|
HC PTCA EA ADD'L VESSEL
|
Facility
|
OP
|
$10,431.00
|
|
|
Service Code
|
CPT 92921
|
| Hospital Charge Code |
906811433
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$14,160.00 |
| Rate for Payer: Adventist Health Commercial |
$2,086.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,166.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8,866.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,737.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,823.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,004.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$5,737.05
|
| Rate for Payer: Cash Price |
$5,737.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,340.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8,866.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,866.35
|
| Rate for Payer: Dignity Health Senior |
$8,866.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,556.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,456.79
|
| Rate for Payer: Heritage Provider Network Senior |
$6,456.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,975.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,888.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,607.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7,301.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7,301.70
|
| Rate for Payer: Multiplan Commercial |
$7,823.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14,160.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11,956.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8,866.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,866.35
|
| Rate for Payer: Vantage Medical Group Senior |
$8,866.35
|
|
|
HC PTCA EA ADD'L VESSEL
|
Facility
|
IP
|
$14,548.00
|
|
|
Service Code
|
CPT 92921
|
| Hospital Charge Code |
906820236
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,633.19 |
| Max. Negotiated Rate |
$10,911.00 |
| Rate for Payer: Adventist Health Commercial |
$2,909.60
|
| Rate for Payer: Cash Price |
$8,001.40
|
| Rate for Payer: Cash Price |
$8,001.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,478.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,982.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,633.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,637.00
|
| Rate for Payer: Multiplan Commercial |
$10,911.00
|
|
|
HC PTCA EX BENT TIP RTRVAL SHEATH
|
Facility
|
OP
|
$270.00
|
|
| Hospital Charge Code |
909081432
|
|
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 |
$144.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$185.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$229.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$148.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$202.50
|
| Rate for Payer: Blue Shield of California Commercial |
$164.70
|
| Rate for Payer: Blue Shield of California EPN |
$131.76
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$175.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$229.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$229.50
|
| Rate for Payer: Dignity Health Senior |
$229.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$175.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$167.13
|
| Rate for Payer: Heritage Provider Network Senior |
$167.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$128.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$189.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$189.00
|
| Rate for Payer: Multiplan Commercial |
$202.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$135.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$135.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$229.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$229.50
|
| Rate for Payer: Vantage Medical Group Senior |
$229.50
|
|
|
HC PTCA EX BENT TIP RTRVAL SHEATH
|
Facility
|
IP
|
$270.00
|
|
| Hospital Charge Code |
909081432
|
|
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: Cash Price |
$148.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$182.79
|
| Rate for Payer: Heritage Provider Network Senior |
$182.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.50
|
| Rate for Payer: Multiplan Commercial |
$202.50
|
|
|
HC PTCA FILTER WIRE EX(E.P.S.)
|
Facility
|
IP
|
$1,943.00
|
|
|
Service Code
|
CPT C1884
|
| Hospital Charge Code |
909081431
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$351.68 |
| Max. Negotiated Rate |
$1,457.25 |
| Rate for Payer: Adventist Health Commercial |
$388.60
|
| Rate for Payer: Cash Price |
$1,068.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,315.41
|
| Rate for Payer: Heritage Provider Network Senior |
$1,315.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$351.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$485.75
|
| Rate for Payer: Multiplan Commercial |
$1,457.25
|
|
|
HC PTCA FILTER WIRE EX(E.P.S.)
