|
HC TISSUE MARKER 11 GA
|
Facility
|
OP
|
$429.00
|
|
|
Service Code
|
CPT A4648
|
| Hospital Charge Code |
909001880
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$85.80 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$85.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$205.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$294.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$364.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$235.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$321.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$266.41
|
| Rate for Payer: Blue Shield of California EPN |
$251.82
|
| Rate for Payer: Cash Price |
$193.05
|
| Rate for Payer: Cash Price |
$193.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$197.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$364.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$364.65
|
| Rate for Payer: Dignity Health Senior |
$364.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$274.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$198.63
|
| Rate for Payer: Heritage Provider Network Senior |
$198.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$214.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$214.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$214.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.25
|
| Rate for Payer: Multiplan Commercial |
$321.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$156.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$143.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$364.65
|
| Rate for Payer: Vantage Medical Group Senior |
$364.65
|
|
|
HC TISSUE MARKER 11 GA
|
Facility
|
IP
|
$429.00
|
|
|
Service Code
|
CPT A4648
|
| Hospital Charge Code |
909001880
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$85.80 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$85.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$205.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$294.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$193.05
|
| Rate for Payer: Cash Price |
$193.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$197.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$231.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$290.43
|
| Rate for Payer: Heritage Provider Network Senior |
$290.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$214.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$214.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$214.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.25
|
| Rate for Payer: Multiplan Commercial |
$321.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$156.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$143.33
|
|
|
HC TISSUE MARKER 18GA
|
Facility
|
IP
|
$1,227.20
|
|
|
Service Code
|
CPT A4648
|
| Hospital Charge Code |
909001881
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$245.44 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$245.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$589.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$843.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$552.24
|
| Rate for Payer: Cash Price |
$552.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$564.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$662.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$830.81
|
| Rate for Payer: Heritage Provider Network Senior |
$830.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$613.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$613.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$613.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$306.80
|
| Rate for Payer: Multiplan Commercial |
$920.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$447.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$410.01
|
|
|
HC TISSUE MARKER 18GA
|
Facility
|
OP
|
$1,227.20
|
|
|
Service Code
|
CPT A4648
|
| Hospital Charge Code |
909001881
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$245.44 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$245.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$589.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$843.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,043.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$674.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$920.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$762.09
|
| Rate for Payer: Blue Shield of California EPN |
$720.37
|
| Rate for Payer: Cash Price |
$552.24
|
| Rate for Payer: Cash Price |
$552.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$564.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,043.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,043.12
|
| Rate for Payer: Dignity Health Senior |
$1,043.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$785.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$568.19
|
| Rate for Payer: Heritage Provider Network Senior |
$568.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$613.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$613.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$613.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$306.80
|
| Rate for Payer: Multiplan Commercial |
$920.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$447.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$410.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,043.12
|
| Rate for Payer: Vantage Medical Group Senior |
$1,043.12
|
|
|
HC TISSUE MARKER 8 GA
|
Facility
|
IP
|
$407.00
|
|
|
Service Code
|
CPT A4648
|
| Hospital Charge Code |
909001129
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.40 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$81.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$195.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$279.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$183.15
|
| Rate for Payer: Cash Price |
$183.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$187.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$275.54
|
| Rate for Payer: Heritage Provider Network Senior |
$275.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$203.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$203.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$203.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$101.75
|
| Rate for Payer: Multiplan Commercial |
$305.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$148.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$135.98
|
|
|
HC TISSUE MARKER 8 GA
|
Facility
|
OP
|
$407.00
|
|
|
Service Code
|
CPT A4648
|
| Hospital Charge Code |
909001129
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.40 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$81.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$195.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$279.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$345.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$223.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$305.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$252.75
|
| Rate for Payer: Blue Shield of California EPN |
$238.91
|
| Rate for Payer: Cash Price |
$183.15
|
| Rate for Payer: Cash Price |
$183.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$187.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$345.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$345.95
|
| Rate for Payer: Dignity Health Senior |
$345.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$260.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$188.44
|
| Rate for Payer: Heritage Provider Network Senior |
$188.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$203.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$203.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$203.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$101.75
|
| Rate for Payer: Multiplan Commercial |
