|
HC SD RECOVERY ADDL 30 MIN
|
Facility
OP
|
$664.00
|
|
| Hospital Charge Code |
907201508
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$120.18 |
| Max. Negotiated Rate |
$564.40 |
| Rate for Payer: Adventist Health Commercial |
$132.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$354.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$456.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$564.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$365.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$498.00
|
| Rate for Payer: Blue Shield of California Commercial |
$412.34
|
| Rate for Payer: Blue Shield of California EPN |
$389.77
|
| Rate for Payer: Cash Price |
$298.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$431.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$564.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$564.40
|
| Rate for Payer: Dignity Health Senior |
$564.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$431.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$411.02
|
| Rate for Payer: Heritage Provider Network Senior |
$411.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$320.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$120.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$166.00
|
| Rate for Payer: Multiplan Commercial |
$498.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$564.40
|
| Rate for Payer: Vantage Medical Group Senior |
$564.40
|
|
|
HC SD RECOVERY ADDL 30 MIN
|
Facility
IP
|
$664.00
|
|
| Hospital Charge Code |
907201508
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$120.18 |
| Max. Negotiated Rate |
$498.00 |
| Rate for Payer: Adventist Health Commercial |
$132.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$456.17
|
| Rate for Payer: Cash Price |
$298.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$449.53
|
| Rate for Payer: Heritage Provider Network Senior |
$449.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$120.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$166.00
|
| Rate for Payer: Multiplan Commercial |
$498.00
|
|
|
HC SD RECOVERY LEVEL IV FIRST HR
|
Facility
OP
|
$1,536.00
|
|
| Hospital Charge Code |
906500107
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$278.02 |
| Max. Negotiated Rate |
$1,305.60 |
| Rate for Payer: Adventist Health Commercial |
$307.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$820.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,055.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,305.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$844.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,152.00
|
| Rate for Payer: Blue Shield of California Commercial |
$953.86
|
| Rate for Payer: Blue Shield of California EPN |
$901.63
|
| Rate for Payer: Cash Price |
$691.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$998.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,305.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,305.60
|
| Rate for Payer: Dignity Health Senior |
$1,305.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$998.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$950.78
|
| Rate for Payer: Heritage Provider Network Senior |
$950.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$740.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$278.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$384.00
|
| Rate for Payer: Multiplan Commercial |
$1,152.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,305.60
|
| Rate for Payer: Vantage Medical Group Senior |
$1,305.60
|
|
|
HC SD RECOVERY LEVEL IV FIRST HR
|
Facility
IP
|
$1,536.00
|
|
| Hospital Charge Code |
906500107
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$278.02 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Adventist Health Commercial |
$307.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,055.23
|
| Rate for Payer: Cash Price |
$691.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,039.87
|
| Rate for Payer: Heritage Provider Network Senior |
$1,039.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$278.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$384.00
|
| Rate for Payer: Multiplan Commercial |
$1,152.00
|
|
|
HC SECONDARY ART M-THROMB ADD-ON
|
Facility
OP
|
$12,452.00
|
|
|
Service Code
|
CPT 37186
|
| Hospital Charge Code |
906820199
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$556.39 |
| Max. Negotiated Rate |
$10,584.20 |
| Rate for Payer: Adventist Health Commercial |
$2,490.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8,554.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,584.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6,848.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9,339.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Blue Shield of California Commercial |
$5,379.37
|
| Rate for Payer: Blue Shield of California EPN |
$4,623.32
|
| Rate for Payer: Cash Price |
$5,603.40
|
| Rate for Payer: Cash Price |
$5,603.40
|
| Rate for Payer: Cash Price |
$5,603.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8,093.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,584.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$10,584.20
|
| Rate for Payer: Dignity Health Senior |
$10,584.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,707.79
|
| Rate for Payer: Heritage Provider Network Senior |
$7,707.79
|
| Rate for Payer: IEHP Medi-Cal |
$556.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6,001.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,253.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,113.00
|
| Rate for Payer: Multiplan Commercial |
$9,339.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,040.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$874.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10,584.20
|
| Rate for Payer: Vantage Medical Group Senior |
$10,584.20
|
|
|
HC SECONDARY ART M-THROMB ADD-ON
|
Facility
OP
|
$14,344.00
|
|
|
Service Code
|
CPT 37186
|
| Hospital Charge Code |
909081845
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$556.39 |
| Max. Negotiated Rate |
$12,192.40 |
| Rate for Payer: Adventist Health Commercial |
$2,868.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9,854.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12,192.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,889.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10,758.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Blue Shield of California Commercial |
