|
HC OT INIT EVAL HIGH
|
Facility
|
OP
|
$510.00
|
|
|
Service Code
|
CPT 97167
|
| Hospital Charge Code |
905197167
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$92.31 |
| Max. Negotiated Rate |
$433.50 |
| Rate for Payer: Adventist Health Commercial |
$209.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$315.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$433.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$280.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$382.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$347.00
|
| 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 |
$229.50
|
| Rate for Payer: Cash Price |
$229.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$331.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$433.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$433.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$433.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$331.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$315.69
|
| Rate for Payer: Heritage Provider Network Senior |
$315.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$243.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$92.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$127.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$357.00
|
| Rate for Payer: Multiplan Commercial |
$382.50
|
| 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 |
$433.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$433.50
|
| Rate for Payer: Vantage Medical Group Senior |
$433.50
|
|
|
HC OT INIT EVAL HIGH
|
Facility
|
IP
|
$510.00
|
|
|
Service Code
|
CPT 97167
|
| Hospital Charge Code |
901397167
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$92.31 |
| Max. Negotiated Rate |
$382.50 |
| Rate for Payer: Adventist Health Commercial |
$102.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$328.44
|
| Rate for Payer: Cash Price |
$229.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$345.27
|
| Rate for Payer: Heritage Provider Network Senior |
$345.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$92.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$127.50
|
| Rate for Payer: Multiplan Commercial |
$382.50
|
|
|
HC OT INIT EVAL HIGH
|
Facility
|
IP
|
$510.00
|
|
|
Service Code
|
CPT 97167
|
| Hospital Charge Code |
905197167
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$92.31 |
| Max. Negotiated Rate |
$382.50 |
| Rate for Payer: Adventist Health Commercial |
$102.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$328.44
|
| Rate for Payer: Cash Price |
$229.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$345.27
|
| Rate for Payer: Heritage Provider Network Senior |
$345.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$92.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$127.50
|
| Rate for Payer: Multiplan Commercial |
$382.50
|
|
|
HC OT INIT EVAL HIGH
|
Facility
|
IP
|
$510.00
|
|
|
Service Code
|
CPT 97167
|
| Hospital Charge Code |
908697167
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$92.31 |
| Max. Negotiated Rate |
$382.50 |
| Rate for Payer: Adventist Health Commercial |
$102.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$328.44
|
| Rate for Payer: Cash Price |
$229.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$345.27
|
| Rate for Payer: Heritage Provider Network Senior |
$345.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$92.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$127.50
|
| Rate for Payer: Multiplan Commercial |
$382.50
|
|
|
HC OT INIT EVAL HIGH
|
Facility
|
OP
|
$510.00
|
|
|
Service Code
|
CPT 97167
|
| Hospital Charge Code |
908697167
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$92.31 |
| Max. Negotiated Rate |
$433.50 |
| Rate for Payer: Adventist Health Commercial |
$209.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$315.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$433.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$280.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$382.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$347.00
|
| 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 |
$229.50
|
| Rate for Payer: Cash Price |
$229.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$331.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$433.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$433.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$433.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$331.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$315.69
|
| Rate for Payer: Heritage Provider Network Senior |
$315.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$243.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$92.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$127.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$357.00
|
| Rate for Payer: Multiplan Commercial |
$382.50
|
| 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 |
$433.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$433.50
|
| Rate for Payer: Vantage Medical Group Senior |
$433.50
|
|
|
HC OT INIT EVAL LOW
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
CPT 97165
|
| Hospital Charge Code |
908697165
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$61.54 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Adventist Health Commercial |
$68.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$218.96
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$230.18
|
| Rate for Payer: Heritage Provider Network Senior |
$230.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$61.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.00
|
| Rate for Payer: Multiplan Commercial |
$255.00
|
|
|
HC OT INIT EVAL LOW
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
CPT 97165
|
| Hospital Charge Code |
908697165
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$61.54 |
| Max. Negotiated Rate |
$354.00 |
| Rate for Payer: Adventist Health Commercial |
$139.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$210.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$289.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$187.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$255.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$347.00
|
| 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 |
$153.00
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$221.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$289.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$289.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$289.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$221.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$210.46
|
| Rate for Payer: Heritage Provider Network Senior |
$210.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$162.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$61.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$238.00
|
| Rate for Payer: Multiplan Commercial |
$255.00
|
| 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 |
$289.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$289.00
|
