|
HC SIMP REP SUP WND 5.1 - 7.5 CM
|
Facility
|
IP
|
$1,128.00
|
|
|
Service Code
|
CPT 12014
|
| Hospital Charge Code |
900501027
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$204.17 |
| Max. Negotiated Rate |
$846.00 |
| Rate for Payer: Adventist Health Commercial |
$225.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$774.94
|
| Rate for Payer: Cash Price |
$507.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$763.66
|
| Rate for Payer: Heritage Provider Network Senior |
$763.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$204.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$282.00
|
| Rate for Payer: Multiplan Commercial |
$846.00
|
|
|
HC SIMP REP SUP WND 7.6 - 12.5 CM
|
Facility
|
OP
|
$997.00
|
|
|
Service Code
|
CPT 12004
|
| Hospital Charge Code |
900501022
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$180.46 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$199.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$684.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Cash Price |
$448.65
|
| Rate for Payer: Cash Price |
$448.65
|
| Rate for Payer: Cash Price |
$448.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$648.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: Dignity Health Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$250.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$674.97
|
| Rate for Payer: Heritage Provider Network Senior |
$674.97
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$480.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$180.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$295.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$249.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.18
|
| Rate for Payer: Multiplan Commercial |
$747.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$362.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$333.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Vantage Medical Group Senior |
$250.14
|
|
|
HC SIMP REP SUP WND 7.6 - 12.5 CM
|
Facility
|
IP
|
$997.00
|
|
|
Service Code
|
CPT 12004
|
| Hospital Charge Code |
900501022
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$180.46 |
| Max. Negotiated Rate |
$747.75 |
| Rate for Payer: Adventist Health Commercial |
$199.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$684.94
|
| Rate for Payer: Cash Price |
$448.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$674.97
|
| Rate for Payer: Heritage Provider Network Senior |
$674.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$180.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$249.25
|
| Rate for Payer: Multiplan Commercial |
$747.75
|
|
|
HC SIMP REP SUP WND 7.6-12.5CM FACE
|
Facility
|
IP
|
$1,241.00
|
|
|
Service Code
|
CPT 12015
|
| Hospital Charge Code |
900501028
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$224.62 |
| Max. Negotiated Rate |
$930.75 |
| Rate for Payer: Adventist Health Commercial |
$248.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$852.57
|
| Rate for Payer: Cash Price |
$558.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$840.16
|
| Rate for Payer: Heritage Provider Network Senior |
$840.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$224.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$310.25
|
| Rate for Payer: Multiplan Commercial |
$930.75
|
|
|
HC SIMP REP SUP WND 7.6-12.5CM FACE
|
Facility
|
OP
|
$1,241.00
|
|
|
Service Code
|
CPT 12015
|
| Hospital Charge Code |
900501028
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$224.62 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$248.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$852.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Cash Price |
$558.45
|
| Rate for Payer: Cash Price |
$558.45
|
| Rate for Payer: Cash Price |
$558.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$806.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: Dignity Health Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$250.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$840.16
|
| Rate for Payer: Heritage Provider Network Senior |
$840.16
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$598.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$224.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$295.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$310.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.18
|
| Rate for Payer: Multiplan Commercial |
$930.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$450.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$414.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Vantage Medical Group Senior |
$250.14
|
|
|
HC SIMP REP SUP WND GT 30.0CM
|
Facility
|
OP
|
$1,767.00
|
|
|
Service Code
|
CPT 12018
|
| Hospital Charge Code |
900501732
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$250.14 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$353.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,213.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Cash Price |
$795.15
|
| Rate for Payer: Cash Price |
$795.15
|
| Rate for Payer: Cash Price |
$795.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,148.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: Dignity Health Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$250.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,196.26
|
| Rate for Payer: Heritage Provider Network Senior |
$1,196.26
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$851.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$319.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$295.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$441.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.18
|
| Rate for Payer: Multiplan Commercial |
$1,325.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$641.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$590.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Vantage Medical Group Senior |
$250.14
|
|
|
HC SIMP REP SUP WND GT 30.0CM
|
Facility
|
IP
|
$1,767.00
|
|
|
Service Code
|
CPT 12018
|
| Hospital Charge Code |
900501732
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$319.83 |
| Max. Negotiated Rate |
$1,325.25 |
| Rate for Payer: Adventist Health Commercial |
$353.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,213.93
|
| Rate for Payer: Cash Price |
$795.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,196.26
|
| Rate for Payer: Heritage Provider Network Senior |
