|
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 |
$71.40 |
| 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: Blue Shield of California Commercial |
$51.24
|
| Rate for Payer: Blue Shield of California EPN |
$40.99
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cash Price |
$46.20
|
| 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 |
$30.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$40.07
|
| 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: Molina Healthcare of CA Medi-Cal |
$58.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$58.80
|
| 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 |
$30.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$71.40
|
| 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: Cash Price |
$46.20
|
| 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 |
$38.89
|
| Rate for Payer: Heritage Provider Network Senior |
$38.89
|
| 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 |
$30.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.81
|
|
|
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 |
$497.31 |
| 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: Blue Shield of California Commercial |
$111.63
|
| Rate for Payer: Blue Shield of California EPN |
$89.30
|
| Rate for Payer: Cash Price |
$100.65
|
| Rate for Payer: Cash Price |
$100.65
|
| 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 |
$497.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$87.29
|
| 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: Molina Healthcare of CA Medi-Cal |
$128.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$128.10
|
| 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 |
$66.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$60.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$155.55
|
| 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: Cash Price |
$100.65
|
| 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 |
$84.73
|
| Rate for Payer: Heritage Provider Network Senior |
$84.73
|
| 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 |
$66.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$60.59
|
|
|
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 |
$51.95 |
| 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: Blue Shield of California Commercial |
$175.07
|
| Rate for Payer: Blue Shield of California EPN |
$140.06
|
| Rate for Payer: Cash Price |
$157.85
|
| 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 |
$136.90
|
| 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: Molina Healthcare of CA Medi-Cal |
$200.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$200.90
|
| 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 |
$103.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$95.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$243.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$243.95
|
| Rate for Payer: Vantage Medical Group Senior |
$243.95
|
|
|
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: Cash Price |
$157.85
|
| 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 |
$132.88
|
| Rate for Payer: Heritage Provider Network Senior |
$132.88
|
| 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 |
$103.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$95.03
|
|
|
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 |
$36.34 |
| 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: Blue Shield of California Commercial |
$140.91
|
| Rate for Payer: Blue Shield of California EPN |
$112.73
|
| Rate for Payer: Cash Price |
$127.05
|
| Rate for Payer: Cash Price |
$127.05
|
| 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 |
$36.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$110.19
|
| 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: Molina Healthcare of CA Medi-Cal |
$161.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$161.70
|
| 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 |
$83.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$76.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$196.35
|
| 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: Cash Price |
$127.05
|
| 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 |
$106.95
|
| Rate for Payer: Heritage Provider Network Senior |
$106.95
|
| 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 |
$83.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$76.48
|
|
|
HC TC-99 PENTETATE AERSL TO 75MCI
|
Facility
|
IP
|
$865.00
|
|
|
Service Code
|
CPT A9567
|
| Hospital Charge Code |
909301543
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$156.56 |
| Max. Negotiated Rate |
$648.75 |
| Rate for Payer: Adventist Health Commercial |
$173.00
|
| Rate for Payer: Cash Price |
$475.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$467.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$585.61
|
| Rate for Payer: Heritage Provider Network Senior |
$585.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$156.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$216.25
|
| Rate for Payer: Multiplan Commercial |
$648.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$312.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$286.40
|
|
|
HC TC-99 PENTETATE AERSL TO 75MCI
|
Facility
|
OP
|
$865.00
|
|
|
Service Code
|
CPT A9567
|
| Hospital Charge Code |
909301543
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$100.02 |
| Max. Negotiated Rate |
$735.25 |
| Rate for Payer: Adventist Health Commercial |
$173.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$735.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$475.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$648.75
|
| Rate for Payer: Blue Shield of California Commercial |
$527.65
|
| Rate for Payer: Blue Shield of California EPN |
$422.12
|
| Rate for Payer: Cash Price |
$475.75
|
| Rate for Payer: Cash Price |
$475.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$562.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$735.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$735.25
|
| Rate for Payer: Dignity Health Senior |
$735.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$553.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$535.43
|
| Rate for Payer: Heritage Provider Network Senior |
$535.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$100.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$412.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$156.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$216.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$605.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$605.50
|
| Rate for Payer: Multiplan Commercial |