| Rate for Payer: Vantage Medical Group Senior |
$289.00
|
|
|
HC OT INIT EVAL LOW
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
CPT 97165
|
| Hospital Charge Code |
901397165
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$61.54 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Adventist Health Commercial |
$68.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$218.96
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$230.18
|
| Rate for Payer: Heritage Provider Network Senior |
$230.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$61.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.00
|
| Rate for Payer: Multiplan Commercial |
$255.00
|
|
|
HC OT INIT EVAL LOW
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
CPT 97165
|
| Hospital Charge Code |
901397165
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$61.54 |
| Max. Negotiated Rate |
$354.00 |
| Rate for Payer: Adventist Health Commercial |
$139.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$210.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$289.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$187.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$255.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$347.00
|
| 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 |
$153.00
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$221.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$289.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$289.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$289.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$221.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$210.46
|
| Rate for Payer: Heritage Provider Network Senior |
$210.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$162.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$61.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$238.00
|
| Rate for Payer: Multiplan Commercial |
$255.00
|
| 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 |
$289.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$289.00
|
| Rate for Payer: Vantage Medical Group Senior |
$289.00
|
|
|
HC OT INIT EVAL MODERATE
|
Facility
|
OP
|
$447.00
|
|
|
Service Code
|
CPT 97166
|
| Hospital Charge Code |
901397166
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$80.91 |
| Max. Negotiated Rate |
$379.95 |
| Rate for Payer: Adventist Health Commercial |
$183.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$276.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$379.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$245.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$335.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$347.00
|
| 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 |
$201.15
|
| Rate for Payer: Cash Price |
$201.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$290.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$379.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$379.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$379.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$290.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$276.69
|
| Rate for Payer: Heritage Provider Network Senior |
$276.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$213.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$80.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$312.90
|
| Rate for Payer: Multiplan Commercial |
$335.25
|
| 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 |
$379.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$379.95
|
| Rate for Payer: Vantage Medical Group Senior |
$379.95
|
|
|
HC OT INIT EVAL MODERATE
|
Facility
|
IP
|
$447.00
|
|
|
Service Code
|
CPT 97166
|
| Hospital Charge Code |
901397166
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$80.91 |
| Max. Negotiated Rate |
$335.25 |
| Rate for Payer: Adventist Health Commercial |
$89.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$287.87
|
| Rate for Payer: Cash Price |
$201.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$302.62
|
| Rate for Payer: Heritage Provider Network Senior |
$302.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$80.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.75
|
| Rate for Payer: Multiplan Commercial |
$335.25
|
|
|
HC OT INIT EVAL MODERATE
|
Facility
|
OP
|
$447.00
|
|
|
Service Code
|
CPT 97166
|
| Hospital Charge Code |
908697166
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$80.91 |
| Max. Negotiated Rate |
$379.95 |
| Rate for Payer: Adventist Health Commercial |
$183.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$276.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$379.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$245.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$335.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$347.00
|
| 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 |
$201.15
|
| Rate for Payer: Cash Price |
$201.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$290.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$379.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$379.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$379.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$290.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$276.69
|
| Rate for Payer: Heritage Provider Network Senior |
$276.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$213.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$80.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$312.90
|
| Rate for Payer: Multiplan Commercial |
$335.25
|
| 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 |
$379.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$379.95
|
| Rate for Payer: Vantage Medical Group Senior |
$379.95
|
|
|
HC OT INIT EVAL MODERATE
|
Facility
|
IP
|
$447.00
|
|
|
Service Code
|
CPT 97166
|
| Hospital Charge Code |
908697166
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$80.91 |
| Max. Negotiated Rate |
$335.25 |
| Rate for Payer: Adventist Health Commercial |
$89.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$287.87
|
| Rate for Payer: Cash Price |
$201.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$302.62
|
| Rate for Payer: Heritage Provider Network Senior |
$302.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$80.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.75
|
| Rate for Payer: Multiplan Commercial |
$335.25
|
|
|
HC OT INIT EVAL MODERATE
|
Facility
|
IP
|
$703.00
|
|
|
Service Code
|
CPT 97166
|
| Hospital Charge Code |
905197166
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$127.24 |
| Max. Negotiated Rate |
$527.25 |
| Rate for Payer: Adventist Health Commercial |
$140.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$452.73
|
| Rate for Payer: Cash Price |
$316.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$475.93
|
| Rate for Payer: Heritage Provider Network Senior |
$475.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$127.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$175.75
|
| Rate for Payer: Multiplan Commercial |