$1,196.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$319.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$441.75
|
| Rate for Payer: Multiplan Commercial |
$1,325.25
|
|
|
HC SIMP REP SUP WND LT 2.5 CM
|
Facility
|
OP
|
$782.00
|
|
|
Service Code
|
CPT 12001
|
| Hospital Charge Code |
900501020
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$141.54 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$156.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$537.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Cash Price |
$351.90
|
| Rate for Payer: Cash Price |
$351.90
|
| Rate for Payer: Cash Price |
$351.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$508.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: Dignity Health Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$250.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$529.41
|
| Rate for Payer: Heritage Provider Network Senior |
$529.41
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$376.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$141.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$295.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$195.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.18
|
| Rate for Payer: Multiplan Commercial |
$586.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$283.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$261.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Vantage Medical Group Senior |
$250.14
|
|
|
HC SIMP REP SUP WND LT 2.5 CM
|
Facility
|
IP
|
$782.00
|
|
|
Service Code
|
CPT 12001
|
| Hospital Charge Code |
900501020
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$141.54 |
| Max. Negotiated Rate |
$586.50 |
| Rate for Payer: Adventist Health Commercial |
$156.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$537.23
|
| Rate for Payer: Cash Price |
$351.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$529.41
|
| Rate for Payer: Heritage Provider Network Senior |
$529.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$141.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$195.50
|
| Rate for Payer: Multiplan Commercial |
$586.50
|
|
|
HC SIMP REP SUP WND LT 2.5CM FACE
|
Facility
|
IP
|
$834.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
900501025
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$150.95 |
| Max. Negotiated Rate |
$625.50 |
| Rate for Payer: Adventist Health Commercial |
$166.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$572.96
|
| Rate for Payer: Cash Price |
$375.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$564.62
|
| Rate for Payer: Heritage Provider Network Senior |
$564.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$150.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$208.50
|
| Rate for Payer: Multiplan Commercial |
$625.50
|
|
|
HC SIMP REP SUP WND LT 2.5CM FACE
|
Facility
|
OP
|
$834.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
900501025
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$131.95 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$166.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$131.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$572.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Cash Price |
$375.30
|
| Rate for Payer: Cash Price |
$375.30
|
| Rate for Payer: Cash Price |
$375.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$542.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: Dignity Health Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$250.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$564.62
|
| Rate for Payer: Heritage Provider Network Senior |
$564.62
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$401.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$150.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$295.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$208.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.18
|
| Rate for Payer: Multiplan Commercial |
$625.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$302.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$278.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Vantage Medical Group Senior |
$250.14
|
|
|
HC SIMP REP SUP WND OVER 30.0 CM
|
Facility
|
OP
|
$1,395.00
|
|
|
Service Code
|
CPT 12007
|
| Hospital Charge Code |
900501024
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$250.14 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$279.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$958.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Cash Price |
$627.75
|
| Rate for Payer: Cash Price |
$627.75
|
| Rate for Payer: Cash Price |
$627.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$906.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: Dignity Health Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$250.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$944.42
|
| Rate for Payer: Heritage Provider Network Senior |
$944.42
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$672.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$252.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$295.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$348.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.18
|
| Rate for Payer: Multiplan Commercial |
$1,046.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$506.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$466.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Vantage Medical Group Senior |
$250.14
|
|
|
HC SIMP REP SUP WND OVER 30.0 CM
|
Facility
|
IP
|
$1,395.00
|
|
|
Service Code
|
CPT 12007
|
| Hospital Charge Code |
900501024
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$252.50 |
| Max. Negotiated Rate |
$1,046.25 |
| Rate for Payer: Adventist Health Commercial |
$279.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$958.36
|
| Rate for Payer: Cash Price |
$627.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$944.42
|
| Rate for Payer: Heritage Provider Network Senior |
$944.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$252.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$348.75
|
| Rate for Payer: Multiplan Commercial |
$1,046.25
|
|
|
HC SIM REP SUP WND 12.6-20CM FACE
|
Facility
|
IP
|
$1,468.00
|
|
|
Service Code
|
CPT 12016
|
| Hospital Charge Code |
900501407
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$265.71 |
| Max. Negotiated Rate |
$1,101.00 |
| Rate for Payer: Adventist Health Commercial |
$293.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,008.52
