|
HC TC-99 MEBROFEN/CHOLETEC LT 15MCI
|
Facility
|
IP
|
$419.00
|
|
|
Service Code
|
CPT A9537
|
| Hospital Charge Code |
909301537
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.84 |
| Max. Negotiated Rate |
$314.25 |
| Rate for Payer: Adventist Health Commercial |
$83.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$287.85
|
| Rate for Payer: Cash Price |
$188.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$192.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$226.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$283.66
|
| Rate for Payer: Heritage Provider Network Senior |
$283.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$75.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$104.75
|
| Rate for Payer: Multiplan Commercial |
$314.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$152.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$139.99
|
|
|
HC TC-99 MEDRONATE/MDP LT 30MCI
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
CPT A9503
|
| Hospital Charge Code |
909301508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.20 |
| Max. Negotiated Rate |
$289.16 |
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$46.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$63.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$289.16
|
| Rate for Payer: Blue Shield of California Commercial |
$52.16
|
| Rate for Payer: Blue Shield of California EPN |
$49.31
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.40
|
| Rate for Payer: Dignity Health Senior |
$71.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.89
|
| Rate for Payer: Heritage Provider Network Senior |
$38.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$29.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$40.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$33.60
|
| Rate for Payer: TriValley Medical Group Senior |
$33.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$30.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$28.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$71.40
|
| Rate for Payer: Vantage Medical Group Senior |
$71.40
|
|
|
HC TC-99 MEDRONATE/MDP LT 30MCI
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
CPT A9503
|
| Hospital Charge Code |
909301508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.20 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$57.71
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$56.87
|
| Rate for Payer: Heritage Provider Network Senior |
$56.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$30.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$28.06
|
|
|
HC TC-99 MERTIATIDE/MAG3 LT 15MCI
|
Facility
|
OP
|
$183.00
|
|
|
Service Code
|
CPT A9562
|
| Hospital Charge Code |
909301531
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.12 |
| Max. Negotiated Rate |
$881.58 |
| Rate for Payer: Adventist Health Commercial |
$36.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$155.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$100.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$137.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$881.58
|
| Rate for Payer: Blue Shield of California Commercial |
$113.64
|
| Rate for Payer: Blue Shield of California EPN |
$107.42
|
| Rate for Payer: Cash Price |
$82.35
|
| Rate for Payer: Cash Price |
$82.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$84.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$155.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$155.55
|
| Rate for Payer: Dignity Health Senior |
$155.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$117.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$84.73
|
| Rate for Payer: Heritage Provider Network Senior |
$84.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$478.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$88.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.75
|
| Rate for Payer: Multiplan Commercial |
$137.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$73.20
|
| Rate for Payer: TriValley Medical Group Senior |
$73.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$66.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$61.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$155.55
|
| Rate for Payer: Vantage Medical Group Senior |
$155.55
|
|
|
HC TC-99 MERTIATIDE/MAG3 LT 15MCI
|
Facility
|
IP
|
$183.00
|
|
|
Service Code
|
CPT A9562
|
| Hospital Charge Code |
909301531
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.12 |
| Max. Negotiated Rate |
$137.25 |
| Rate for Payer: Adventist Health Commercial |
$36.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$125.72
|
| Rate for Payer: Cash Price |
$82.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$84.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$98.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$123.89
|
| Rate for Payer: Heritage Provider Network Senior |
$123.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.75
|
| Rate for Payer: Multiplan Commercial |
$137.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$66.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$61.14
|
|
|
HC TC-99M PERTECHNETATE PER MCI
|
Facility
|
IP
|
$287.00
|
|
|
Service Code
|
CPT A9512
|
| Hospital Charge Code |
909301501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.95 |
| Max. Negotiated Rate |
$215.25 |
| Rate for Payer: Adventist Health Commercial |
$57.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$197.17
|
| Rate for Payer: Cash Price |
$129.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$132.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$154.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$194.30
|
| Rate for Payer: Heritage Provider Network Senior |
$194.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$51.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$71.75
|
| Rate for Payer: Multiplan Commercial |
$215.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$104.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$95.89
|
|
|
HC TC-99M PERTECHNETATE PER MCI
|
Facility
|
OP
|
$287.00
|
|
|
Service Code
|
CPT A9512
|
| Hospital Charge Code |
909301501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.42 |
| Max. Negotiated Rate |
$243.95 |
| Rate for Payer: Adventist Health Commercial |
