|
HC RBC PED PAK ALIQUOT
|
Facility
OP
|
$677.00
|
|
|
Service Code
|
CPT P9011
|
| Hospital Charge Code |
900904531
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$122.54 |
| Max. Negotiated Rate |
$596.00 |
| Rate for Payer: Adventist Health Commercial |
$135.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$134.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$465.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$293.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$215.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$195.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$388.26
|
| Rate for Payer: Blue Shield of California Commercial |
$420.42
|
| Rate for Payer: Blue Shield of California EPN |
$397.40
|
| Rate for Payer: Cash Price |
$304.65
|
| Rate for Payer: Cash Price |
$304.65
|
| Rate for Payer: Cash Price |
$304.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$440.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$293.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$215.03
|
| Rate for Payer: Dignity Health Senior |
$195.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$440.05
|
| Rate for Payer: EPIC Health Plan Medicare |
$195.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$419.06
|
| Rate for Payer: Heritage Provider Network Senior |
$419.06
|
| Rate for Payer: Humana Medicare |
$195.48
|
| Rate for Payer: IEHP Medi-Cal |
$232.75
|
| Rate for Payer: IEHP Medicare Advantage |
$195.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$371.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$122.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$230.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$169.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$246.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$246.30
|
| Rate for Payer: Multiplan Commercial |
$507.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$215.03
|
| Rate for Payer: TriValley Medical Group Senior |
$195.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$596.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$501.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$293.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$215.03
|
| Rate for Payer: Vantage Medical Group Senior |
$195.48
|
|
|
HC RBC PED PAK ALIQUOT
|
Facility
IP
|
$677.00
|
|
|
Service Code
|
CPT P9011
|
| Hospital Charge Code |
900904531
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$122.54 |
| Max. Negotiated Rate |
$507.75 |
| Rate for Payer: Adventist Health Commercial |
$135.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$465.10
|
| Rate for Payer: Cash Price |
$304.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$458.33
|
| Rate for Payer: Heritage Provider Network Senior |
$458.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$122.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$169.25
|
| Rate for Payer: Multiplan Commercial |
$507.75
|
|
|
HC RDLGC SM INT FLW THRGH STDY
|
Facility
OP
|
$896.00
|
|
|
Service Code
|
CPT 74248
|
| Hospital Charge Code |
909004248
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$107.56 |
| Max. Negotiated Rate |
$761.60 |
| Rate for Payer: Adventist Health Commercial |
$179.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$107.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$615.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$761.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$492.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$672.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$304.86
|
| Rate for Payer: Blue Shield of California Commercial |
$260.82
|
| Rate for Payer: Blue Shield of California EPN |
$148.32
|
| Rate for Payer: Cash Price |
$403.20
|
| Rate for Payer: Cash Price |
$403.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$582.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$761.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$761.60
|
| Rate for Payer: Dignity Health Senior |
$761.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$582.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$554.62
|
| Rate for Payer: Heritage Provider Network Senior |
$554.62
|
| Rate for Payer: IEHP Medi-Cal |
$116.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$431.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$162.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$224.00
|
| Rate for Payer: Multiplan Commercial |
$672.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$761.60
|
| Rate for Payer: Vantage Medical Group Senior |
$761.60
|
|
|
HC RDLGC SM INT FLW THRGH STDY
|
Facility
IP
|
$896.00
|
|
|
Service Code
|
CPT 74248
|
| Hospital Charge Code |
909004248
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$162.18 |
| Max. Negotiated Rate |
$672.00 |
| Rate for Payer: Adventist Health Commercial |
$179.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$615.55
|
| Rate for Payer: Cash Price |
$403.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$606.59
|
| Rate for Payer: Heritage Provider Network Senior |
$606.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$162.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$224.00
|
| Rate for Payer: Multiplan Commercial |
$672.00
|
|
|
HC RDLGC XM ESPHGS DBL CNTST STY
|
Facility
IP
|
$528.00
|
|
|
Service Code
|
CPT 74221
|
| Hospital Charge Code |
909004221
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$95.57 |
| Max. Negotiated Rate |
$396.00 |
| Rate for Payer: Adventist Health Commercial |
$105.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$362.74
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$357.46
|
| Rate for Payer: Heritage Provider Network Senior |
$357.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$95.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.00
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