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$993.84
|
| Rate for Payer: Heritage Provider Network Senior |
$993.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$265.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$367.00
|
| Rate for Payer: Multiplan Commercial |
$1,101.00
|
|
|
HC SIM REP SUP WND 12.6-20CM FACE
|
Facility
|
OP
|
$1,468.00
|
|
|
Service Code
|
CPT 12016
|
| Hospital Charge Code |
900501407
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$265.71 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$293.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,008.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$498.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$954.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$747.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$548.02
|
| Rate for Payer: Dignity Health Senior |
$498.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$498.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$993.84
|
| Rate for Payer: Heritage Provider Network Senior |
$993.84
|
| Rate for Payer: Humana Medicare |
$498.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$498.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$707.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$265.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$587.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$367.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$627.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$627.73
|
| Rate for Payer: Multiplan Commercial |
$1,101.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$533.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$490.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Vantage Medical Group Senior |
$498.20
|
|
|
HC SIM REP SUP WND 20.1-30CM FACE
|
Facility
|
OP
|
$1,648.00
|
|
|
Service Code
|
CPT 12017
|
| Hospital Charge Code |
900501243
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$298.29 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$329.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,132.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$498.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Cash Price |
$741.60
|
| Rate for Payer: Cash Price |
$741.60
|
| Rate for Payer: Cash Price |
$741.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,071.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$747.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$548.02
|
| Rate for Payer: Dignity Health Senior |
$498.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$498.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,115.70
|
| Rate for Payer: Heritage Provider Network Senior |
$1,115.70
|
| Rate for Payer: Humana Medicare |
$498.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$498.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$794.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$298.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$587.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$412.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$627.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$627.73
|
| Rate for Payer: Multiplan Commercial |
$1,236.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$598.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$550.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Vantage Medical Group Senior |
$498.20
|
|
|
HC SIM REP SUP WND 20.1-30CM FACE
|
Facility
|
IP
|
$1,648.00
|
|
|
Service Code
|
CPT 12017
|
| Hospital Charge Code |
900501243
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$298.29 |
| Max. Negotiated Rate |
$1,236.00 |
| Rate for Payer: Adventist Health Commercial |
$329.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,132.18
|
| Rate for Payer: Cash Price |
$741.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,115.70
|
| Rate for Payer: Heritage Provider Network Senior |
$1,115.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$298.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$412.00
|
| Rate for Payer: Multiplan Commercial |
$1,236.00
|
|
|
HC SINOGRAM/FISTULAGRAM ABSCESS
|
Facility
|
OP
|
$1,650.00
|
|
|
Service Code
|
CPT 76080
|
| Hospital Charge Code |
909001858
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$65.19 |
| Max. Negotiated Rate |
$1,309.63 |
| Rate for Payer: Adventist Health Commercial |
$330.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$79.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,133.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,033.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$758.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$689.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$251.44
|
| Rate for Payer: Blue Shield of California Commercial |
$216.27
|
| Rate for Payer: Blue Shield of California EPN |
$122.99
|
| Rate for Payer: Cash Price |
$742.50
|
| Rate for Payer: Cash Price |
$742.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,072.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,033.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$758.21
|
| Rate for Payer: Dignity Health Senior |
$689.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,072.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$689.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,021.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1,021.35
|
| Rate for Payer: Humana Medicare |
$689.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$65.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$689.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,309.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$298.65
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$813.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$412.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$868.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$868.49
|
| Rate for Payer: Multiplan Commercial |
$1,237.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$689.28
|
| Rate for Payer: TriValley Medical Group Senior |
$689.28
|
| 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 |
$1,033.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$758.21
|
| Rate for Payer: Vantage Medical Group Senior |
$689.28
|
|
|
HC SINOGRAM/FISTULAGRAM ABSCESS
|
Facility
|
IP
|
$1,650.00
|
|
|
Service Code
|
CPT 76080
|
| Hospital Charge Code |
909001858
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$298.65 |
| Max. Negotiated Rate |
$1,237.50 |
| Rate for Payer: Adventist Health Commercial |