$5,379.37
|
| Rate for Payer: Blue Shield of California EPN |
$4,623.32
|
| Rate for Payer: Cash Price |
$6,454.80
|
| Rate for Payer: Cash Price |
$6,454.80
|
| Rate for Payer: Cash Price |
$6,454.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9,323.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12,192.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$12,192.40
|
| Rate for Payer: Dignity Health Senior |
$12,192.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$8,878.94
|
| Rate for Payer: Heritage Provider Network Senior |
$8,878.94
|
| Rate for Payer: IEHP Medi-Cal |
$556.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6,913.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,596.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,586.00
|
| Rate for Payer: Multiplan Commercial |
$10,758.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,040.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$874.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12,192.40
|
| Rate for Payer: Vantage Medical Group Senior |
$12,192.40
|
|
|
HC SECONDARY ART M-THROMB ADD-ON
|
Facility
IP
|
$14,344.00
|
|
|
Service Code
|
CPT 37186
|
| Hospital Charge Code |
909081845
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,596.26 |
| Max. Negotiated Rate |
$10,758.00 |
| Rate for Payer: Adventist Health Commercial |
$2,868.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9,854.33
|
| Rate for Payer: Cash Price |
$6,454.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$9,710.89
|
| Rate for Payer: Heritage Provider Network Senior |
$9,710.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,596.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,586.00
|
| Rate for Payer: Multiplan Commercial |
$10,758.00
|
|
|
HC SECONDARY ART M-THROMB ADD-ON
|
Facility
IP
|
$12,452.00
|
|
|
Service Code
|
CPT 37186
|
| Hospital Charge Code |
906820199
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,253.81 |
| Max. Negotiated Rate |
$9,339.00 |
| Rate for Payer: Adventist Health Commercial |
$2,490.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8,554.52
|
| Rate for Payer: Cash Price |
$5,603.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$8,430.00
|
| Rate for Payer: Heritage Provider Network Senior |
$8,430.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,253.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,113.00
|
| Rate for Payer: Multiplan Commercial |
$9,339.00
|
|
|
HC SEDATION EA ADDL 15 MIN
|
Facility
IP
|
$481.00
|
|
| Hospital Charge Code |
906820142
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$87.06 |
| Max. Negotiated Rate |
$360.75 |
| Rate for Payer: Adventist Health Commercial |
$96.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$330.45
|
| Rate for Payer: Cash Price |
$216.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$325.64
|
| Rate for Payer: Heritage Provider Network Senior |
$325.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$87.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.25
|
| Rate for Payer: Multiplan Commercial |
$360.75
|
|
|
HC SEDATION EA ADDL 15 MIN
|
Facility
OP
|
$481.00
|
|
| Hospital Charge Code |
906820142
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$87.06 |
| Max. Negotiated Rate |
$408.85 |
| Rate for Payer: Adventist Health Commercial |
$96.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$257.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$330.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$408.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$264.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$360.75
|
| Rate for Payer: Blue Shield of California Commercial |
$298.70
|
| Rate for Payer: Blue Shield of California EPN |
$282.35
|
| Rate for Payer: Cash Price |
$216.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$312.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$408.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$408.85
|
| Rate for Payer: Dignity Health Senior |
$408.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$312.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$297.74
|
| Rate for Payer: Heritage Provider Network Senior |
$297.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$231.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$87.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.25
|
| Rate for Payer: Multiplan Commercial |
$360.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$408.85
|
| Rate for Payer: Vantage Medical Group Senior |
$408.85
|
|
|
HC SEDATION EA ADDL 15 MIN
|
Facility
OP
|
$477.00
|
|
| Hospital Charge Code |
907201215
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$86.34 |
| Max. Negotiated Rate |
$405.45 |
| Rate for Payer: Adventist Health Commercial |
$95.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$254.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$327.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$405.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$262.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$357.75
|
| Rate for Payer: Blue Shield of California Commercial |
$296.22
|
| Rate for Payer: Blue Shield of California EPN |
$280.00
|
| Rate for Payer: Cash Price |
$214.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$310.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$405.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$405.45
|
| Rate for Payer: Dignity Health Senior |
$405.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$310.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$295.26
|
| Rate for Payer: Heritage Provider Network Senior |
$295.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$229.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.25
|
| Rate for Payer: Multiplan Commercial |
$357.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$405.45
|
| Rate for Payer: Vantage Medical Group Senior |
$405.45
|
|
|
HC SEDATION EA ADDL 15 MIN
|
Facility
IP
|
$477.00
|
|
| Hospital Charge Code |
907201215
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$86.34 |
| Max. Negotiated Rate |
$357.75 |
| Rate for Payer: Adventist Health Commercial |
$95.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$327.70
|
| Rate for Payer: Cash Price |
$214.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$322.93