$305.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$148.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$135.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$345.95
|
| Rate for Payer: Vantage Medical Group Senior |
$345.95
|
|
|
HC TL-201 THAL CL PER MCI THALLIU
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
CPT A9505
|
| Hospital Charge Code |
909301524
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.43 |
| Max. Negotiated Rate |
$109.50 |
| Rate for Payer: Adventist Health Commercial |
$29.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$100.30
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$67.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$78.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$98.84
|
| Rate for Payer: Heritage Provider Network Senior |
$98.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.50
|
| Rate for Payer: Multiplan Commercial |
$109.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$53.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$48.78
|
|
|
HC TL-201 THAL CL PER MCI THALLIU
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
CPT A9505
|
| Hospital Charge Code |
909301524
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.43 |
| Max. Negotiated Rate |
$124.10 |
| Rate for Payer: Adventist Health Commercial |
$29.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$124.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$80.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$109.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$58.34
|
| Rate for Payer: Blue Shield of California Commercial |
$90.67
|
| Rate for Payer: Blue Shield of California EPN |
$85.70
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$67.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$124.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.10
|
| Rate for Payer: Dignity Health Senior |
$124.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$67.60
|
| Rate for Payer: Heritage Provider Network Senior |
$67.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$41.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$70.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.50
|
| Rate for Payer: Multiplan Commercial |
$109.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$58.40
|
| Rate for Payer: TriValley Medical Group Senior |
$58.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$53.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$48.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.10
|
| Rate for Payer: Vantage Medical Group Senior |
$124.10
|
|
|
HC T & L JUNCTION AP AND LATERAL
|
Facility
|
IP
|
$585.00
|
|
|
Service Code
|
CPT 72080
|
| Hospital Charge Code |
909001312
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$105.88 |
| Max. Negotiated Rate |
$438.75 |
| Rate for Payer: Adventist Health Commercial |
$117.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$401.90
|
| Rate for Payer: Cash Price |
$263.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$396.04
|
| Rate for Payer: Heritage Provider Network Senior |
$396.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$105.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$146.25
|
| Rate for Payer: Multiplan Commercial |
$438.75
|
|
|
HC T & L JUNCTION AP AND LATERAL
|
Facility
|
OP
|
$585.00
|
|
|
Service Code
|
CPT 72080
|
| Hospital Charge Code |
909001312
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$42.73 |
| Max. Negotiated Rate |
$438.75 |
| Rate for Payer: Adventist Health Commercial |
$117.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$55.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$401.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$113.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$160.49
|
| 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 |
$263.25
|
| Rate for Payer: Cash Price |
$263.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$380.25
|
| 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 |
$380.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$362.12
|
| Rate for Payer: Heritage Provider Network Senior |
$362.12
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$42.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$113.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$105.88
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$146.25
|
| 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 |
$438.75
|
| 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 TLSO TRIPLANAR CNTRL 2 PIECE
|
Facility
|
OP
|
$3,126.00
|
|
|
Service Code
|
CPT L0484
|
| Hospital Charge Code |
905350484
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$625.20 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$625.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,500.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,147.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,657.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,719.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,344.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,941.25
|
| Rate for Payer: Blue Shield of California EPN |
$1,834.96
|
| Rate for Payer: Cash Price |
$1,406.70
|
| Rate for Payer: Cash Price |
$1,406.70
|
| Rate for Payer: Cash Price |
$1,406.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,437.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,657.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,657.10
|
| Rate for Payer: Dignity Health Senior |
$2,657.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,000.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,447.34
|
| Rate for Payer: Heritage Provider Network Senior |
$1,447.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,950.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,563.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,563.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,563.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$781.50
|
| Rate for Payer: Multiplan Commercial |
$2,344.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,139.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,044.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,657.10
|
| Rate for Payer: Vantage Medical Group Senior |
$2,657.10
|
|
|
HC TLSO TRIPLANAR CNTRL 2 PIECE
|
Facility
|
IP
|
$3,126.00
|
|
|
Service Code
|
CPT L0484
|
| Hospital Charge Code |
905350484
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$625.20 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$625.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,500.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,147.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$1,406.70
|
| Rate for Payer: Cash Price |
$1,406.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,437.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,688.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,116.30
|
| Rate for Payer: Heritage Provider Network Senior |
$7,571.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,563.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,563.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,563.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$781.50
|
| Rate for Payer: Multiplan Commercial |
$2,344.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,139.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,044.40
|
|
|
HC TLSO TRIPLANAR CNTRL HYPEREXT
|
Facility
|
OP
|
$870.00
|
|
|
Service Code
|
CPT L0472
|
| Hospital Charge Code |
905350472
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$174.00 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$174.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$417.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$597.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$739.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$478.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$652.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$540.27
|
| Rate for Payer: Blue Shield of California EPN |