|
|
HC RDLGC XM ESPHGS DBL CNTST STY
|
Facility
OP
|
$528.00
|
|
|
Service Code
|
CPT 74221
|
| Hospital Charge Code |
909004221
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$95.57 |
| Max. Negotiated Rate |
$473.69 |
| Rate for Payer: Adventist Health Commercial |
$105.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$167.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$362.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$344.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$252.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$229.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$473.69
|
| Rate for Payer: Blue Shield of California Commercial |
$405.37
|
| Rate for Payer: Blue Shield of California EPN |
$230.52
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$343.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$344.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$252.52
|
| Rate for Payer: Dignity Health Senior |
$229.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$343.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$229.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$326.83
|
| Rate for Payer: Heritage Provider Network Senior |
$326.83
|
| Rate for Payer: Humana Medicare |
$229.56
|
| Rate for Payer: IEHP Medi-Cal |
$155.05
|
| Rate for Payer: IEHP Medicare Advantage |
$229.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$436.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$95.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$270.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$289.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$289.25
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$229.56
|
| Rate for Payer: TriValley Medical Group Senior |
$229.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$291.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$291.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$344.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$252.52
|
| Rate for Payer: Vantage Medical Group Senior |
$229.56
|
|
|
HC RDLGC XM ESPHGS SNGL CNTST STY
|
Facility
IP
|
$528.00
|
|
|
Service Code
|
CPT 74220
|
| Hospital Charge Code |
909004220
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$95.57 |
| Max. Negotiated Rate |
$396.00 |
| Rate for Payer: Adventist Health Commercial |
$105.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$362.74
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$357.46
|
| Rate for Payer: Heritage Provider Network Senior |
$357.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$95.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.00
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
|
|
HC RDLGC XM ESPHGS SNGL CNTST STY
|
Facility
OP
|
$528.00
|
|
|
Service Code
|
CPT 74220
|
| Hospital Charge Code |
909004220
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.42 |
| Max. Negotiated Rate |
$436.16 |
| Rate for Payer: Adventist Health Commercial |
$105.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$150.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$362.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$344.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$252.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$229.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$266.31
|
| Rate for Payer: Blue Shield of California Commercial |
$241.76
|
| Rate for Payer: Blue Shield of California EPN |
$137.48
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$343.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$344.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$252.52
|
| Rate for Payer: Dignity Health Senior |
$229.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$343.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$229.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$326.83
|
| Rate for Payer: Heritage Provider Network Senior |
$326.83
|
| Rate for Payer: Humana Medicare |
$229.56
|
| Rate for Payer: IEHP Medi-Cal |
$59.42
|
| Rate for Payer: IEHP Medicare Advantage |
$229.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$436.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$95.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$270.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$289.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$289.25
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$229.56
|
| Rate for Payer: TriValley Medical Group Senior |
$229.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$137.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$137.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$344.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$252.52
|
| Rate for Payer: Vantage Medical Group Senior |
$229.56
|
|
|
HC RDLGC XM UPR GI TRC DBL CNTST
|
Facility
OP
|
$528.00
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
909004246
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$95.57 |
| Max. Negotiated Rate |
$436.16 |
| Rate for Payer: Adventist Health Commercial |
$105.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$192.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$362.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$344.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$252.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$229.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$396.03
|
| Rate for Payer: Blue Shield of California Commercial |
$337.62
|
| Rate for Payer: Blue Shield of California EPN |
$191.99
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$343.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$344.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$252.52
|
| Rate for Payer: Dignity Health Senior |
$229.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$343.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$229.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$326.83