|
| Rate for Payer: Heritage Provider Network Senior |
$322.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.25
|
| Rate for Payer: Multiplan Commercial |
$357.75
|
|
|
HC SEDATION GT 5 YRS FIRST 30 MIN
|
Facility
IP
|
$869.00
|
|
| Hospital Charge Code |
906820141
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$157.29 |
| Max. Negotiated Rate |
$651.75 |
| Rate for Payer: Adventist Health Commercial |
$173.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$597.00
|
| Rate for Payer: Cash Price |
$391.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$588.31
|
| Rate for Payer: Heritage Provider Network Senior |
$588.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$157.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$217.25
|
| Rate for Payer: Multiplan Commercial |
$651.75
|
|
|
HC SEDATION GT 5 YRS FIRST 30 MIN
|
Facility
IP
|
$1,254.00
|
|
| Hospital Charge Code |
907201214
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$226.97 |
| Max. Negotiated Rate |
$940.50 |
| Rate for Payer: Adventist Health Commercial |
$250.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$861.50
|
| Rate for Payer: Cash Price |
$564.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$848.96
|
| Rate for Payer: Heritage Provider Network Senior |
$848.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$226.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$313.50
|
| Rate for Payer: Multiplan Commercial |
$940.50
|
|
|
HC SEDATION GT 5 YRS FIRST 30 MIN
|
Facility
OP
|
$1,254.00
|
|
| Hospital Charge Code |
907201214
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$226.97 |
| Max. Negotiated Rate |
$1,065.90 |
| Rate for Payer: Adventist Health Commercial |
$250.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$670.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$861.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,065.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$689.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$940.50
|
| Rate for Payer: Blue Shield of California Commercial |
$778.73
|
| Rate for Payer: Blue Shield of California EPN |
$736.10
|
| Rate for Payer: Cash Price |
$564.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$815.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,065.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,065.90
|
| Rate for Payer: Dignity Health Senior |
$1,065.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$815.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$776.23
|
| Rate for Payer: Heritage Provider Network Senior |
$776.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$604.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$226.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$313.50
|
| Rate for Payer: Multiplan Commercial |
$940.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,065.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1,065.90
|
|
|
HC SEDATION GT 5 YRS FIRST 30 MIN
|
Facility
OP
|
$869.00
|
|
| Hospital Charge Code |
906820141
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$157.29 |
| Max. Negotiated Rate |
$738.65 |
| Rate for Payer: Adventist Health Commercial |
$173.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$464.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$597.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$738.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$477.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$651.75
|
| Rate for Payer: Blue Shield of California Commercial |
$539.65
|
| Rate for Payer: Blue Shield of California EPN |
$510.10
|
| Rate for Payer: Cash Price |
$391.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$564.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$738.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$738.65
|
| Rate for Payer: Dignity Health Senior |
$738.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$564.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$537.91
|
| Rate for Payer: Heritage Provider Network Senior |
$537.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$418.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$157.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$217.25
|
| Rate for Payer: Multiplan Commercial |
$651.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$738.65
|
| Rate for Payer: Vantage Medical Group Senior |
$738.65
|
|
|
HC SEDATION LT 5 YRS FIRST 30 MIN
|
Facility
IP
|
$1,254.00
|
|
| Hospital Charge Code |
907201213
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$226.97 |
| Max. Negotiated Rate |
$940.50 |
| Rate for Payer: Adventist Health Commercial |
$250.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$861.50
|
| Rate for Payer: Cash Price |
$564.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$848.96
|
| Rate for Payer: Heritage Provider Network Senior |
$848.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$226.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$313.50
|
| Rate for Payer: Multiplan Commercial |
$940.50
|
|
|
HC SEDATION LT 5 YRS FIRST 30 MIN
|
Facility
IP
|
$1,136.00
|
|
| Hospital Charge Code |
909201305
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$205.62 |
| Max. Negotiated Rate |
$852.00 |
| Rate for Payer: Adventist Health Commercial |
$227.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$780.43
|
| Rate for Payer: Cash Price |
$511.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$769.07
|
| Rate for Payer: Heritage Provider Network Senior |
$769.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$205.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$284.00
|
| Rate for Payer: Multiplan Commercial |
$852.00
|
|
|
HC SEDATION LT 5 YRS FIRST 30 MIN
|
Facility
OP
|
$996.00
|
|
| Hospital Charge Code |
906820140
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$180.28 |
| Max. Negotiated Rate |
$846.60 |
| Rate for Payer: Adventist Health Commercial |
$199.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$532.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$684.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$846.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$547.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$747.00
|
| Rate for Payer: Blue Shield of California Commercial |
$618.52
|
| Rate for Payer: Blue Shield of California EPN |
$584.65
|
| Rate for Payer: Cash Price |