$510.69
|
| Rate for Payer: Cash Price |
$391.50
|
| Rate for Payer: Cash Price |
$391.50
|
| Rate for Payer: Cash Price |
$391.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$400.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$739.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$739.50
|
| Rate for Payer: Dignity Health Senior |
$739.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$556.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$402.81
|
| Rate for Payer: Heritage Provider Network Senior |
$402.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$506.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$435.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$435.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$435.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$217.50
|
| Rate for Payer: Multiplan Commercial |
$652.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$317.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$290.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$739.50
|
| Rate for Payer: Vantage Medical Group Senior |
$739.50
|
|
|
HC TLSO TRIPLANAR CNTRL HYPEREXT
|
Facility
|
IP
|
$870.00
|
|
|
Service Code
|
CPT L0472
|
| Hospital Charge Code |
905350472
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$174.00 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$174.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$417.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$597.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$391.50
|
| Rate for Payer: Cash Price |
$391.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$400.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$469.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$588.99
|
| Rate for Payer: Heritage Provider Network Senior |
$7,571.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$435.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$435.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$435.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$217.50
|
| Rate for Payer: Multiplan Commercial |
$652.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$317.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$290.67
|
|
|
HC TLSO TRIPLANAR CNTRL SEG 4 SHE
|
Facility
|
IP
|
$2,502.00
|
|
|
Service Code
|
CPT L0464
|
| Hospital Charge Code |
905350464
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$500.40 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$500.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,200.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,718.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$1,125.90
|
| Rate for Payer: Cash Price |
$1,125.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,150.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,351.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,693.85
|
| Rate for Payer: Heritage Provider Network Senior |
$7,571.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,251.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,251.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,251.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$625.50
|
| Rate for Payer: Multiplan Commercial |
$1,876.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$912.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$835.92
|
|
|
HC TLSO TRIPLANAR CNTRL SEG 4 SHE
|
Facility
|
OP
|
$2,502.00
|
|
|
Service Code
|
CPT L0464
|
| Hospital Charge Code |
905350464
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$500.40 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$500.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,200.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,718.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,126.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,376.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,876.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,553.74
|
| Rate for Payer: Blue Shield of California EPN |
$1,468.67
|
| Rate for Payer: Cash Price |
$1,125.90
|
| Rate for Payer: Cash Price |
$1,125.90
|
| Rate for Payer: Cash Price |
$1,125.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,150.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,126.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,126.70
|
| Rate for Payer: Dignity Health Senior |
$2,126.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,601.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,158.43
|
| Rate for Payer: Heritage Provider Network Senior |
$1,158.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,457.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,251.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,251.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,251.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$625.50
|
| Rate for Payer: Multiplan Commercial |
$1,876.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$912.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$835.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,126.70
|
| Rate for Payer: Vantage Medical Group Senior |
$2,126.70
|
|
|
HC TLSO TRIPLANAR CNTRL SEG STERN
|
Facility
|
IP
|
$1,690.00
|
|
|
Service Code
|
CPT L0460
|
| Hospital Charge Code |
905350460
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$338.00 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$338.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$811.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,161.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$760.50
|
| Rate for Payer: Cash Price |
$760.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$777.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$912.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,144.13
|
| Rate for Payer: Heritage Provider Network Senior |
$7,571.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$845.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$845.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$845.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$422.50
|
| Rate for Payer: Multiplan Commercial |
$1,267.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$616.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$564.63
|
|
|
HC TLSO TRIPLANAR CNTRL SEG STERN
|
Facility
|
OP
|
$1,690.00
|
|
|
Service Code
|
CPT L0460
|
| Hospital Charge Code |
905350460
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$338.00 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$338.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$811.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,161.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,436.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$929.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,267.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,049.49
|
| Rate for Payer: Blue Shield of California EPN |
$992.03
|
| Rate for Payer: Cash Price |
$760.50
|
| Rate for Payer: Cash Price |
$760.50
|
| Rate for Payer: Cash Price |
$760.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$777.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,436.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,436.50
|
| Rate for Payer: Dignity Health Senior |
$1,436.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,081.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$782.47
|
| Rate for Payer: Heritage Provider Network Senior |
$782.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$984.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$845.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$845.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$845.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$422.50
|
| Rate for Payer: Multiplan Commercial |
$1,267.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$616.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$564.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,436.50
|
| Rate for Payer: Vantage Medical Group Senior |
