|
HC SACROILIAC ARTHROGRAPHY
|
Facility
IP
|
$1,876.00
|
|
|
Service Code
|
CPT 27096
|
| Hospital Charge Code |
909000223
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$339.56 |
| Max. Negotiated Rate |
$1,407.00 |
| Rate for Payer: Adventist Health Commercial |
$375.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,288.81
|
| Rate for Payer: Cash Price |
$844.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,270.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1,270.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$339.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$469.00
|
| Rate for Payer: Multiplan Commercial |
$1,407.00
|
|
|
HC SACRO ILIAC JOINTS
|
Facility
IP
|
$560.00
|
|
|
Service Code
|
CPT 72202
|
| Hospital Charge Code |
909001344
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$101.36 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Adventist Health Commercial |
$112.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$384.72
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$379.12
|
| Rate for Payer: Heritage Provider Network Senior |
$379.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$101.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$140.00
|
| Rate for Payer: Multiplan Commercial |
$420.00
|
|
|
HC SACRO ILIAC JOINTS
|
Facility
OP
|
$560.00
|
|
|
Service Code
|
CPT 72202
|
| Hospital Charge Code |
909001344
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$46.13 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Adventist Health Commercial |
$112.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$56.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$384.72
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$206.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$151.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$137.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$148.26
|
| Rate for Payer: Blue Shield of California Commercial |
$127.22
|
| Rate for Payer: Blue Shield of California EPN |
$72.34
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$364.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$206.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$151.10
|
| Rate for Payer: Dignity Health Senior |
$137.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$364.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$137.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$346.64
|
| Rate for Payer: Heritage Provider Network Senior |
$346.64
|
| Rate for Payer: Humana Medicare |
$137.36
|
| Rate for Payer: IEHP Medi-Cal |
$46.13
|
| Rate for Payer: IEHP Medicare Advantage |
$137.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$260.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$101.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$162.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$140.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$173.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$173.07
|
| Rate for Payer: Multiplan Commercial |
$420.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$137.36
|
| Rate for Payer: TriValley Medical Group Senior |
$137.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$206.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$151.10
|
| Rate for Payer: Vantage Medical Group Senior |
$137.36
|
|
|
HC SACRUM AND COCCYX
|
Facility
OP
|
$594.00
|
|
|
Service Code
|
CPT 72220
|
| Hospital Charge Code |
909001343
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$39.03 |
| Max. Negotiated Rate |
$445.50 |
| Rate for Payer: Adventist Health Commercial |
$118.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$46.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$408.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$113.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$136.59
|
| Rate for Payer: Blue Shield of California Commercial |
$117.39
|
| Rate for Payer: Blue Shield of California EPN |
$66.75
|
| Rate for Payer: Cash Price |
$267.30
|
| Rate for Payer: Cash Price |
$267.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$386.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.89
|
| Rate for Payer: Dignity Health Senior |
$113.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$386.10
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$367.69
|
| Rate for Payer: Heritage Provider Network Senior |
$367.69
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: IEHP Medi-Cal |
$39.03
|
| Rate for Payer: IEHP Medicare Advantage |
$113.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$148.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$143.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$143.06
|
| Rate for Payer: Multiplan Commercial |
$445.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$113.54
|
| Rate for Payer: TriValley Medical Group Senior |
$113.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Vantage Medical Group Senior |
$113.54
|
|
|
HC SACRUM AND COCCYX
|
Facility
IP
|
$594.00
|
|
|
Service Code
|
CPT 72220
|
| Hospital Charge Code |
909001343
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$107.51 |
| Max. Negotiated Rate |
$445.50 |
| Rate for Payer: Adventist Health Commercial |
$118.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$408.08
|
| Rate for Payer: Cash Price |
$267.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$402.14
|
| Rate for Payer: Heritage Provider Network Senior |
$402.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$148.50
|
| Rate for Payer: Multiplan Commercial |
$445.50
|
|
|
HC SALICYLATES
|
Facility
OP
|
$31.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900910366
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$515.78 |
| Rate for Payer: Adventist Health Commercial |
$6.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$165.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$62.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$515.78
|
| Rate for Payer: Blue Shield of California Commercial |
$446.14
|
| Rate for Payer: Blue Shield of California EPN |
$348.77
|
| Rate for Payer: Cash Price |
$13.95
|
| Rate for Payer: Cash Price |
$13.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$93.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.35
|
| Rate for Payer: Dignity Health Senior |
$62.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$62.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.19
|
| Rate for Payer: Heritage Provider Network Senior |