|
Facility
|
OP
|
$1,943.00
|
|
|
Service Code
|
CPT C1884
|
| Hospital Charge Code |
909081431
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$351.68 |
| Max. Negotiated Rate |
$1,651.55 |
| Rate for Payer: Adventist Health Commercial |
$388.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,038.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,334.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,651.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,068.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,457.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1,185.23
|
| Rate for Payer: Blue Shield of California EPN |
$948.18
|
| Rate for Payer: Cash Price |
$1,068.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,262.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,651.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,651.55
|
| Rate for Payer: Dignity Health Senior |
$1,651.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,262.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,202.72
|
| Rate for Payer: Heritage Provider Network Senior |
$1,202.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$926.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$351.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$485.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,360.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,360.10
|
| Rate for Payer: Multiplan Commercial |
$1,457.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$971.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$971.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,651.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,651.55
|
| Rate for Payer: Vantage Medical Group Senior |
$1,651.55
|
|
|
HC PTCA SINGLER VESSEL
|
Facility
|
OP
|
$23,930.00
|
|
|
Service Code
|
CPT 92920
|
| Hospital Charge Code |
906820235
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$17,947.50 |
| Rate for Payer: Adventist Health Commercial |
$4,786.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16,439.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,866.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7,968.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,244.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14,720.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$13,161.50
|
| Rate for Payer: Cash Price |
$13,161.50
|
| Rate for Payer: Cash Price |
$13,161.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,340.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,866.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,968.78
|
| Rate for Payer: Dignity Health Senior |
$7,244.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,556.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,244.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$14,812.67
|
| Rate for Payer: Heritage Provider Network Senior |
$8,910.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$704.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,244.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,764.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,331.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,331.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,982.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,127.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,127.88
|
| Rate for Payer: Multiplan Commercial |
$17,947.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,968.78
|
| Rate for Payer: TriValley Medical Group Senior |
$7,244.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14,160.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11,956.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,866.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,968.78
|
| Rate for Payer: Vantage Medical Group Senior |
$7,244.35
|
|
|
HC PTCA SINGLER VESSEL
|
Facility
|
IP
|
$15,556.00
|
|
|
Service Code
|
CPT 92920
|
| Hospital Charge Code |
906811432
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,815.64 |
| Max. Negotiated Rate |
$11,667.00 |
| Rate for Payer: Adventist Health Commercial |
$3,111.20
|
| Rate for Payer: Cash Price |
$8,555.80
|
| Rate for Payer: Cash Price |
$8,555.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,478.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,982.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,815.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,889.00
|
| Rate for Payer: Multiplan Commercial |
$11,667.00
|
|
|
HC PTCA SINGLER VESSEL
|
Facility
|
OP
|
$15,556.00
|
|
|
Service Code
|
CPT 92920
|
| Hospital Charge Code |
906811432
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$14,720.00 |
| Rate for Payer: Adventist Health Commercial |
$3,111.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10,686.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,866.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7,968.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,244.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14,720.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$8,555.80
|
| Rate for Payer: Cash Price |
$8,555.80
|
| Rate for Payer: Cash Price |
$8,555.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,340.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,866.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,968.78
|
| Rate for Payer: Dignity Health Senior |
$7,244.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,556.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,244.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$9,629.16
|
| Rate for Payer: Heritage Provider Network Senior |
$8,910.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$704.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,244.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,764.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,815.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,331.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,889.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,127.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,127.88
|