$448.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$647.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$846.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$846.60
|
| Rate for Payer: Dignity Health Senior |
$846.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$647.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$616.52
|
| Rate for Payer: Heritage Provider Network Senior |
$616.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$480.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$180.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$249.00
|
| Rate for Payer: Multiplan Commercial |
$747.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$846.60
|
| Rate for Payer: Vantage Medical Group Senior |
$846.60
|
|
|
HC SEDATION LT 5 YRS FIRST 30 MIN
|
Facility
IP
|
$996.00
|
|
| Hospital Charge Code |
906820140
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$180.28 |
| Max. Negotiated Rate |
$747.00 |
| Rate for Payer: Adventist Health Commercial |
$199.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$684.25
|
| Rate for Payer: Cash Price |
$448.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$674.29
|
| Rate for Payer: Heritage Provider Network Senior |
$674.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$180.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$249.00
|
| Rate for Payer: Multiplan Commercial |
$747.00
|
|
|
HC SEDATION LT 5 YRS FIRST 30 MIN
|
Facility
OP
|
$1,136.00
|
|
| Hospital Charge Code |
909201305
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$205.62 |
| Max. Negotiated Rate |
$965.60 |
| Rate for Payer: Adventist Health Commercial |
$227.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$607.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$780.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$965.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$624.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$852.00
|
| Rate for Payer: Blue Shield of California Commercial |
$705.46
|
| Rate for Payer: Blue Shield of California EPN |
$666.83
|
| Rate for Payer: Cash Price |
$511.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$738.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$965.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$965.60
|
| Rate for Payer: Dignity Health Senior |
$965.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$738.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$703.18
|
| Rate for Payer: Heritage Provider Network Senior |
$703.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$547.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$205.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$284.00
|
| Rate for Payer: Multiplan Commercial |
$852.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$965.60
|
| Rate for Payer: Vantage Medical Group Senior |
$965.60
|
|
|
HC SEDATION LT 5 YRS FIRST 30 MIN
|
Facility
OP
|
$1,254.00
|
|
| Hospital Charge Code |
907201213
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$226.97 |
| Max. Negotiated Rate |
$1,065.90 |
| Rate for Payer: Adventist Health Commercial |
$250.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$670.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$861.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,065.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$689.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$940.50
|
| Rate for Payer: Blue Shield of California Commercial |
$778.73
|
| Rate for Payer: Blue Shield of California EPN |
$736.10
|
| Rate for Payer: Cash Price |
$564.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$815.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,065.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,065.90
|
| Rate for Payer: Dignity Health Senior |
$1,065.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$815.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$776.23
|
| Rate for Payer: Heritage Provider Network Senior |
$776.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$604.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$226.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$313.50
|
| Rate for Payer: Multiplan Commercial |
$940.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,065.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1,065.90
|
|
|
HC SED RATE WESTERGREN MANUAL
|
Facility
IP
|
$156.00
|
|
|
Service Code
|
CPT 85651
|
| Hospital Charge Code |
900912022
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$28.24 |
| Max. Negotiated Rate |
$117.00 |
| Rate for Payer: Adventist Health Commercial |
$31.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$107.17
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$105.61
|
| Rate for Payer: Heritage Provider Network Senior |
$105.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.00
|
| Rate for Payer: Multiplan Commercial |
$117.00
|
|
|
HC SED RATE WESTERGREN MANUAL
|
Facility
OP
|
$12.00
|
|
|
Service Code
|
CPT 85651
|
| Hospital Charge Code |
900912022
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$29.70 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$29.70
|
| Rate for Payer: Blue Shield of California Commercial |
$27.73
|
| Rate for Payer: Blue Shield of California EPN |
$21.68
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.70
|
| Rate for Payer: Dignity Health Senior |
$4.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.43
|
| Rate for Payer: Heritage Provider Network Senior |
$7.43
|
| Rate for Payer: Humana Medicare |
$4.27
|
| Rate for Payer: IEHP Medi-Cal |
$3.70
|
| Rate for Payer: IEHP Medicare Advantage |
$4.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.38
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.27
|
| Rate for Payer: TriValley Medical Group Senior |
$4.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.70
|
| Rate for Payer: Vantage Medical Group Senior |
$4.27
|
|
|
HC SED RATE WESTERGRN AUTOMATED
|
Facility
IP
|
$132.00
|
|
|
Service Code
|
CPT 85652
|
| Hospital Charge Code |
900910025
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$23.89 |
| Max. Negotiated Rate |
$99.00 |
| Rate for Payer: Adventist Health Commercial |
$26.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$90.68
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$89.36
|
| Rate for Payer: Heritage Provider Network Senior |
$89.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$99.00
|
|