|
| Rate for Payer: Heritage Provider Network Senior |
$326.83
|
| Rate for Payer: Humana Medicare |
$229.56
|
| Rate for Payer: IEHP Medi-Cal |
$179.79
|
| Rate for Payer: IEHP Medicare Advantage |
$229.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$436.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$95.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$270.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$289.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$289.25
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$229.56
|
| Rate for Payer: TriValley Medical Group Senior |
$229.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$137.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$137.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$344.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$252.52
|
| Rate for Payer: Vantage Medical Group Senior |
$229.56
|
|
|
HC RDLGC XM UPR GI TRC DBL CNTST
|
Facility
IP
|
$528.00
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
909004246
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$95.57 |
| Max. Negotiated Rate |
$396.00 |
| Rate for Payer: Adventist Health Commercial |
$105.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$362.74
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$357.46
|
| Rate for Payer: Heritage Provider Network Senior |
$357.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$95.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.00
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
|
|
HC RDLGC XM UPR GI TRC SNGL CNTST
|
Facility
OP
|
$528.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
909004240
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$95.57 |
| Max. Negotiated Rate |
$436.16 |
| Rate for Payer: Adventist Health Commercial |
$105.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$173.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$362.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$344.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$252.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$229.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$351.01
|
| Rate for Payer: Blue Shield of California Commercial |
$297.54
|
| Rate for Payer: Blue Shield of California EPN |
$169.20
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$343.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$344.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$252.52
|
| Rate for Payer: Dignity Health Senior |
$229.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$343.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$229.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$326.83
|
| Rate for Payer: Heritage Provider Network Senior |
$326.83
|
| Rate for Payer: Humana Medicare |
$229.56
|
| Rate for Payer: IEHP Medi-Cal |
$159.17
|
| Rate for Payer: IEHP Medicare Advantage |
$229.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$436.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$95.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$270.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$289.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$289.25
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$229.56
|
| Rate for Payer: TriValley Medical Group Senior |
$229.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$137.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$137.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$344.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$252.52
|
| Rate for Payer: Vantage Medical Group Senior |
$229.56
|
|
|
HC RDLGC XM UPR GI TRC SNGL CNTST
|
Facility
IP
|
$528.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
909004240
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$95.57 |
| Max. Negotiated Rate |
$396.00 |
| Rate for Payer: Adventist Health Commercial |
$105.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$362.74
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$357.46
|
| Rate for Payer: Heritage Provider Network Senior |
$357.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$95.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.00
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
|
|
HC RECOVERY LEVEL I FIRST HR
|
Facility
IP
|
$1,381.00
|
|
| Hospital Charge Code |
907201701
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$249.96 |
| Max. Negotiated Rate |
$1,035.75 |
| Rate for Payer: Adventist Health Commercial |
$276.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$948.75
|
| Rate for Payer: Cash Price |
$621.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$934.94
|
| Rate for Payer: Heritage Provider Network Senior |
$934.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$249.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$345.25
|
| Rate for Payer: Multiplan Commercial |
$1,035.75
|
|
|
HC RECOVERY LEVEL I FIRST HR
|
Facility
OP
|
$1,381.00
|
|
| Hospital Charge Code |
907201701
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$249.96 |
| Max. Negotiated Rate |
$1,173.85 |
| Rate for Payer: Adventist Health Commercial |
$276.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$738.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$948.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,173.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$759.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,035.75
|
| Rate for Payer: Blue Shield of California Commercial |
$857.60
|
| Rate for Payer: Blue Shield of California EPN |
$810.65
|
| Rate for Payer: Cash Price |
$621.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$897.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,173.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,173.85
|
| Rate for Payer: Dignity Health Senior |