$19.19
|
| Rate for Payer: Humana Medicare |
$62.14
|
| Rate for Payer: IEHP Medi-Cal |
$67.86
|
| Rate for Payer: IEHP Medicare Advantage |
$62.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$118.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$73.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$78.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78.30
|
| Rate for Payer: Multiplan Commercial |
$23.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$62.14
|
| Rate for Payer: TriValley Medical Group Senior |
$62.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$67.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$67.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: Vantage Medical Group Senior |
$62.14
|
|
|
HC SALICYLATES
|
Facility
IP
|
$221.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900910366
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$40.00 |
| Max. Negotiated Rate |
$165.75 |
| Rate for Payer: Adventist Health Commercial |
$44.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$151.83
|
| Rate for Payer: Cash Price |
$99.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$149.62
|
| Rate for Payer: Heritage Provider Network Senior |
$149.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.25
|
| Rate for Payer: Multiplan Commercial |
$165.75
|
|
|
HC SALIVARY DUCT DILATOR
|
Facility
OP
|
$79.00
|
|
| Hospital Charge Code |
909081730
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.30 |
| Max. Negotiated Rate |
$67.15 |
| Rate for Payer: Adventist Health Commercial |
$15.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$42.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$54.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$67.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$43.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$59.25
|
| Rate for Payer: Blue Shield of California Commercial |
$49.06
|
| Rate for Payer: Blue Shield of California EPN |
$46.37
|
| Rate for Payer: Cash Price |
$35.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$51.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$67.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$67.15
|
| Rate for Payer: Dignity Health Senior |
$67.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.90
|
| Rate for Payer: Heritage Provider Network Senior |
$48.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.75
|
| Rate for Payer: Multiplan Commercial |
$59.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$67.15
|
| Rate for Payer: Vantage Medical Group Senior |
$67.15
|
|
|
HC SALIVARY DUCT DILATOR
|
Facility
IP
|
$79.00
|
|
| Hospital Charge Code |
909081730
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.30 |
| Max. Negotiated Rate |
$59.25 |
| Rate for Payer: Adventist Health Commercial |
$15.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$54.27
|
| Rate for Payer: Cash Price |
$35.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$53.48
|
| Rate for Payer: Heritage Provider Network Senior |
$53.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.75
|
| Rate for Payer: Multiplan Commercial |
$59.25
|
|
|
HC SALIVARY GLAND
|
Facility
OP
|
$240.00
|
|
|
Service Code
|
CPT 70380
|
| Hospital Charge Code |
909001145
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$43.21 |
| Max. Negotiated Rate |
$215.73 |
| Rate for Payer: Adventist Health Commercial |
$48.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$67.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$113.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$159.76
|
| Rate for Payer: Blue Shield of California Commercial |
$137.00
|
| Rate for Payer: Blue Shield of California EPN |
$77.91
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$156.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.89
|
| Rate for Payer: Dignity Health Senior |
$113.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$156.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$148.56
|
| Rate for Payer: Heritage Provider Network Senior |
$148.56
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: IEHP Medi-Cal |
$43.21
|
| Rate for Payer: IEHP Medicare Advantage |
$113.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$143.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$143.06
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$113.54
|
| Rate for Payer: TriValley Medical Group Senior |
$113.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Vantage Medical Group Senior |
$113.54
|
|
|
HC SALIVARY GLAND
|
Facility
IP
|
$240.00
|
|
|
Service Code
|
CPT 70380
|
| Hospital Charge Code |
909001145
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$43.44 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Adventist Health Commercial |
$48.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.88
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$162.48
|
| Rate for Payer: Heritage Provider Network Senior |
$162.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
|
|
HC SALIV (PAROTID) SCAN
|
Facility
OP
|
$1,105.00
|
|
|
Service Code
|
CPT 78230
|
| Hospital Charge Code |
909301355
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$94.52 |
| Max. Negotiated Rate |
$979.11 |
| Rate for Payer: Adventist Health Commercial |
$221.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$319.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$759.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$772.98
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$566.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$515.32
|
| Rate for Payer: Blue Shield of California Commercial |
$445.73
|
| Rate for Payer: Blue Shield of California EPN |
$253.47
|
| Rate for Payer: Cash Price |
$497.25
|
| Rate for Payer: Cash Price |
$497.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$718.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$772.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$566.85
|
| Rate for Payer: Dignity Health Senior |
$515.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$718.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$515.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$684.00
|
| Rate for Payer: Heritage Provider Network Senior |
$684.00
|
| Rate for Payer: Humana Medicare |
$515.32
|
| Rate for Payer: IEHP Medi-Cal |
$94.52
|
| Rate for Payer: IEHP Medicare Advantage |