| Rate for Payer: Multiplan Commercial |
$11,667.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,968.78
|
| Rate for Payer: TriValley Medical Group Senior |
$7,244.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14,160.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11,956.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,866.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,968.78
|
| Rate for Payer: Vantage Medical Group Senior |
$7,244.35
|
|
|
HC PTCA SINGLER VESSEL
|
Facility
|
IP
|
$23,930.00
|
|
|
Service Code
|
CPT 92920
|
| Hospital Charge Code |
906820235
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$4,331.33 |
| Max. Negotiated Rate |
$17,947.50 |
| Rate for Payer: Adventist Health Commercial |
$4,786.00
|
| Rate for Payer: Cash Price |
$13,161.50
|
| Rate for Payer: Cash Price |
$13,161.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,478.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,982.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,331.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,982.50
|
| Rate for Payer: Multiplan Commercial |
$17,947.50
|
|
|
HC PT EVALUATION PRELIM MCAL
|
Facility
|
IP
|
$338.00
|
|
| Hospital Charge Code |
900400022
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$61.18 |
| Max. Negotiated Rate |
$253.50 |
| Rate for Payer: Adventist Health Commercial |
$67.60
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$228.83
|
| Rate for Payer: Heritage Provider Network Senior |
$228.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.50
|
| Rate for Payer: Multiplan Commercial |
$253.50
|
|
|
HC PT EVALUATION PRELIM MCAL
|
Facility
|
OP
|
$338.00
|
|
| Hospital Charge Code |
900400022
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$61.18 |
| Max. Negotiated Rate |
$354.00 |
| Rate for Payer: Adventist Health Commercial |
$138.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$180.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$232.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$287.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$185.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$253.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$334.00
|
| Rate for Payer: Blue Shield of California Commercial |
$354.00
|
| Rate for Payer: Blue Shield of California EPN |
$284.00
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$219.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$287.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$287.30
|
| Rate for Payer: Dignity Health Senior |
$287.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$209.22
|
| Rate for Payer: Heritage Provider Network Senior |
$209.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$161.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$236.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$236.60
|
| Rate for Payer: Multiplan Commercial |
$253.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$261.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$220.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$287.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$287.30
|
| Rate for Payer: Vantage Medical Group Senior |
$287.30
|
|
|
HC PT INIT EVAL HIGH
|
Facility
|
IP
|
$602.00
|
|
|
Service Code
|
CPT 97163
|
| Hospital Charge Code |
900407163
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$108.96 |
| Max. Negotiated Rate |
$451.50 |
| Rate for Payer: Adventist Health Commercial |
$120.40
|
| Rate for Payer: Cash Price |
$331.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$407.55
|
| Rate for Payer: Heritage Provider Network Senior |
$407.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$150.50
|
| Rate for Payer: Multiplan Commercial |
$451.50
|
|
|
HC PT INIT EVAL HIGH
|
Facility
|
IP
|
$602.00
|
|
|
Service Code
|
CPT 97163
|
| Hospital Charge Code |
900497163
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$108.96 |
| Max. Negotiated Rate |
$451.50 |
| Rate for Payer: Adventist Health Commercial |
$120.40
|
| Rate for Payer: Cash Price |
$331.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$407.55
|
| Rate for Payer: Heritage Provider Network Senior |
$407.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$150.50
|
| Rate for Payer: Multiplan Commercial |
$451.50
|
|
|
HC PT INIT EVAL HIGH
|
Facility
|
OP
|
$602.00
|
|
|
Service Code
|
CPT 97163
|
| Hospital Charge Code |
900417163
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$100.00 |
| Max. Negotiated Rate |
$511.70 |
| Rate for Payer: Adventist Health Commercial |
$246.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$321.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$413.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$511.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$331.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$451.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$334.00
|
| Rate for Payer: Blue Shield of California Commercial |
$354.00
|
| Rate for Payer: Blue Shield of California EPN |
$284.00
|
| Rate for Payer: Cash Price |
$331.10
|
| Rate for Payer: Cash Price |
$331.10
|
| Rate for Payer: Cash Price |
$331.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$391.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$511.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$511.70
|
| Rate for Payer: Dignity Health Senior |
$511.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$391.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$372.64
|
| Rate for Payer: Heritage Provider Network Senior |
$372.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$219.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$287.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$150.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$421.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$421.40
|
| Rate for Payer: Multiplan Commercial |
$451.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$261.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$220.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$511.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$511.70