$1,173.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$897.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$854.84
|
| Rate for Payer: Heritage Provider Network Senior |
$854.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$665.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$249.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$345.25
|
| Rate for Payer: Multiplan Commercial |
$1,035.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,173.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1,173.85
|
|
|
HC RECOVERY LEVEL II FIRST HOUR
|
Facility
IP
|
$1,828.00
|
|
| Hospital Charge Code |
907201703
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$330.87 |
| Max. Negotiated Rate |
$1,371.00 |
| Rate for Payer: Adventist Health Commercial |
$365.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,255.84
|
| Rate for Payer: Cash Price |
$822.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,237.56
|
| Rate for Payer: Heritage Provider Network Senior |
$1,237.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$330.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$457.00
|
| Rate for Payer: Multiplan Commercial |
$1,371.00
|
|
|
HC RECOVERY LEVEL II FIRST HOUR
|
Facility
OP
|
$1,828.00
|
|
| Hospital Charge Code |
907201703
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$330.87 |
| Max. Negotiated Rate |
$1,553.80 |
| Rate for Payer: Adventist Health Commercial |
$365.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$977.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,255.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,553.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,005.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,371.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,135.19
|
| Rate for Payer: Blue Shield of California EPN |
$1,073.04
|
| Rate for Payer: Cash Price |
$822.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,188.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,553.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,553.80
|
| Rate for Payer: Dignity Health Senior |
$1,553.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,188.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,131.53
|
| Rate for Payer: Heritage Provider Network Senior |
$1,131.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$881.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$330.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$457.00
|
| Rate for Payer: Multiplan Commercial |
$1,371.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,553.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1,553.80
|
|
|
HC RECOVERY LEVEL III EA ADDL 30
|
Facility
IP
|
$1,301.00
|
|
| Hospital Charge Code |
907201706
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$235.48 |
| Max. Negotiated Rate |
$975.75 |
| Rate for Payer: Adventist Health Commercial |
$260.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$893.79
|
| Rate for Payer: Cash Price |
$585.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$880.78
|
| Rate for Payer: Heritage Provider Network Senior |
$880.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$235.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$325.25
|
| Rate for Payer: Multiplan Commercial |
$975.75
|
|
|
HC RECOVERY LEVEL III EA ADDL 30
|
Facility
OP
|
$1,301.00
|
|
| Hospital Charge Code |
907201706
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$235.48 |
| Max. Negotiated Rate |
$1,105.85 |
| Rate for Payer: Adventist Health Commercial |
$260.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$695.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$893.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,105.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$715.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$975.75
|
| Rate for Payer: Blue Shield of California Commercial |
$807.92
|
| Rate for Payer: Blue Shield of California EPN |
$763.69
|
| Rate for Payer: Cash Price |
$585.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$845.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,105.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,105.85
|
| Rate for Payer: Dignity Health Senior |
$1,105.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$845.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$805.32
|
| Rate for Payer: Heritage Provider Network Senior |
$805.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$627.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$235.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$325.25
|
| Rate for Payer: Multiplan Commercial |
$975.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,105.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1,105.85
|
|
|
HC RECOVERY LEVEL III FIRST HOUR
|
Facility
IP
|
$2,351.00
|
|
| Hospital Charge Code |
907201705
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$425.53 |
| Max. Negotiated Rate |
$1,763.25 |
| Rate for Payer: Adventist Health Commercial |
$470.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,615.14
|
| Rate for Payer: Cash Price |
$1,057.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,591.63
|
| Rate for Payer: Heritage Provider Network Senior |
$1,591.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$425.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$587.75
|
| Rate for Payer: Multiplan Commercial |
$1,763.25
|
|
|
HC RECOVERY LEVEL III FIRST HOUR
|
Facility
OP
|
$2,351.00
|
|
| Hospital Charge Code |
907201705
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$425.53 |
| Max. Negotiated Rate |
$1,998.35 |
| Rate for Payer: Adventist Health Commercial |
$470.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,256.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,615.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,998.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,293.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,763.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1,459.97
