|
HC TC-99 ARCITUMOMAB/CEA TO 45MCI
|
Facility
IP
|
$5,382.00
|
|
|
Service Code
|
CPT A9568
|
| Hospital Charge Code |
909301539
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$974.14 |
| Max. Negotiated Rate |
$4,036.50 |
| Rate for Payer: Adventist Health Commercial |
$1,076.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,697.43
|
| Rate for Payer: Cash Price |
$2,421.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,906.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,643.61
|
| Rate for Payer: Heritage Provider Network Senior |
$3,643.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$974.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,345.50
|
| Rate for Payer: Multiplan Commercial |
$4,036.50
|
|
|
HC TC-99 ARCITUMOMAB/CEA TO 45MCI
|
Facility
OP
|
$5,382.00
|
|
|
Service Code
|
CPT A9568
|
| Hospital Charge Code |
909301539
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$974.14 |
| Max. Negotiated Rate |
$4,574.70 |
| Rate for Payer: Adventist Health Commercial |
$1,076.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4,574.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,960.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,036.50
|
| Rate for Payer: Blue Shield of California Commercial |
$3,342.22
|
| Rate for Payer: Blue Shield of California EPN |
$3,159.23
|
| Rate for Payer: Cash Price |
$2,421.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,498.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,574.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,574.70
|
| Rate for Payer: Dignity Health Senior |
$4,574.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,444.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,331.46
|
| Rate for Payer: Heritage Provider Network Senior |
$3,331.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,594.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$974.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,345.50
|
| Rate for Payer: Multiplan Commercial |
$4,036.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,574.70
|
| Rate for Payer: Vantage Medical Group Senior |
$4,574.70
|
|
|
HC TC-99 BICISTAE/NUEROLITE LT 25MCI
|
Facility
OP
|
$4,978.00
|
|
|
Service Code
|
CPT A9557
|
| Hospital Charge Code |
909301541
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$529.37 |
| Max. Negotiated Rate |
$4,231.30 |
| Rate for Payer: Adventist Health Commercial |
$995.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4,231.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,737.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,733.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$757.35
|
| Rate for Payer: Blue Shield of California Commercial |
$3,091.34
|
| Rate for Payer: Blue Shield of California EPN |
$2,922.09
|
| Rate for Payer: Cash Price |
$2,240.10
|
| Rate for Payer: Cash Price |
$2,240.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,289.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,231.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,231.30
|
| Rate for Payer: Dignity Health Senior |
$4,231.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,185.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,304.81
|
| Rate for Payer: Heritage Provider Network Senior |
$2,304.81
|
| Rate for Payer: IEHP Medi-Cal |
$529.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,399.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$901.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,244.50
|
| Rate for Payer: Multiplan Commercial |
$3,733.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,814.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,663.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,231.30
|
| Rate for Payer: Vantage Medical Group Senior |
$4,231.30
|
|
|
HC TC-99 BICISTAE/NUEROLITE LT 25MCI
|
Facility
IP
|
$4,978.00
|
|
|
Service Code
|
CPT A9557
|
| Hospital Charge Code |
909301541
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$901.02 |
| Max. Negotiated Rate |
$3,733.50 |
| Rate for Payer: Adventist Health Commercial |
$995.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,419.89
|
| Rate for Payer: Cash Price |
$2,240.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,289.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,688.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,370.11
|
| Rate for Payer: Heritage Provider Network Senior |
$3,370.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$901.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,244.50
|
| Rate for Payer: Multiplan Commercial |
$3,733.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,814.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,663.15
|
|
|
HC TC-99 CERETEC UP TO 25 MCI
|
Facility
IP
|
$4,512.00
|
|
|
Service Code
|
CPT A9521
|
| Hospital Charge Code |
909301535
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$816.67 |
| Max. Negotiated Rate |
$3,384.00 |
| Rate for Payer: Adventist Health Commercial |
$902.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,099.74
|
| Rate for Payer: Cash Price |
$2,030.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,075.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,436.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,054.62
|
| Rate for Payer: Heritage Provider Network Senior |
$3,054.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$816.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,128.00
|
| Rate for Payer: Multiplan Commercial |
$3,384.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,645.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,507.46
|
|
|
HC TC-99 CERETEC UP TO 25 MCI
|
Facility
OP
|
$4,512.00
|
|
|
Service Code
|
CPT A9521
|
| Hospital Charge Code |
909301535
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$708.38 |
| Max. Negotiated Rate |
$3,835.20 |
| Rate for Payer: Adventist Health Commercial |
$902.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,835.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,481.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,384.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,669.61
|
| Rate for Payer: Blue Shield of California Commercial |
$2,801.95
|
| Rate for Payer: Blue Shield of California EPN |
$2,648.54
|
| Rate for Payer: Cash Price |
$2,030.40
|
| Rate for Payer: Cash Price |
$2,030.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,075.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,835.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,835.20
|
| Rate for Payer: Dignity Health Senior |
$3,835.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,887.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,089.06
|
| Rate for Payer: Heritage Provider Network Senior |
$2,089.06
|
| Rate for Payer: IEHP Medi-Cal |
$708.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,174.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$816.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,128.00
|
| Rate for Payer: Multiplan Commercial |
$3,384.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,645.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,507.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,835.20