$1,436.50
|
|
|
HC TMJ ARTHROGRAPHY INJECTION
|
Facility
|
OP
|
$296.00
|
|
|
Service Code
|
CPT 21116
|
| Hospital Charge Code |
909000112
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$53.58 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$59.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$203.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$251.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$162.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$222.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,689.75
|
| Rate for Payer: Blue Shield of California EPN |
$7,468.44
|
| Rate for Payer: Cash Price |
$133.20
|
| Rate for Payer: Cash Price |
$133.20
|
| Rate for Payer: Cash Price |
$133.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$192.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$251.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$251.60
|
| Rate for Payer: Dignity Health Senior |
$251.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$183.22
|
| Rate for Payer: Heritage Provider Network Senior |
$183.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$213.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$142.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$53.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$74.00
|
| Rate for Payer: Multiplan Commercial |
$222.00
|
| 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 |
$251.60
|
| Rate for Payer: Vantage Medical Group Senior |
$251.60
|
|
|
HC TMJ ARTHROGRAPHY INJECTION
|
Facility
|
IP
|
$296.00
|
|
|
Service Code
|
CPT 21116
|
| Hospital Charge Code |
909000112
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$53.58 |
| Max. Negotiated Rate |
$222.00 |
| Rate for Payer: Adventist Health Commercial |
$59.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$203.35
|
| Rate for Payer: Cash Price |
$133.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$200.39
|
| Rate for Payer: Heritage Provider Network Senior |
$200.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$53.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$74.00
|
| Rate for Payer: Multiplan Commercial |
$222.00
|
|
|
HC TMJ OPEN CLOSE UNILATERAL
|
Facility
|
IP
|
$451.00
|
|
|
Service Code
|
CPT 70328
|
| Hospital Charge Code |
909001164
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.63 |
| Max. Negotiated Rate |
$338.25 |
| Rate for Payer: Adventist Health Commercial |
$90.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$309.84
|
| Rate for Payer: Cash Price |
$202.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$305.33
|
| Rate for Payer: Heritage Provider Network Senior |
$305.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$112.75
|
| Rate for Payer: Multiplan Commercial |
$338.25
|
|
|
HC TMJ OPEN CLOSE UNILATERAL
|
Facility
|
OP
|
$451.00
|
|
|
Service Code
|
CPT 70328
|
| Hospital Charge Code |
909001164
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$38.14 |
| Max. Negotiated Rate |
$338.25 |
| Rate for Payer: Adventist Health Commercial |
$90.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$48.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$309.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$113.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$118.11
|
| Rate for Payer: Blue Shield of California Commercial |
$98.89
|
| Rate for Payer: Blue Shield of California EPN |
$56.23
|
| Rate for Payer: Cash Price |
$202.95
|
| Rate for Payer: Cash Price |
$202.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$293.15
|
| 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 |
$293.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$279.17
|
| Rate for Payer: Heritage Provider Network Senior |
$279.17
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$38.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$113.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$112.75
|
| 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 |
$338.25
|
| 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 TM JT ARTHROGRAM
|
Facility
|
OP
|
$1,007.00
|
|
|
Service Code
|
CPT 70332
|
| Hospital Charge Code |
909001166
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$106.08 |
| Max. Negotiated Rate |
$755.25 |
| Rate for Payer: Adventist Health Commercial |
$201.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$127.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$691.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$459.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$336.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$306.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$503.33
|
| Rate for Payer: Blue Shield of California Commercial |
$428.67
|
| Rate for Payer: Blue Shield of California EPN |
$243.77
|
| Rate for Payer: Cash Price |
$453.15
|
| Rate for Payer: Cash Price |
$453.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$654.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$459.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$336.78
|
| Rate for Payer: Dignity Health Senior |
$306.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$654.55
|
| Rate for Payer: EPIC Health Plan Medicare |
$306.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$623.33
|
| Rate for Payer: Heritage Provider Network Senior |
$623.33
|
| Rate for Payer: Humana Medicare |
$306.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$106.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$306.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$581.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$182.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$361.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$251.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$385.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$385.76
|
| Rate for Payer: Multiplan Commercial |
$755.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$306.16
|
| Rate for Payer: TriValley Medical Group Senior |
$306.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$448.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$448.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$459.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$336.78
|
| Rate for Payer: Vantage Medical Group Senior |
$306.16
|
|
|
HC TM JT ARTHROGRAM
|
Facility
|
IP
|
$1,007.00
|
|
|
Service Code
|
CPT 70332
|
| Hospital Charge Code |
909001166
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$182.27 |
| Max. Negotiated Rate |
$755.25 |
| Rate for Payer: Adventist Health Commercial |
$201.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$691.81
|
| Rate for Payer: Cash Price |
$453.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$681.74
|
| Rate for Payer: Heritage Provider Network Senior |
$681.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$182.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$251.75
|
| Rate for Payer: Multiplan Commercial |
$755.25
|
|
|
HC TOBRAMYCIN
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT 80200
|
| Hospital Charge Code |
900910408
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$134.90 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$46.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$134.90
|
| Rate for Payer: Blue Shield of California Commercial |
$125.89
|
| Rate for Payer: Blue Shield of California EPN |
$98.41
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.74
|
| Rate for Payer: Dignity Health Senior |
$16.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.95
|
| Rate for Payer: Heritage Provider Network Senior |
$30.95
|
| Rate for Payer: Humana Medicare |
$16.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$30.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.32
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.13
|
| Rate for Payer: TriValley Medical Group Senior |
$16.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.74
|
| Rate for Payer: Vantage Medical Group Senior |
$16.13
|
|