$648.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$312.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$286.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$735.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$735.25
|
| Rate for Payer: Vantage Medical Group Senior |
$735.25
|
|
|
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 |
$21.06 |
| 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: Blue Shield of California Commercial |
$109.19
|
| Rate for Payer: Blue Shield of California EPN |
$87.35
|
| Rate for Payer: Cash Price |
$98.45
|
| Rate for Payer: Cash Price |
$98.45
|
| 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 |
$21.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$85.38
|
| 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: Molina Healthcare of CA Medi-Cal |
$125.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$125.30
|
| 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 |
$64.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$59.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$152.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$152.15
|
| Rate for Payer: Vantage Medical Group Senior |
$152.15
|
|
|
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: Cash Price |
$98.45
|
| 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 |
$82.88
|
| Rate for Payer: Heritage Provider Network Senior |
$82.88
|
| 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 |
$64.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$59.27
|
|
|
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 |
$56.47 |
| 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: Blue Shield of California Commercial |
$190.32
|
| Rate for Payer: Blue Shield of California EPN |
$152.26
|
| Rate for Payer: Cash Price |
$171.60
|
| Rate for Payer: Cash Price |
$171.60
|
| 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 |
$103.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$148.82
|
| 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: Molina Healthcare of CA Medi-Cal |
$218.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$218.40
|
| 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 |
$112.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$103.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$265.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$265.20
|
| Rate for Payer: Vantage Medical Group Senior |
$265.20
|
|
|
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: Cash Price |
$171.60
|
| 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 |
$144.46
|
| Rate for Payer: Heritage Provider Network Senior |
$144.46
|
| 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 |
$112.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$103.30
|
|
|
HC TC-99 SSBI/CARDIOLITE LT 40MCI
|
Facility
|
OP
|
$451.00
|
|
|
Service Code
|
CPT A9500
|
| Hospital Charge Code |
909301563
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$81.63 |
| Max. Negotiated Rate |
$383.35 |
| Rate for Payer: Adventist Health Commercial |
$90.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$383.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$248.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$338.25
|
| Rate for Payer: Blue Shield of California Commercial |
$275.11
|
| Rate for Payer: Blue Shield of California EPN |
$220.09
|
| Rate for Payer: Cash Price |
$248.05
|
| Rate for Payer: Cash Price |
$248.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$293.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$383.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$383.35
|
| Rate for Payer: Dignity Health Senior |
$383.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$288.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$279.17
|
| Rate for Payer: Heritage Provider Network Senior |
$279.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$157.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.13
|
| 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: Molina Healthcare of CA Medi-Cal |
$315.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.70
|
| Rate for Payer: Multiplan Commercial |
$338.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$162.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$149.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$383.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$383.35
|
| Rate for Payer: Vantage Medical Group Senior |
$383.35
|
|
|
HC TC-99 SSBI/CARDIOLITE LT 40MCI
|
Facility
|
IP
|
$451.00
|
|
|
Service Code
|
CPT A9500
|
| Hospital Charge Code |
909301563
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$81.63 |
| Max. Negotiated Rate |
$338.25 |
| Rate for Payer: Adventist Health Commercial |
$90.20
|
| Rate for Payer: Cash Price |
$248.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$243.54
|
| 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
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$162.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$149.33
|
|
|
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: Blue Shield of California Commercial |
$430.66
|
| Rate for Payer: Blue Shield of California EPN |
$344.53
|
| Rate for Payer: Cash Price |
$388.30
|
| Rate for Payer: Cash Price |
$388.30
|
| 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 |
$164.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$336.76
|
| 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: Molina Healthcare of CA Medi-Cal |
$494.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$494.20
|
| 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 |
$255.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$233.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$600.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$600.10
|
| Rate for Payer: Vantage Medical Group Senior |
$600.10
|
|
|
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: Cash Price |
$388.30
|
| 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 |
$326.88
|
| Rate for Payer: Heritage Provider Network Senior |
$326.88
|
| 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 |
$255.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$233.76
|
|
|
HC TC-99 SULPHUR COLLOID LT 20MCI
|
Facility
|
OP
|
$1,341.00
|
|
|
Service Code
|
CPT A9541
|
| Hospital Charge Code |
909301502
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$68.95 |
| Max. Negotiated Rate |
$1,139.85 |
| Rate for Payer: Adventist Health Commercial |
$268.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,139.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$737.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,005.75
|
| Rate for Payer: Blue Shield of California Commercial |
$818.01
|
| Rate for Payer: Blue Shield of California EPN |
