for Payer: Blue Shield of California EPN |
$54.01
|
| Rate for Payer: Cash Price |
$227.25
|
| Rate for Payer: Cash Price |
$227.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$328.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.89
|
| Rate for Payer: Dignity Health Senior |
$113.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$328.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$312.60
|
| Rate for Payer: Heritage Provider Network Senior |
$312.60
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$26.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$113.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$126.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$143.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$143.06
|
| Rate for Payer: Multiplan Commercial |
$378.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$113.54
|
| Rate for Payer: TriValley Medical Group Senior |
$113.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Vantage Medical Group Senior |
$113.54
|
|
|
HC SHUNT EVALUATION
|
Facility
|
IP
|
$1,444.00
|
|
|
Service Code
|
CPT 78645
|
| Hospital Charge Code |
909301415
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$261.36 |
| Max. Negotiated Rate |
$1,083.00 |
| Rate for Payer: Adventist Health Commercial |
$288.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$992.03
|
| Rate for Payer: Cash Price |
$649.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$977.59
|
| Rate for Payer: Heritage Provider Network Senior |
$977.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$261.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$361.00
|
| Rate for Payer: Multiplan Commercial |
$1,083.00
|
|
|
HC SHUNT EVALUATION
|
Facility
|
OP
|
$1,444.00
|
|
|
Service Code
|
CPT 78645
|
| Hospital Charge Code |
909301415
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$233.00 |
| Max. Negotiated Rate |
$1,283.13 |
| Rate for Payer: Adventist Health Commercial |
$288.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$535.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$992.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,013.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$742.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$675.33
|
| Rate for Payer: Blue Shield of California Commercial |
$699.84
|
| Rate for Payer: Blue Shield of California EPN |
$397.98
|
| Rate for Payer: Cash Price |
$649.80
|
| Rate for Payer: Cash Price |
$649.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$938.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,013.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$742.86
|
| Rate for Payer: Dignity Health Senior |
$675.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$938.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$675.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$893.84
|
| Rate for Payer: Heritage Provider Network Senior |
$893.84
|
| Rate for Payer: Humana Medicare |
$675.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$233.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$675.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,283.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$261.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$796.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$361.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$850.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$850.92
|
| Rate for Payer: Multiplan Commercial |
$1,083.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$742.86
|
| Rate for Payer: TriValley Medical Group Senior |
$675.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,013.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$742.86
|
| Rate for Payer: Vantage Medical Group Senior |
$675.33
|
|
|
HC SHUNTOGRAM
|
Facility
|
IP
|
$1,865.00
|
|
|
Service Code
|
CPT 75809
|
| Hospital Charge Code |
909001355
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$337.56 |
| Max. Negotiated Rate |
$1,398.75 |
| Rate for Payer: Adventist Health Commercial |
$373.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,281.26
|
| Rate for Payer: Cash Price |
$839.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,262.60
|
| Rate for Payer: Heritage Provider Network Senior |
$1,262.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$337.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$466.25
|
| Rate for Payer: Multiplan Commercial |
$1,398.75
|
|
|
HC SHUNTOGRAM
|
Facility
|
OP
|
$1,865.00
|
|
|
Service Code
|
CPT 75809
|
| Hospital Charge Code |
909001355
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$38.73 |
| Max. Negotiated Rate |
$1,398.75 |
| Rate for Payer: Adventist Health Commercial |
$373.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$165.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,281.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$206.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$151.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$137.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$188.04
|
| Rate for Payer: Blue Shield of California Commercial |
$161.94
|
| Rate for Payer: Blue Shield of California EPN |
$92.09
|
| Rate for Payer: Cash Price |
$839.25
|
| Rate for Payer: Cash Price |
$839.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,212.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$206.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$151.10
|
| Rate for Payer: Dignity Health Senior |
$137.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,212.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$137.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,154.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1,154.44
|
| Rate for Payer: Humana Medicare |
$137.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$38.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$137.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$260.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$337.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$162.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$466.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$173.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$173.07
|
| Rate for Payer: Multiplan Commercial |
$1,398.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$137.36
|
| Rate for Payer: TriValley Medical Group Senior |
$137.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$120.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$120.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$206.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$151.10
|
| Rate for Payer: Vantage Medical Group Senior |
$137.36
|
|
|
HC SIALOGRAM
|
Facility
|
IP
|
$760.00
|
|
|
Service Code
|
CPT 70390
|
| Hospital Charge Code |
909001167
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$137.56 |
| Max. Negotiated Rate |
$570.00 |
| Rate for Payer: Adventist Health Commercial |
$152.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$522.12
|
| Rate for Payer: Cash Price |
$342.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$514.52
|
| Rate for Payer: Heritage Provider Network Senior |
$514.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$137.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$190.00
|
| Rate for Payer: Multiplan Commercial |
$570.00
|
|
|
HC SIALOGRAM
|
Facility
|
OP
|
$760.00
|
|
|
Service Code
|
CPT 70390
|
| Hospital Charge Code |
909001167
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$64.47 |
| Max. Negotiated Rate |
$581.70 |
| Rate for Payer: Adventist Health Commercial |
$152.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$184.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$522.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$459.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$336.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$306.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$425.62
|
| Rate for Payer: Blue Shield of California Commercial |
$366.46
|
| Rate for Payer: Blue Shield of California EPN |
$208.40
|
| Rate for Payer: Cash Price |
$342.00
|
| Rate for Payer: Cash Price |
$342.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$494.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$459.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$336.78
|
| Rate for Payer: Dignity Health Senior |
$306.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$494.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$306.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$470.44
|
| Rate for Payer: Heritage Provider Network Senior |
$470.44
|
| Rate for Payer: Humana Medicare |
$306.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$64.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$306.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$581.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$137.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$361.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$190.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$385.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$385.76
|
| Rate for Payer: Multiplan Commercial |
$570.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$306.16
|
| Rate for Payer: TriValley Medical Group Senior |
$306.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$378.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$378.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$459.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$336.78
|
| Rate for Payer: Vantage Medical Group Senior |
$306.16
|
|
|
HC SIALOGRAPHY DUCT DILATION
|
Facility
|
OP
|
$3,031.00
|
|
|
Service Code
|
CPT 42660
|
| Hospital Charge Code |
909000133
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$60.98 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$606.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,082.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,031.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$756.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$687.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,517.28
|
| Rate for Payer: Blue Shield of California EPN |
$3,022.94
|
| Rate for Payer: Cash Price |
$1,363.95
|
| Rate for Payer: Cash Price |
$1,363.95
|
| Rate for Payer: Cash Price |
$1,363.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,970.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,031.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$756.18
|
| Rate for Payer: Dignity Health Senior |
$687.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$687.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,876.19
|
| Rate for Payer: Heritage Provider Network Senior |
$845.55
|
| Rate for Payer: Humana Medicare |
$687.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$60.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$687.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,306.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$548.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$811.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$757.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$866.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$866.17
|
| Rate for Payer: Multiplan Commercial |
$2,273.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$756.18
|
| Rate for Payer: TriValley Medical Group Senior |
$756.18
|
| 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 Commercial/Exchange |
$1,031.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$756.18
|
| Rate for Payer: Vantage Medical Group Senior |
$687.44
|
|