$57.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$243.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$157.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$215.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.42
|
| Rate for Payer: Blue Shield of California Commercial |
$178.23
|
| Rate for Payer: Blue Shield of California EPN |
$168.47
|
| Rate for Payer: Cash Price |
$129.15
|
| Rate for Payer: Cash Price |
$129.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$132.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$243.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$243.95
|
| Rate for Payer: Dignity Health Senior |
$243.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$183.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$132.88
|
| Rate for Payer: Heritage Provider Network Senior |
$132.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$138.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$51.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$71.75
|
| Rate for Payer: Multiplan Commercial |
$215.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$114.80
|
| Rate for Payer: TriValley Medical Group Senior |
$114.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$104.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$95.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$243.95
|
| Rate for Payer: Vantage Medical Group Senior |
$243.95
|
|
|
HC TC-99 OXIDRONATE/HDP LT 30MCI
|
Facility
|
OP
|
$231.00
|
|
|
Service Code
|
CPT A9561
|
| Hospital Charge Code |
909301536
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.99 |
| Max. Negotiated Rate |
$196.35 |
| Rate for Payer: Adventist Health Commercial |
$46.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$196.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$127.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$173.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.96
|
| Rate for Payer: Blue Shield of California Commercial |
$143.45
|
| Rate for Payer: Blue Shield of California EPN |
$135.60
|
| Rate for Payer: Cash Price |
$103.95
|
| Rate for Payer: Cash Price |
$103.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$106.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$196.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$196.35
|
| Rate for Payer: Dignity Health Senior |
$196.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$147.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$106.95
|
| Rate for Payer: Heritage Provider Network Senior |
$106.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$34.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$111.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.75
|
| Rate for Payer: Multiplan Commercial |
$173.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$92.40
|
| Rate for Payer: TriValley Medical Group Senior |
$92.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$84.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$77.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$196.35
|
| Rate for Payer: Vantage Medical Group Senior |
$196.35
|
|
|
HC TC-99 OXIDRONATE/HDP LT 30MCI
|
Facility
|
IP
|
$231.00
|
|
|
Service Code
|
CPT A9561
|
| Hospital Charge Code |
909301536
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.81 |
| Max. Negotiated Rate |
$173.25 |
| Rate for Payer: Adventist Health Commercial |
$46.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$158.70
|
| Rate for Payer: Cash Price |
$103.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$106.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$124.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$156.39
|
| Rate for Payer: Heritage Provider Network Senior |
$156.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.75
|
| Rate for Payer: Multiplan Commercial |
$173.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$84.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$77.18
|
|
|
HC TC-99 PENTETATE/DTPA LT 25MCI
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
CPT A9539
|
| Hospital Charge Code |
909301510
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.40 |
| Max. Negotiated Rate |
$134.25 |
| Rate for Payer: Adventist Health Commercial |
$35.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$122.97
|
| Rate for Payer: Cash Price |
$80.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$82.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$121.18
|
| Rate for Payer: Heritage Provider Network Senior |
$121.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.75
|
| Rate for Payer: Multiplan Commercial |
$134.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$65.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$59.80
|
|
|
HC TC-99 PENTETATE/DTPA LT 25MCI
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
CPT A9539
|
| Hospital Charge Code |
909301510
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.28 |
| Max. Negotiated Rate |
$152.15 |
| Rate for Payer: Adventist Health Commercial |
$35.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$152.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$98.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$134.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.16
|
| Rate for Payer: Blue Shield of California Commercial |
$111.16
|
| Rate for Payer: Blue Shield of California EPN |
$105.07
|
| Rate for Payer: Cash Price |
$80.55
|
| Rate for Payer: Cash Price |
$80.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$82.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$152.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$152.15
|
| Rate for Payer: Dignity Health Senior |
$152.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$114.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$82.88
|
| Rate for Payer: Heritage Provider Network Senior |
$82.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$20.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$86.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.75
|
| Rate for Payer: Multiplan Commercial |
$134.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$71.60
|
| Rate for Payer: TriValley Medical Group Senior |
$71.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$65.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$59.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$152.15
|
| Rate for Payer: Vantage Medical Group Senior |
$152.15
|
|
|
HC TC-99 PYROPHOSPHATE LT 25 MCI
|
Facility
|
IP
|
$312.00
|
|
|
Service Code
|
CPT A9538
|