$527.25
|
|
|
HC OT INIT EVAL MODERATE
|
Facility
|
OP
|
$703.00
|
|
|
Service Code
|
CPT 97166
|
| Hospital Charge Code |
905197166
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$100.00 |
| Max. Negotiated Rate |
$597.55 |
| Rate for Payer: Adventist Health Commercial |
$288.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$434.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$597.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$386.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$527.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$347.00
|
| 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 |
$316.35
|
| Rate for Payer: Cash Price |
$316.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$456.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$597.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$597.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$597.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$456.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$435.16
|
| Rate for Payer: Heritage Provider Network Senior |
$435.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$335.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$127.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$175.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$492.10
|
| Rate for Payer: Multiplan Commercial |
$527.25
|
| 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 |
$597.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$597.55
|
| Rate for Payer: Vantage Medical Group Senior |
$597.55
|
|
|
HC OTOLARYNGOLOGIC EXAM GEN ANEST
|
Facility
|
OP
|
$674.00
|
|
|
Service Code
|
CPT 92502
|
| Hospital Charge Code |
900501620
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$121.99 |
| Max. Negotiated Rate |
$3,672.00 |
| Rate for Payer: Adventist Health Commercial |
$134.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$416.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,040.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$763.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$693.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$320.15
|
| Rate for Payer: Blue Shield of California EPN |
$254.77
|
| Rate for Payer: Cash Price |
$303.30
|
| Rate for Payer: Cash Price |
$303.30
|
| Rate for Payer: Cash Price |
$303.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$438.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,040.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$763.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$693.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$438.10
|
| Rate for Payer: EPIC Health Plan Medicare |
$693.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$456.30
|
| Rate for Payer: Heritage Provider Network Senior |
$456.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$693.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$321.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$121.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$797.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$168.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$929.52
|
| Rate for Payer: Multiplan Commercial |
$505.50
|
| Rate for Payer: Multiplan WC |
$1,030.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$404.40
|
| Rate for Payer: TriValley Medical Group Senior |
$404.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,040.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$763.04
|
| Rate for Payer: Vantage Medical Group Senior |
$693.67
|
|
|
HC OTOLARYNGOLOGIC EXAM GEN ANEST
|
Facility
|
IP
|
$674.00
|
|
|
Service Code
|
CPT 92502
|
| Hospital Charge Code |
900501620
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$121.99 |
| Max. Negotiated Rate |
$505.50 |
| Rate for Payer: Adventist Health Commercial |
$134.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$434.06
|
| Rate for Payer: Cash Price |
$303.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$456.30
|
| Rate for Payer: Heritage Provider Network Senior |
$456.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$121.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$168.50
|
| Rate for Payer: Multiplan Commercial |
$505.50
|
|
|
HC OT PRELIMINARY EVALUATION
|
Facility
|
OP
|
$282.00
|
|
| Hospital Charge Code |
905104349
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$51.04 |
| Max. Negotiated Rate |
$354.00 |
| Rate for Payer: Adventist Health Commercial |
$115.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$174.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$239.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$155.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$211.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$347.00
|
| 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 |
$126.90
|
| Rate for Payer: Cash Price |
$126.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$183.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$239.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$239.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$239.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$183.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$174.56
|
| Rate for Payer: Heritage Provider Network Senior |
$174.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$134.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$51.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$197.40
|
| Rate for Payer: Multiplan Commercial |
$211.50
|
| 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 |
$239.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$239.70
|
| Rate for Payer: Vantage Medical Group Senior |
$239.70
|
|
|
HC OT PRELIMINARY EVALUATION
|
Facility
|
IP
|
$282.00
|
|
| Hospital Charge Code |
905104349
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$51.04 |
| Max. Negotiated Rate |
$211.50 |
| Rate for Payer: Adventist Health Commercial |
$56.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$181.61
|
| Rate for Payer: Cash Price |
$126.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$190.91
|
| Rate for Payer: Heritage Provider Network Senior |
$190.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$51.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.50
|
| Rate for Payer: Multiplan Commercial |
$211.50
|
|
|
HC OT RE-EVALUATION
|
Facility
|
IP
|
$319.00
|
|
|
Service Code
|
CPT 97168
|
| Hospital Charge Code |
905104008
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$57.74 |
| Max. Negotiated Rate |
$239.25 |
| Rate for Payer: Adventist Health Commercial |
$63.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$205.44
|
| Rate for Payer: Cash Price |
$143.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$215.96
|
| Rate for Payer: Heritage Provider Network Senior |
$215.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$57.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$79.75
|
| Rate for Payer: Multiplan Commercial |
$239.25
|
|
|
HC OT RE-EVALUATION
|
Facility
|
OP
|
$319.00
|
|
|
Service Code
|
CPT 97168
|
| Hospital Charge Code |
905104008