|
| Rate for Payer: Vantage Medical Group Senior |
$511.70
|
|
|
HC PT INIT EVAL HIGH
|
Facility
|
OP
|
$602.00
|
|
|
Service Code
|
CPT 97163
|
| Hospital Charge Code |
900407163
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$100.00 |
| Max. Negotiated Rate |
$511.70 |
| Rate for Payer: Adventist Health Commercial |
$246.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$321.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$413.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$511.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$331.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$451.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$334.00
|
| Rate for Payer: Blue Shield of California Commercial |
$354.00
|
| Rate for Payer: Blue Shield of California EPN |
$284.00
|
| Rate for Payer: Cash Price |
$331.10
|
| Rate for Payer: Cash Price |
$331.10
|
| Rate for Payer: Cash Price |
$331.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$391.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$511.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$511.70
|
| Rate for Payer: Dignity Health Senior |
$511.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$391.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$372.64
|
| Rate for Payer: Heritage Provider Network Senior |
$372.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$219.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$287.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$150.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$421.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$421.40
|
| Rate for Payer: Multiplan Commercial |
$451.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$261.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$220.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$511.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$511.70
|
| Rate for Payer: Vantage Medical Group Senior |
$511.70
|
|
|
HC PT INIT EVAL HIGH
|
Facility
|
OP
|
$602.00
|
|
|
Service Code
|
CPT 97163
|
| Hospital Charge Code |
900497163
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$100.00 |
| Max. Negotiated Rate |
$511.70 |
| Rate for Payer: Adventist Health Commercial |
$246.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$321.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$413.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$511.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$331.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$451.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$334.00
|
| Rate for Payer: Blue Shield of California Commercial |
$354.00
|
| Rate for Payer: Blue Shield of California EPN |
$284.00
|
| Rate for Payer: Cash Price |
$331.10
|
| Rate for Payer: Cash Price |
$331.10
|
| Rate for Payer: Cash Price |
$331.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$391.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$511.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$511.70
|
| Rate for Payer: Dignity Health Senior |
$511.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$391.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$372.64
|
| Rate for Payer: Heritage Provider Network Senior |
$372.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$219.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$287.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$150.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$421.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$421.40
|
| Rate for Payer: Multiplan Commercial |
$451.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$261.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$220.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$511.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$511.70
|
| Rate for Payer: Vantage Medical Group Senior |
$511.70
|
|
|
HC PT INIT EVAL HIGH
|
Facility
|
OP
|
$602.00
|
|
|
Service Code
|
CPT 97163
|
| Hospital Charge Code |
905197163
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$100.00 |
| Max. Negotiated Rate |
$511.70 |
| Rate for Payer: Adventist Health Commercial |
$246.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$321.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$413.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$511.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$331.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$451.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$334.00
|
| Rate for Payer: Blue Shield of California Commercial |
$354.00
|
| Rate for Payer: Blue Shield of California EPN |
$284.00
|
| Rate for Payer: Cash Price |
$331.10
|
| Rate for Payer: Cash Price |
$331.10
|
| Rate for Payer: Cash Price |
$331.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$391.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$511.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$511.70
|
| Rate for Payer: Dignity Health Senior |
$511.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$391.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$372.64
|
| Rate for Payer: Heritage Provider Network Senior |
$372.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$219.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$287.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$150.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$421.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$421.40
|
| Rate for Payer: Multiplan Commercial |
$451.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$261.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$220.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$511.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$511.70
|
| Rate for Payer: Vantage Medical Group Senior |
$511.70
|
|
|
HC PT INIT EVAL HIGH
|
Facility
|
IP
|
$602.00
|
|
|
Service Code
|
CPT 97163
|
| Hospital Charge Code |
905197163
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$108.96 |
| Max. Negotiated Rate |
$451.50 |
| Rate for Payer: Adventist Health Commercial |
$120.40
|
| Rate for Payer: Cash Price |
$331.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$407.55