| Hospital Charge Code |
909301507
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.47 |
| Max. Negotiated Rate |
$234.00 |
| Rate for Payer: Adventist Health Commercial |
$62.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$214.34
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$143.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$168.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$211.22
|
| Rate for Payer: Heritage Provider Network Senior |
$211.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$56.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.00
|
| Rate for Payer: Multiplan Commercial |
$234.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$113.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$104.24
|
|
|
HC TC-99 PYROPHOSPHATE LT 25 MCI
|
Facility
|
OP
|
$312.00
|
|
|
Service Code
|
CPT A9538
|
| Hospital Charge Code |
909301507
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.88 |
| Max. Negotiated Rate |
$265.20 |
| Rate for Payer: Adventist Health Commercial |
$62.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$265.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$171.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$234.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.88
|
| Rate for Payer: Blue Shield of California Commercial |
$193.75
|
| Rate for Payer: Blue Shield of California EPN |
$183.14
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$143.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$265.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$265.20
|
| Rate for Payer: Dignity Health Senior |
$265.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$144.46
|
| Rate for Payer: Heritage Provider Network Senior |
$144.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$99.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$150.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$56.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.00
|
| Rate for Payer: Multiplan Commercial |
$234.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$124.80
|
| Rate for Payer: TriValley Medical Group Senior |
$124.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$113.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$104.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$265.20
|
| Rate for Payer: Vantage Medical Group Senior |
$265.20
|
|
|
HC TC-99 SUCCIMER/DMSA LT 10 MCI
|
Facility
|
IP
|
$706.00
|
|
|
Service Code
|
CPT A9551
|
| Hospital Charge Code |
909301500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.79 |
| Max. Negotiated Rate |
$529.50 |
| Rate for Payer: Adventist Health Commercial |
$141.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$485.02
|
| Rate for Payer: Cash Price |
$317.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$324.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$381.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$477.96
|
| Rate for Payer: Heritage Provider Network Senior |
$477.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$127.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$176.50
|
| Rate for Payer: Multiplan Commercial |
$529.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$257.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$235.87
|
|
|
HC TC-99 SUCCIMER/DMSA LT 10 MCI
|
Facility
|
OP
|
$706.00
|
|
|
Service Code
|
CPT A9551
|
| Hospital Charge Code |
909301500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.79 |
| Max. Negotiated Rate |
$600.10 |
| Rate for Payer: Adventist Health Commercial |
$141.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$600.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$388.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$529.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$250.58
|
| Rate for Payer: Blue Shield of California Commercial |
$438.43
|
| Rate for Payer: Blue Shield of California EPN |
$414.42
|
| Rate for Payer: Cash Price |
$317.70
|
| Rate for Payer: Cash Price |
$317.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$324.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$600.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$600.10
|
| Rate for Payer: Dignity Health Senior |
$600.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$451.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$326.88
|
| Rate for Payer: Heritage Provider Network Senior |
$326.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$158.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$340.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$127.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$176.50
|
| Rate for Payer: Multiplan Commercial |
$529.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$282.40
|
| Rate for Payer: TriValley Medical Group Senior |
$282.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$257.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$235.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$600.10
|
| Rate for Payer: Vantage Medical Group Senior |
$600.10
|
|
|
HC TC-99 TETROFOSMN/MYOVIEW LT 40MCI
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
CPT A9502
|
| Hospital Charge Code |
909301544
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.72 |
| Max. Negotiated Rate |
$224.40 |
| Rate for Payer: Adventist Health Commercial |
$45.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$191.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$123.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$168.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$224.40
|
| Rate for Payer: Blue Shield of California Commercial |
$139.72
|
| Rate for Payer: Blue Shield of California EPN |
$132.08
|
| Rate for Payer: Cash Price |
$101.25
|
| Rate for Payer: Cash Price |
$101.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$103.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$191.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$191.25
|
| Rate for Payer: Dignity Health Senior |
$191.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$144.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$104.18
|
| Rate for Payer: Heritage Provider Network Senior |
$104.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$151.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$108.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.25
|
| Rate for Payer: Multiplan Commercial |
$168.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$90.00