|
| Rate for Payer: Vantage Medical Group Senior |
$3,835.20
|
|
|
HC TC-99 GHT UP TO 25 MCI
|
Facility
OP
|
$256.00
|
|
|
Service Code
|
CPT A9550
|
| Hospital Charge Code |
909301509
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.34 |
| Max. Negotiated Rate |
$217.60 |
| Rate for Payer: Adventist Health Commercial |
$51.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$217.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$140.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$192.00
|
| Rate for Payer: Blue Shield of California Commercial |
$158.98
|
| Rate for Payer: Blue Shield of California EPN |
$150.27
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$117.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$217.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$217.60
|
| Rate for Payer: Dignity Health Senior |
$217.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$163.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$118.53
|
| Rate for Payer: Heritage Provider Network Senior |
$118.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$123.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.00
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$93.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$85.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$217.60
|
| Rate for Payer: Vantage Medical Group Senior |
$217.60
|
|
|
HC TC-99 GHT UP TO 25 MCI
|
Facility
IP
|
$256.00
|
|
|
Service Code
|
CPT A9550
|
| Hospital Charge Code |
909301509
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.34 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Adventist Health Commercial |
$51.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$175.87
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$117.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$138.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$173.31
|
| Rate for Payer: Heritage Provider Network Senior |
$173.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.00
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$93.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$85.53
|
|
|
HC TC-99 HEPATOLITE UP TO 15 MCI
|
Facility
IP
|
$352.00
|
|
|
Service Code
|
CPT A9510
|
| Hospital Charge Code |
909301505
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.71 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Adventist Health Commercial |
$70.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$241.82
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$161.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$190.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$238.30
|
| Rate for Payer: Heritage Provider Network Senior |
$238.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.00
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$128.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$117.60
|
|
|
HC TC-99 HEPATOLITE UP TO 15 MCI
|
Facility
OP
|
$352.00
|
|
|
Service Code
|
CPT A9510
|
| Hospital Charge Code |
909301505
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.33 |
| Max. Negotiated Rate |
$299.20 |
| Rate for Payer: Adventist Health Commercial |
$70.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$299.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$193.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$264.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$106.86
|
| Rate for Payer: Blue Shield of California Commercial |
$218.59
|
| Rate for Payer: Blue Shield of California EPN |
$206.62
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$161.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$299.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$299.20
|
| Rate for Payer: Dignity Health Senior |
$299.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$225.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$162.98
|
| Rate for Payer: Heritage Provider Network Senior |
$162.98
|
| Rate for Payer: IEHP Medi-Cal |
$54.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$169.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.00
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$128.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$117.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$299.20
|
| Rate for Payer: Vantage Medical Group Senior |
$299.20
|
|
|
HC TC-99 MAA UP TO 10 MCI
|
Facility
IP
|
$420.00
|
|
|
Service Code
|
CPT A9540
|
| Hospital Charge Code |
909301506
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.02 |
| Max. Negotiated Rate |
$315.00 |
| Rate for Payer: Adventist Health Commercial |
$84.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$288.54
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$193.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$226.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$284.34
|
| Rate for Payer: Heritage Provider Network Senior |
$284.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$76.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$105.00
|
| Rate for Payer: Multiplan Commercial |
$315.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$153.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$140.32
|
|
|
HC TC-99 MAA UP TO 10 MCI
|
Facility
OP
|
$420.00
|
|
|
Service Code
|
CPT A9540
|
| Hospital Charge Code |
909301506
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.60 |
| Max. Negotiated Rate |
$357.00 |
| Rate for Payer: Adventist Health Commercial |
$84.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$357.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$231.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$315.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.60
|
| Rate for Payer: Blue Shield of California Commercial |
$260.82
|
| Rate for Payer: Blue Shield of California EPN |
$246.54
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$193.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$357.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$357.00
|
| Rate for Payer: Dignity Health Senior |
$357.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$268.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$194.46
|
| Rate for Payer: Heritage Provider Network Senior |
$194.46
|
| Rate for Payer: IEHP Medi-Cal |
$46.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$202.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$76.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$105.00
|
| Rate for Payer: Multiplan Commercial |
$315.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$153.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$140.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$357.00
|
| Rate for Payer: Vantage Medical Group Senior |
$357.00
|
|
|
HC TC-99M APCITIDE/ACCUTEC LT 20MCI
|
Facility
OP
|
$1,933.00
|
|
|
Service Code
|
CPT A9504
|
| Hospital Charge Code |
909301540
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$349.87 |
| Max. Negotiated Rate |
$1,643.05 |
| Rate for Payer: Adventist Health Commercial |
$386.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,643.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,063.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,449.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$890.46