|
| Rate for Payer: Heritage Provider Network Senior |
$407.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$150.50
|
| Rate for Payer: Multiplan Commercial |
$451.50
|
|
|
HC PT INIT EVAL HIGH
|
Facility
|
IP
|
$602.00
|
|
|
Service Code
|
CPT 97163
|
| Hospital Charge Code |
900417163
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$108.96 |
| Max. Negotiated Rate |
$451.50 |
| Rate for Payer: Adventist Health Commercial |
$120.40
|
| Rate for Payer: Cash Price |
$331.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$407.55
|
| Rate for Payer: Heritage Provider Network Senior |
$407.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$150.50
|
| Rate for Payer: Multiplan Commercial |
$451.50
|
|
|
HC PT INIT EVAL LOW
|
Facility
|
OP
|
$363.00
|
|
|
Service Code
|
CPT 97161
|
| Hospital Charge Code |
905197161
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$65.70 |
| Max. Negotiated Rate |
$354.00 |
| Rate for Payer: Adventist Health Commercial |
$148.83
|
| Rate for Payer: Aetna of CA Gatekeeper |
$194.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$249.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$308.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$199.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$272.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$334.00
|
| Rate for Payer: Blue Shield of California Commercial |
$354.00
|
| Rate for Payer: Blue Shield of California EPN |
$284.00
|
| Rate for Payer: Cash Price |
$199.65
|
| Rate for Payer: Cash Price |
$199.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$235.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$308.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$308.55
|
| Rate for Payer: Dignity Health Senior |
$308.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$235.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$224.70
|
| Rate for Payer: Heritage Provider Network Senior |
$224.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$173.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$65.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$254.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$254.10
|
| Rate for Payer: Multiplan Commercial |
$272.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$261.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$220.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$308.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$308.55
|
| Rate for Payer: Vantage Medical Group Senior |
$308.55
|
|
|
HC PT INIT EVAL LOW
|
Facility
|
IP
|
$363.00
|
|
|
Service Code
|
CPT 97161
|
| Hospital Charge Code |
900497161
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$65.70 |
| Max. Negotiated Rate |
$272.25 |
| Rate for Payer: Adventist Health Commercial |
$72.60
|
| Rate for Payer: Cash Price |
$199.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$245.75
|
| Rate for Payer: Heritage Provider Network Senior |
$245.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$65.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.75
|
| Rate for Payer: Multiplan Commercial |
$272.25
|
|
|
HC PT INIT EVAL LOW
|
Facility
|
OP
|
$363.00
|
|
|
Service Code
|
CPT 97161
|
| Hospital Charge Code |
900417161
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$65.70 |
| Max. Negotiated Rate |
$354.00 |
| Rate for Payer: Adventist Health Commercial |
$148.83
|
| Rate for Payer: Aetna of CA Gatekeeper |
$194.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$249.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$308.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$199.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$272.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$334.00
|
| Rate for Payer: Blue Shield of California Commercial |
$354.00
|
| Rate for Payer: Blue Shield of California EPN |
$284.00
|
| Rate for Payer: Cash Price |
$199.65
|
| Rate for Payer: Cash Price |
$199.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$235.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$308.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$308.55
|
| Rate for Payer: Dignity Health Senior |
$308.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$235.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$224.70
|
| Rate for Payer: Heritage Provider Network Senior |
$224.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$173.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$65.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$254.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$254.10
|
| Rate for Payer: Multiplan Commercial |
$272.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$261.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$220.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$308.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$308.55
|
| Rate for Payer: Vantage Medical Group Senior |
$308.55
|
|
|
HC PT INIT EVAL LOW
|
Facility
|
IP
|
$363.00
|
|
|
Service Code
|
CPT 97161
|
| Hospital Charge Code |
900407161
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$65.70 |
| Max. Negotiated Rate |
$272.25 |
| Rate for Payer: Adventist Health Commercial |
$72.60
|
| Rate for Payer: Cash Price |
$199.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$245.75
|
| Rate for Payer: Heritage Provider Network Senior |
$245.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$65.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.75
|
| Rate for Payer: Multiplan Commercial |
$272.25
|
|
|
HC PT INIT EVAL LOW
|
Facility
|
IP
|
$363.00
|
|
|
Service Code
|
CPT 97161
|
| Hospital Charge Code |
905197161
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$65.70 |
| Max. Negotiated Rate |
$272.25 |
| Rate for Payer: Adventist Health Commercial |
$72.60
|
| Rate for Payer: Cash Price |
$199.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$245.75
|
| Rate for Payer: Heritage Provider Network Senior |
$245.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$65.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.75
|
| Rate for Payer: Multiplan Commercial |
$272.25
|
|