$515.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$979.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$200.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$608.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$276.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$649.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$649.30
|
| Rate for Payer: Multiplan Commercial |
$828.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$566.85
|
| Rate for Payer: TriValley Medical Group Senior |
$515.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$772.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$566.85
|
| Rate for Payer: Vantage Medical Group Senior |
$515.32
|
|
|
HC SALIV (PAROTID) SCAN
|
Facility
IP
|
$1,105.00
|
|
|
Service Code
|
CPT 78230
|
| Hospital Charge Code |
909301355
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$200.00 |
| Max. Negotiated Rate |
$828.75 |
| Rate for Payer: Adventist Health Commercial |
$221.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$759.14
|
| Rate for Payer: Cash Price |
$497.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$748.08
|
| Rate for Payer: Heritage Provider Network Senior |
$748.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$200.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$276.25
|
| Rate for Payer: Multiplan Commercial |
$828.75
|
|
|
HC SARS-COV2-2 RNA POC
|
Facility
IP
|
$77.00
|
|
|
Service Code
|
CPT 87635
|
| Hospital Charge Code |
900912260
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$13.94 |
| Max. Negotiated Rate |
$57.75 |
| Rate for Payer: Adventist Health Commercial |
$15.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$52.90
|
| Rate for Payer: Cash Price |
$34.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.13
|
| Rate for Payer: Heritage Provider Network Senior |
$52.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.25
|
| Rate for Payer: Multiplan Commercial |
$57.75
|
|
|
HC SARS-COV2-2 RNA POC
|
Facility
OP
|
$57.00
|
|
|
Service Code
|
CPT 87635
|
| Hospital Charge Code |
900912260
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$10.32 |
| Max. Negotiated Rate |
$301.99 |
| Rate for Payer: Adventist Health Commercial |
$11.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$54.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$54.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$76.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$56.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$51.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$301.99
|
| Rate for Payer: Blue Shield of California Commercial |
$35.40
|
| Rate for Payer: Blue Shield of California EPN |
$33.46
|
| Rate for Payer: Cash Price |
$25.65
|
| Rate for Payer: Cash Price |
$25.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$37.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$76.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$56.44
|
| Rate for Payer: Dignity Health Senior |
$51.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.05
|
| Rate for Payer: EPIC Health Plan Medicare |
$51.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.28
|
| Rate for Payer: Heritage Provider Network Senior |
$35.28
|
| Rate for Payer: Humana Medicare |
$51.31
|
| Rate for Payer: IEHP Medi-Cal |
$80.04
|
| Rate for Payer: IEHP Medicare Advantage |
$51.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$97.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$60.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$64.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$64.65
|
| Rate for Payer: Multiplan Commercial |
$42.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$51.31
|
| Rate for Payer: TriValley Medical Group Senior |
$51.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$55.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$55.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$76.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$56.44
|
| Rate for Payer: Vantage Medical Group Senior |
$51.31
|
|
|
HC SARSCOV2 MOD BV BOOSTER 50MCG/0.5ML
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
CPT 91313
|
| Hospital Charge Code |
949001349
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
|
|
HC SARSCOV2 MOD BV BOOSTER 50MCG/0.5ML
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
CPT 91313
|
| Hospital Charge Code |
949001349
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.00
|
| Rate for Payer: Cash Price |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
HC SARSCOV2 MOD BV PEDS (6-11YRS) BOOSTER 25MCG/0.25ML
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
CPT 91314
|
| Hospital Charge Code |
949001351
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.00
|
| Rate for Payer: Cash Price |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
HC SARSCOV2 MOD BV PEDS (6-11YRS) BOOSTER 25MCG/0.25ML
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
CPT 91314
|
| Hospital Charge Code |
949001351
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
|
|
HC SARSCOV2 MOD BV PEDS (6MS-5YRS) BOOSTER 10MCG/0.2ML
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
CPT 91316
|
| Hospital Charge Code |
949001354
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
|
|
HC SARSCOV2 MOD BV PEDS (6MS-5YRS) BOOSTER 10MCG/0.2ML
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
CPT 91316
|
| Hospital Charge Code |
949001354
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.00
|
| Rate for Payer: Cash Price |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
HC SARSCOV2 PF BV BOOSTER 30MCG/0.3ML 12YRS OR OLDER
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
CPT 91312
|
| Hospital Charge Code |
949001345
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
|
|
HC SARSCOV2 PF BV BOOSTER 30MCG/0.3ML 12YRS OR OLDER
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
CPT 91312
|
| Hospital Charge Code |
949001345
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.00
|
| Rate for Payer: Cash Price |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
HC SARSCOV2 PF BV PEDS (5-11YRS) BOOSTER 10MCG/0.2ML
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
CPT 91315
|
| Hospital Charge Code |
949001347
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.00
|
| Rate for Payer: Cash Price |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
HC SARSCOV2 PF BV PEDS (5-11YRS) BOOSTER 10MCG/0.2ML
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
CPT 91315
|
| Hospital Charge Code |
949001347
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
|