|
| Rate for Payer: TriValley Medical Group Senior |
$90.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$82.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$75.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$191.25
|
| Rate for Payer: Vantage Medical Group Senior |
$191.25
|
|
|
HC TC-99 TETROFOSMN/MYOVIEW LT 40MCI
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
CPT A9502
|
| Hospital Charge Code |
909301544
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.72 |
| Max. Negotiated Rate |
$168.75 |
| Rate for Payer: Adventist Health Commercial |
$45.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$154.58
|
| Rate for Payer: Cash Price |
$101.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$103.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$121.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$152.32
|
| Rate for Payer: Heritage Provider Network Senior |
$152.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.25
|
| Rate for Payer: Multiplan Commercial |
$168.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$82.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$75.17
|
|
|
HC TC-99 ULTRATAG UP TO 30 MCI
|
Facility
|
IP
|
$2,343.00
|
|
|
Service Code
|
CPT A9560
|
| Hospital Charge Code |
909301534
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$424.08 |
| Max. Negotiated Rate |
$1,757.25 |
| Rate for Payer: Adventist Health Commercial |
$468.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,609.64
|
| Rate for Payer: Cash Price |
$1,054.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,077.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,265.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,586.21
|
| Rate for Payer: Heritage Provider Network Senior |
$1,586.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$424.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$585.75
|
| Rate for Payer: Multiplan Commercial |
$1,757.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$854.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$782.80
|
|
|
HC TC-99 ULTRATAG UP TO 30 MCI
|
Facility
|
OP
|
$2,343.00
|
|
|
Service Code
|
CPT A9560
|
| Hospital Charge Code |
909301534
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.81 |
| Max. Negotiated Rate |
$1,991.55 |
| Rate for Payer: Adventist Health Commercial |
$468.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,991.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,288.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,757.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$225.58
|
| Rate for Payer: Blue Shield of California Commercial |
$1,455.00
|
| Rate for Payer: Blue Shield of California EPN |
$1,375.34
|
| Rate for Payer: Cash Price |
$1,054.35
|
| Rate for Payer: Cash Price |
$1,054.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,077.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,991.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,991.55
|
| Rate for Payer: Dignity Health Senior |
$1,991.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,499.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,084.81
|
| Rate for Payer: Heritage Provider Network Senior |
$1,084.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$80.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,129.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$424.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$585.75
|
| Rate for Payer: Multiplan Commercial |
$1,757.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$937.20
|
| Rate for Payer: TriValley Medical Group Senior |
$937.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$854.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$782.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,991.55
|
| Rate for Payer: Vantage Medical Group Senior |
$1,991.55
|
|
|
HC TCATH RMVL OR DBLK ICAR MASS OR VEG
|
Facility
|
OP
|
$14,072.00
|
|
|
Service Code
|
CPT 0644T
|
| Hospital Charge Code |
906820292
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$933.56 |
| Max. Negotiated Rate |
$13,568.56 |
| Rate for Payer: Adventist Health Commercial |
$2,814.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,822.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9,667.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,712.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7,855.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,141.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1,086.22
|
| Rate for Payer: Blue Shield of California EPN |
$933.56
|
| Rate for Payer: Cash Price |
$6,332.40
|
| Rate for Payer: Cash Price |
$6,332.40
|
| Rate for Payer: Cash Price |
$6,332.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,340.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,712.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,855.48
|
| Rate for Payer: Dignity Health Senior |
$7,141.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,141.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$8,710.57
|
| Rate for Payer: Heritage Provider Network Senior |
$8,783.86
|
| Rate for Payer: Humana Medicare |
$7,141.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,141.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,568.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,547.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,426.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,518.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,998.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,998.10
|
| Rate for Payer: Multiplan Commercial |
$10,554.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,855.48
|
| Rate for Payer: TriValley Medical Group Senior |
$7,141.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13,479.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11,381.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,712.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,855.48
|
| Rate for Payer: Vantage Medical Group Senior |
$7,141.35
|
|
|
HC TCATH RMVL OR DBLK ICAR MASS OR VEG
|
Facility
|
IP
|
$14,072.00
|
|
|
Service Code
|
CPT 0644T
|
| Hospital Charge Code |
906820292
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,547.03 |
| Max. Negotiated Rate |
$10,554.00 |
| Rate for Payer: Adventist Health Commercial |
$2,814.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9,667.46
|
| Rate for Payer: Cash Price |