$654.41
|
| Rate for Payer: Cash Price |
$737.55
|
| Rate for Payer: Cash Price |
$737.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$871.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,139.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,139.85
|
| Rate for Payer: Dignity Health Senior |
$1,139.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$858.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$830.08
|
| Rate for Payer: Heritage Provider Network Senior |
$830.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$68.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$639.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$242.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$335.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$938.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$938.70
|
| Rate for Payer: Multiplan Commercial |
$1,005.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$484.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$444.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,139.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,139.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1,139.85
|
|
|
HC TC-99 SULPHUR COLLOID LT 20MCI
|
Facility
|
IP
|
$1,341.00
|
|
|
Service Code
|
CPT A9541
|
| Hospital Charge Code |
909301502
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$242.72 |
| Max. Negotiated Rate |
$1,005.75 |
| Rate for Payer: Adventist Health Commercial |
$268.20
|
| Rate for Payer: Cash Price |
$737.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$724.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$907.86
|
| Rate for Payer: Heritage Provider Network Senior |
$907.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$242.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$335.25
|
| Rate for Payer: Multiplan Commercial |
$1,005.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$484.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$444.01
|
|
|
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 |
$40.73 |
| Max. Negotiated Rate |
$168.75 |
| Rate for Payer: Adventist Health Commercial |
$45.00
|
| Rate for Payer: Cash Price |
$123.75
|
| 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 |
$104.17
|
| Rate for Payer: Heritage Provider Network Senior |
$104.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.73
|
| 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 |
$81.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$74.50
|
|
|
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 |
$40.73 |
| Max. Negotiated Rate |
$191.25 |
| 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: Blue Shield of California Commercial |
$137.25
|
| Rate for Payer: Blue Shield of California EPN |
$109.80
|
| Rate for Payer: Cash Price |
$123.75
|
| Rate for Payer: Cash Price |
$123.75
|
| 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 |
$104.17
|
| Rate for Payer: Heritage Provider Network Senior |
$104.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$156.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$107.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$157.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$157.50
|
| 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 |
$81.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$74.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$191.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$191.25
|
| Rate for Payer: Vantage Medical Group Senior |
$191.25
|
|
|
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 |
$83.92 |
| 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: Blue Shield of California Commercial |
$1,429.23
|
| Rate for Payer: Blue Shield of California EPN |
$1,143.38
|
| Rate for Payer: Cash Price |
$1,288.65
|
| Rate for Payer: Cash Price |
$1,288.65
|
| 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 |
$83.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,117.61
|
| 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: Molina Healthcare of CA Medi-Cal |
$1,640.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,640.10
|
| 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 |
$846.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$775.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,991.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,991.55
|
| Rate for Payer: Vantage Medical Group Senior |
$1,991.55
|
|
|
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: Cash Price |
$1,288.65
|
| 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 |
$1,084.81
|
| Rate for Payer: Heritage Provider Network Senior |
$1,084.81
|
| 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 |
$846.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$775.77
|
|
|
HC TCATH RMVL OR DBLK ICAR MASS OR VEG
|
Facility
|
OP
|
$13,368.00
|
|
|
Service Code
|
CPT 0644T
|
| Hospital Charge Code |
906820292
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$14,160.00 |
| Rate for Payer: Adventist Health Commercial |
$2,673.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9,183.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,866.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7,968.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,244.35
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$7,352.40
|
| Rate for Payer: Cash Price |
$7,352.40
|
| Rate for Payer: Cash Price |
$7,352.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,340.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,866.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,968.78
|
| Rate for Payer: Dignity Health Senior |
$7,244.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,244.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$8,274.79
|
| Rate for Payer: Heritage Provider Network Senior |
$8,910.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,244.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,764.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,419.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,331.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,342.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,127.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,127.88
|
| Rate for Payer: Multiplan Commercial |
$10,026.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,968.78
|
| Rate for Payer: TriValley Medical Group Senior |
$7,244.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14,160.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11,956.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,866.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,968.78
|
| Rate for Payer: Vantage Medical Group Senior |
$7,244.35
|
|