|
| Rate for Payer: Blue Shield of California EPN |
$1,380.04
|
| Rate for Payer: Cash Price |
$1,057.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,528.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,998.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,998.35
|
| Rate for Payer: Dignity Health Senior |
$1,998.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,528.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,455.27
|
| Rate for Payer: Heritage Provider Network Senior |
$1,455.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,133.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$425.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$587.75
|
| Rate for Payer: Multiplan Commercial |
$1,763.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,998.35
|
| Rate for Payer: Vantage Medical Group Senior |
$1,998.35
|
|
|
HC RECOVERY LEVEL IV FIRST HOUR
|
Facility
IP
|
$2,614.00
|
|
| Hospital Charge Code |
907201707
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$473.13 |
| Max. Negotiated Rate |
$1,960.50 |
| Rate for Payer: Adventist Health Commercial |
$522.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,795.82
|
| Rate for Payer: Cash Price |
$1,176.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,769.68
|
| Rate for Payer: Heritage Provider Network Senior |
$1,769.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$473.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$653.50
|
| Rate for Payer: Multiplan Commercial |
$1,960.50
|
|
|
HC RECOVERY LEVEL IV FIRST HOUR
|
Facility
OP
|
$2,614.00
|
|
| Hospital Charge Code |
907201707
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$473.13 |
| Max. Negotiated Rate |
$2,221.90 |
| Rate for Payer: Adventist Health Commercial |
$522.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,397.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,795.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2,221.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,437.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,960.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1,623.29
|
| Rate for Payer: Blue Shield of California EPN |
$1,534.42
|
| Rate for Payer: Cash Price |
$1,176.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,699.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,221.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,221.90
|
| Rate for Payer: Dignity Health Senior |
$2,221.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,699.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,618.07
|
| Rate for Payer: Heritage Provider Network Senior |
$1,618.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,259.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$473.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$653.50
|
| Rate for Payer: Multiplan Commercial |
$1,960.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,221.90
|
| Rate for Payer: Vantage Medical Group Senior |
$2,221.90
|
|
|
HC RECOVERY LEVL I EA ADDL 30 MIN
|
Facility
IP
|
$695.00
|
|
| Hospital Charge Code |
907201702
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$125.80 |
| Max. Negotiated Rate |
$521.25 |
| Rate for Payer: Adventist Health Commercial |
$139.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$477.46
|
| Rate for Payer: Cash Price |
$312.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$470.52
|
| Rate for Payer: Heritage Provider Network Senior |
$470.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$125.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$173.75
|
| Rate for Payer: Multiplan Commercial |
$521.25
|
|
|
HC RECOVERY LEVL I EA ADDL 30 MIN
|
Facility
OP
|
$695.00
|
|
| Hospital Charge Code |
907201702
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$125.80 |
| Max. Negotiated Rate |
$590.75 |
| Rate for Payer: Adventist Health Commercial |
$139.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$371.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$477.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$590.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$382.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$521.25
|
| Rate for Payer: Blue Shield of California Commercial |
$431.60
|
| Rate for Payer: Blue Shield of California EPN |
$407.96
|
| Rate for Payer: Cash Price |
$312.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$451.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$590.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$590.75
|
| Rate for Payer: Dignity Health Senior |
$590.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$451.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$430.20
|
| Rate for Payer: Heritage Provider Network Senior |
$430.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$334.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$125.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$173.75
|
| Rate for Payer: Multiplan Commercial |
$521.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$590.75
|
| Rate for Payer: Vantage Medical Group Senior |
$590.75
|
|
|
HC RECOVERY LEVL II EA ADDL 30 MIN
|
Facility
IP
|
$881.00
|
|
| Hospital Charge Code |
907201704
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$159.46 |
| Max. Negotiated Rate |
$660.75 |
| Rate for Payer: Adventist Health Commercial |
$176.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$605.25
|
| Rate for Payer: Cash Price |
$396.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$596.44
|
| Rate for Payer: Heritage Provider Network Senior |
$596.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$159.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$220.25
|
| Rate for Payer: Multiplan Commercial |
$660.75
|
|