$6,332.40
|
| Rate for Payer: Cash Price |
$6,332.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,478.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,982.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,547.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,518.00
|
| Rate for Payer: Multiplan Commercial |
$10,554.00
|
|
|
HC TCAT IMPL WRLS PUL ART PRS SNR
|
Facility
|
OP
|
$21,934.00
|
|
|
Service Code
|
CPT 33289
|
| Hospital Charge Code |
906820143
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$251.00 |
| Max. Negotiated Rate |
$68,997.06 |
| Rate for Payer: Adventist Health Commercial |
$4,386.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15,068.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$54,471.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$39,945.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$36,314.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,496.00
|
| Rate for Payer: Blue Shield of California Commercial |
$13,621.01
|
| Rate for Payer: Blue Shield of California EPN |
$12,875.26
|
| Rate for Payer: Cash Price |
$9,870.30
|
| Rate for Payer: Cash Price |
$9,870.30
|
| Rate for Payer: Cash Price |
$9,870.30
|
| Rate for Payer: Cash Price |
$9,870.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14,257.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$54,471.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$39,945.66
|
| Rate for Payer: Dignity Health Senior |
$36,314.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$36,314.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$13,577.15
|
| Rate for Payer: Heritage Provider Network Senior |
$13,577.15
|
| Rate for Payer: Humana Medicare |
$36,314.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$430.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$36,314.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$68,997.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,970.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$42,850.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,483.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$45,755.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$45,755.94
|
| Rate for Payer: Multiplan Commercial |
$16,450.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$39,945.66
|
| Rate for Payer: TriValley Medical Group Senior |
$36,314.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$298.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$251.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$54,471.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39,945.66
|
| Rate for Payer: Vantage Medical Group Senior |
$36,314.24
|
|
|
HC TCAT IMPL WRLS PUL ART PRS SNR
|
Facility
|
OP
|
$18,604.00
|
|
|
Service Code
|
CPT 33289
|
| Hospital Charge Code |
906811492
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$251.00 |
| Max. Negotiated Rate |
$68,997.06 |
| Rate for Payer: Adventist Health Commercial |
$3,720.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12,780.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$54,471.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$39,945.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$36,314.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,496.00
|
| Rate for Payer: Blue Shield of California Commercial |
$11,553.08
|
| Rate for Payer: Blue Shield of California EPN |
$10,920.55
|
| Rate for Payer: Cash Price |
$8,371.80
|
| Rate for Payer: Cash Price |
$8,371.80
|
| Rate for Payer: Cash Price |
$8,371.80
|
| Rate for Payer: Cash Price |
$8,371.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12,092.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$54,471.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$39,945.66
|
| Rate for Payer: Dignity Health Senior |
$36,314.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$36,314.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$11,515.88
|
| Rate for Payer: Heritage Provider Network Senior |
$11,515.88
|
| Rate for Payer: Humana Medicare |
$36,314.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$430.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$36,314.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$68,997.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,367.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$42,850.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4,651.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$45,755.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$45,755.94
|
| Rate for Payer: Multiplan Commercial |
$13,953.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$39,945.66
|
| Rate for Payer: TriValley Medical Group Senior |
$36,314.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$298.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$251.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$54,471.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39,945.66
|
| Rate for Payer: Vantage Medical Group Senior |
$36,314.24
|
|
|
HC TCAT IMPL WRLS PUL ART PRS SNR
|
Facility
|
IP
|
$21,934.00
|
|
|
Service Code
|
CPT 33289
|
| Hospital Charge Code |
906820143
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$3,970.05 |
| Max. Negotiated Rate |
$16,450.50 |
| Rate for Payer: Adventist Health Commercial |
$4,386.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15,068.66
|
| Rate for Payer: Cash Price |
$9,870.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$14,849.32
|
| Rate for Payer: Heritage Provider Network Senior |
$14,849.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,970.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,483.50
|
| Rate for Payer: Multiplan Commercial |
$16,450.50
|
|
|
HC TCAT IMPL WRLS PUL ART PRS SNR
|
Facility
|
IP
|
$18,604.00
|
|
|
Service Code
|
CPT 33289
|
| Hospital Charge Code |
906811492
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$3,367.32 |
| Max. Negotiated Rate |
$13,953.00 |
| Rate for Payer: Adventist Health Commercial |
$3,720.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12,780.95
|
| Rate for Payer: Cash Price |
$8,371.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$12,594.91
|
| Rate for Payer: Heritage Provider Network Senior |
$12,594.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,367.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4,651.00
|
| Rate for Payer: Multiplan Commercial |
$13,953.00
|
|