|
| Rate for Payer: Blue Shield of California Commercial |
$1,200.39
|
| Rate for Payer: Blue Shield of California EPN |
$1,134.67
|
| Rate for Payer: Cash Price |
$869.85
|
| Rate for Payer: Cash Price |
$869.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$889.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,643.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,643.05
|
| Rate for Payer: Dignity Health Senior |
$1,643.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,237.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$894.98
|
| Rate for Payer: Heritage Provider Network Senior |
$894.98
|
| Rate for Payer: IEHP Medi-Cal |
$592.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$931.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$349.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$483.25
|
| Rate for Payer: Multiplan Commercial |
$1,449.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$704.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$645.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,643.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1,643.05
|
|
|
HC TC-99M APCITIDE/ACCUTEC LT 20MCI
|
Facility
IP
|
$1,933.00
|
|
|
Service Code
|
CPT A9504
|
| Hospital Charge Code |
909301540
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$349.87 |
| Max. Negotiated Rate |
$1,449.75 |
| Rate for Payer: Adventist Health Commercial |
$386.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,327.97
|
| Rate for Payer: Cash Price |
$869.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$889.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,043.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,308.64
|
| Rate for Payer: Heritage Provider Network Senior |
$1,308.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$349.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$483.25
|
| Rate for Payer: Multiplan Commercial |
$1,449.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$704.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$645.82
|
|
|
HC TC-99M DEPREOTID NEOTEC LT 35MCI
|
Facility
IP
|
$2,398.00
|
|
|
Service Code
|
CPT A9536
|
| Hospital Charge Code |
909301542
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$434.04 |
| Max. Negotiated Rate |
$1,798.50 |
| Rate for Payer: Adventist Health Commercial |
$479.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,647.43
|
| Rate for Payer: Cash Price |
$1,079.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,103.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,294.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,623.45
|
| Rate for Payer: Heritage Provider Network Senior |
$1,623.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$434.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$599.50
|
| Rate for Payer: Multiplan Commercial |
$1,798.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$874.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$801.17
|
|
|
HC TC-99M DEPREOTID NEOTEC LT 35MCI
|
Facility
OP
|
$2,398.00
|
|
|
Service Code
|
CPT A9536
|
| Hospital Charge Code |
909301542
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$434.04 |
| Max. Negotiated Rate |
$2,038.30 |
| Rate for Payer: Adventist Health Commercial |
$479.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2,038.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,318.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,798.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,503.89
|
| Rate for Payer: Blue Shield of California Commercial |
$1,489.16
|
| Rate for Payer: Blue Shield of California EPN |
$1,407.63
|
| Rate for Payer: Cash Price |
$1,079.10
|
| Rate for Payer: Cash Price |
$1,079.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,103.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,038.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,038.30
|
| Rate for Payer: Dignity Health Senior |
$2,038.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,534.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,110.27
|
| Rate for Payer: Heritage Provider Network Senior |
$1,110.27
|
| Rate for Payer: IEHP Medi-Cal |
$948.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,155.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$434.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$599.50
|
| Rate for Payer: Multiplan Commercial |
$1,798.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$874.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$801.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,038.30
|
| Rate for Payer: Vantage Medical Group Senior |
$2,038.30
|
|
|
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 MEBROFEN/CHOLETEC LT 15MCI
|
Facility
OP
|
$419.00
|
|
|
Service Code
|
CPT A9537
|
| Hospital Charge Code |
909301537
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.76 |
| Max. Negotiated Rate |
$356.15 |
| Rate for Payer: Adventist Health Commercial |
$83.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$356.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$230.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$314.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$117.82
|
| Rate for Payer: Blue Shield of California Commercial |
$260.20
|
| Rate for Payer: Blue Shield of California EPN |
$245.95
|
| Rate for Payer: Cash Price |
$188.55
|
| Rate for Payer: Cash Price |
$188.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$192.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$356.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$356.15
|
| Rate for Payer: Dignity Health Senior |
$356.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$268.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$194.00
|
| Rate for Payer: Heritage Provider Network Senior |
$194.00
|
| Rate for Payer: IEHP Medi-Cal |
$70.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$201.96
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$356.15
|
| Rate for Payer: Vantage Medical Group Senior |
$356.15
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$46.20
|
| Rate for Payer: AlphaCare 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: 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: 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
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-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: AlphaCare Medical Group Commercial/Exchange |
$155.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$100.65
|
| Rate for Payer: AlphaCare 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: 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: 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-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: AlphaCare Medical Group Commercial/Exchange |
$243.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$157.85
|
| Rate for Payer: AlphaCare 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: 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-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-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
|
|