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$57.74 |
| Max. Negotiated Rate |
$354.00 |
| Rate for Payer: Adventist Health Commercial |
$130.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$197.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$271.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$175.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$239.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$347.00
|
| 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 |
$143.55
|
| Rate for Payer: Cash Price |
$143.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$207.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$271.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$271.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$271.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$207.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$197.46
|
| Rate for Payer: Heritage Provider Network Senior |
$197.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$152.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$57.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$79.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$223.30
|
| Rate for Payer: Multiplan Commercial |
$239.25
|
| 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 |
$271.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$271.15
|
| Rate for Payer: Vantage Medical Group Senior |
$271.15
|
|
|
HC OUTBACK CATHETER
|
Facility
|
IP
|
$5,075.00
|
|
|
Service Code
|
CPT C1757
|
| Hospital Charge Code |
909020023
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,015.00 |
| Max. Negotiated Rate |
$13,808.00 |
| Rate for Payer: Adventist Health Commercial |
$1,015.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,268.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,808.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,040.15
|
| Rate for Payer: Blue Shield of California EPN |
$2,040.15
|
| Rate for Payer: Cash Price |
$2,283.75
|
| Rate for Payer: Cash Price |
$2,283.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,334.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,740.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,349.72
|
| Rate for Payer: Heritage Provider Network Senior |
$2,349.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,537.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,537.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,537.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,268.75
|
| Rate for Payer: Multiplan Commercial |
$3,806.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,833.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,680.33
|
|
|
HC OUTBACK CATHETER
|
Facility
|
OP
|
$5,075.00
|
|
|
Service Code
|
CPT C1757
|
| Hospital Charge Code |
909020023
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,015.00 |
| Max. Negotiated Rate |
$13,770.00 |
| Rate for Payer: Adventist Health Commercial |
$1,015.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,136.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,313.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,791.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,806.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,770.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,040.15
|
| Rate for Payer: Blue Shield of California EPN |
$2,040.15
|
| Rate for Payer: Cash Price |
$2,283.75
|
| Rate for Payer: Cash Price |
$2,283.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,334.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,313.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,313.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,313.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,248.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,349.72
|
| Rate for Payer: Heritage Provider Network Senior |
$2,349.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,537.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,537.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,537.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,268.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,552.50
|
| Rate for Payer: Multiplan Commercial |
$3,806.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,833.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,680.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,313.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,313.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4,313.75
|
|
|
HC OVA & PARASITES, PRESERVED
|
Facility
|
IP
|
$142.00
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
900911726
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$25.70 |
| Max. Negotiated Rate |
$106.50 |
| Rate for Payer: Adventist Health Commercial |
$28.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$91.45
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$96.13
|
| Rate for Payer: Heritage Provider Network Senior |
$96.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$25.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.50
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
|
|
HC OVA & PARASITES, PRESERVED
|
Facility
|
OP
|
$95.00
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
900911726
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$84.06 |
| Rate for Payer: Adventist Health Commercial |
$19.00
|
| Rate for Payer: Adventist Health Commercial |
$28.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$87.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$58.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$84.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$84.06
|
| Rate for Payer: Blue Shield of California Commercial |
$71.60
|
| Rate for Payer: Blue Shield of California Commercial |
$71.60
|
| Rate for Payer: Blue Shield of California EPN |
$57.43
|
| Rate for Payer: Blue Shield of California EPN |
$57.43
|
| Rate for Payer: Cash Price |
$42.75
|
| Rate for Payer: Cash Price |
$42.75
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$92.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$61.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.79
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$83.78
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$87.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.80
|
| Rate for Payer: Heritage Provider Network Senior |
$87.90
|
| Rate for Payer: Heritage Provider Network Senior |
$58.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$67.73
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$45.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$25.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11.93
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
| Rate for Payer: Multiplan Commercial |
$71.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.90
|
| Rate for Payer: TriValley Medical Group Senior |
$8.90
|
| Rate for Payer: TriValley Medical Group Senior |
$8.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.79
|
| Rate for Payer: Vantage Medical Group Senior |
$8.90
|
| Rate for Payer: Vantage Medical Group Senior |
$8.90
|
|