$330.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,133.55
|
| Rate for Payer: Cash Price |
$742.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,117.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1,117.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$298.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$412.50
|
| Rate for Payer: Multiplan Commercial |
$1,237.50
|
|
|
HC SINUS/ PARANASAL COMPLETE
|
Facility
|
IP
|
$754.00
|
|
|
Service Code
|
CPT 70220
|
| Hospital Charge Code |
909001141
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$136.47 |
| Max. Negotiated Rate |
$565.50 |
| Rate for Payer: Adventist Health Commercial |
$150.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$518.00
|
| Rate for Payer: Cash Price |
$339.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$510.46
|
| Rate for Payer: Heritage Provider Network Senior |
$510.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$136.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$188.50
|
| Rate for Payer: Multiplan Commercial |
$565.50
|
|
|
HC SINUS/ PARANASAL COMPLETE
|
Facility
|
OP
|
$754.00
|
|
|
Service Code
|
CPT 70220
|
| Hospital Charge Code |
909001141
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$52.03 |
| Max. Negotiated Rate |
$565.50 |
| Rate for Payer: Adventist Health Commercial |
$150.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$59.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$518.00
|
| 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 |
$188.49
|
| 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 |
$339.30
|
| Rate for Payer: Cash Price |
$339.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$490.10
|
| 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 |
$490.10
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$466.73
|
| Rate for Payer: Heritage Provider Network Senior |
$466.73
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$52.03
|
| 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 |
$136.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$188.50
|
| 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 |
$565.50
|
| 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 SIROLIMUS
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
CPT 80195
|
| Hospital Charge Code |
900912167
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.59 |
| Max. Negotiated Rate |
$112.36 |
| Rate for Payer: Adventist Health Commercial |
$10.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$39.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$36.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$112.36
|
| Rate for Payer: Blue Shield of California Commercial |
$107.16
|
| Rate for Payer: Blue Shield of California EPN |
$83.77
|
| Rate for Payer: Cash Price |
$23.85
|
| Rate for Payer: Cash Price |
$23.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$34.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.10
|
| Rate for Payer: Dignity Health Senior |
$13.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.81
|
| Rate for Payer: Heritage Provider Network Senior |
$32.81
|
| Rate for Payer: Humana Medicare |
$13.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$26.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$16.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.30
|
| Rate for Payer: Multiplan Commercial |
$39.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.73
|
| Rate for Payer: TriValley Medical Group Senior |
$13.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.10
|
| Rate for Payer: Vantage Medical Group Senior |
$13.73
|
|
|
HC SIROLIMUS
|
Facility
|
IP
|
$216.00
|
|
|
Service Code
|
CPT 80195
|
| Hospital Charge Code |
900912167
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$39.10 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Adventist Health Commercial |
$43.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$148.39
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$146.23
|
| Rate for Payer: Heritage Provider Network Senior |
$146.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54.00
|
| Rate for Payer: Multiplan Commercial |
$162.00
|
|
|
HC S & I STENT/CHEST VERT ART EA
|
Facility
|
OP
|
$4,972.00
|
|
|
Service Code
|
CPT 0076T
|
| Hospital Charge Code |
909081391
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$899.93 |
| Max. Negotiated Rate |
$12,620.00 |
| Rate for Payer: Adventist Health Commercial |
$994.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12,620.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,415.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,226.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,734.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,729.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,792.00
|
| 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 |
$2,237.40
|
| Rate for Payer: Cash Price |
$2,237.40
|
| Rate for Payer: Cash Price |
$2,237.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,231.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,226.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,226.20
|
| Rate for Payer: Dignity Health Senior |
$4,226.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,983.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,077.67
|
| Rate for Payer: Heritage Provider Network Senior |
$3,077.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,396.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$899.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,243.00
|
| Rate for Payer: Multiplan Commercial |
$3,729.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,374.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,841.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,226.20
|
| Rate for Payer: Vantage Medical Group Senior |
$4,226.20
|
|
|
HC S & I STENT/CHEST VERT ART EA
|
Facility
|
IP
|
$4,972.00
|
|
|
Service Code
|
CPT 0076T
|
| Hospital Charge Code |
909081391
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$899.93 |
| Max. Negotiated Rate |
$3,729.00 |
| Rate for Payer: Adventist Health Commercial |
$994.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,415.76
|
| Rate for Payer: Cash Price |
$2,237.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,366.04
|
| Rate for Payer: Heritage Provider Network Senior |
$3,366.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$899.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,243.00
|
| Rate for Payer: Multiplan Commercial |
$3,729.00
|
|
