|
HC US TRGT DYN MBUBB EA ADD LSN
|
Facility
|
OP
|
$326.00
|
|
|
Service Code
|
CPT 76979
|
| Hospital Charge Code |
906676979
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$59.01 |
| Max. Negotiated Rate |
$1,014.00 |
| Rate for Payer: Adventist Health Commercial |
$65.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$201.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$277.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$179.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$244.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$163.07
|
| Rate for Payer: Blue Shield of California Commercial |
$1,014.00
|
| Rate for Payer: Blue Shield of California EPN |
$815.42
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$211.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$277.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$277.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$277.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$192.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$201.79
|
| Rate for Payer: Heritage Provider Network Senior |
$201.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$155.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$59.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$81.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$228.20
|
| Rate for Payer: Multiplan Commercial |
$244.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$163.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$163.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$277.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$277.10
|
| Rate for Payer: Vantage Medical Group Senior |
$277.10
|
|
|
HC US TRGT DYN MBUBB EA ADD LSN
|
Facility
|
IP
|
$326.00
|
|
|
Service Code
|
CPT 76979
|
| Hospital Charge Code |
906676979
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$59.01 |
| Max. Negotiated Rate |
$244.50 |
| Rate for Payer: Adventist Health Commercial |
$65.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$209.94
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$220.70
|
| Rate for Payer: Heritage Provider Network Senior |
$220.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$59.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$81.50
|
| Rate for Payer: Multiplan Commercial |
$244.50
|
|
|
HC US ULTRA GUIDE/PSEU.AVFISTULA
|
Facility
|
OP
|
$1,642.00
|
|
|
Service Code
|
CPT 76936
|
| Hospital Charge Code |
909001485
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$170.66 |
| Max. Negotiated Rate |
$1,325.71 |
| Rate for Payer: Adventist Health Commercial |
$328.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,014.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$416.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$305.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$277.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$821.33
|
| Rate for Payer: Blue Shield of California Commercial |
$1,325.71
|
| Rate for Payer: Blue Shield of California EPN |
$1,066.09
|
| Rate for Payer: Cash Price |
$738.90
|
| Rate for Payer: Cash Price |
$738.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,067.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$416.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$305.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$277.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$968.78
|
| Rate for Payer: EPIC Health Plan Medicare |
$277.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,016.40
|
| Rate for Payer: Heritage Provider Network Senior |
$1,016.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$277.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$783.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$297.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$319.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$410.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$372.13
|
| Rate for Payer: Multiplan Commercial |
$1,231.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$277.71
|
| Rate for Payer: TriValley Medical Group Senior |
$277.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$170.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$170.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$416.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$305.48
|
| Rate for Payer: Vantage Medical Group Senior |
$277.71
|
|
|
HC US ULTRA GUIDE/PSEU.AVFISTULA
|
Facility
|
IP
|
$1,642.00
|
|
|
Service Code
|
CPT 76936
|
| Hospital Charge Code |
909001485
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$297.20 |
| Max. Negotiated Rate |
$1,231.50 |
| Rate for Payer: Adventist Health Commercial |
$328.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,057.45
|
| Rate for Payer: Cash Price |
$738.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,111.63
|
| Rate for Payer: Heritage Provider Network Senior |
$1,111.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$297.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$410.50
|
| Rate for Payer: Multiplan Commercial |
$1,231.50
|
|
|
HC US URINE CAPACITY MEASURE
|
Facility
|
OP
|
$169.00
|
|
|
Service Code
|
CPT 51798
|
| Hospital Charge Code |
900501798
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$30.59 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$33.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$104.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$113.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$83.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$75.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$80.28
|
| Rate for Payer: Blue Shield of California EPN |
$63.88
|
| Rate for Payer: Cash Price |
$76.05
|
| Rate for Payer: Cash Price |
$76.05
|
| Rate for Payer: Cash Price |
$76.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$113.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$83.46
|
| Rate for Payer: Dignity Health Medicare Advantage |
$75.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$75.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$114.41
|
| Rate for Payer: Heritage Provider Network Senior |
$114.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$75.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$80.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$30.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$87.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$101.67
|
| Rate for Payer: Multiplan Commercial |
$126.75
|
| Rate for Payer: Multiplan WC |
$120.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$101.40
|
| Rate for Payer: TriValley Medical Group Senior |
$101.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$113.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$83.46
|
| Rate for Payer: Vantage Medical Group Senior |
$75.87
|
|
|
HC US URINE CAPACITY MEASURE
|
Facility
|
IP
|
$169.00
|
|
|
Service Code
|
CPT 51798
|
| Hospital Charge Code |
900501798
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$30.59 |
| Max. Negotiated Rate |
$126.75 |
| Rate for Payer: Adventist Health Commercial |
$33.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$108.84
|
| Rate for Payer: Cash Price |
$76.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$114.41
|
| Rate for Payer: Heritage Provider Network Senior |
$114.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$30.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.25
|
| Rate for Payer: Multiplan Commercial |
$126.75
|
|
|
HC UTRAVERSE BALLOON
|
Facility
|
OP
|
$805.00
|
|
|
Service Code
|
CPT C1725
|
| Hospital Charge Code |
909000018
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$161.00 |
| Max. Negotiated Rate |
$13,770.00 |
| Rate for Payer: Adventist Health Commercial |
$161.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$497.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$684.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$442.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$603.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,770.00
|
| Rate for Payer: Blue Shield of California Commercial |
$323.61
|
| Rate for Payer: Blue Shield of California EPN |
$323.61
|
| Rate for Payer: Cash Price |
$362.25
|
| Rate for Payer: Cash Price |
$362.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$370.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$684.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$684.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$684.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$515.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$372.71
|
| Rate for Payer: Heritage Provider Network Senior |
$372.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$402.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$402.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$402.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$201.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$563.50
|
| Rate for Payer: Multiplan Commercial |
$603.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$290.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$266.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$684.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$684.25
|
| Rate for Payer: Vantage Medical Group Senior |
$684.25
|
|
|
HC UTRAVERSE BALLOON
|
Facility
|
IP
|
$805.00
|
|
|
Service Code
|
CPT C1725
|
| Hospital Charge Code |
909000018
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$161.00 |
| Max. Negotiated Rate |
$13,808.00 |
| Rate for Payer: Adventist Health Commercial |
$161.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$518.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,808.00
|
| Rate for Payer: Blue Shield of California Commercial |
$323.61
|
| Rate for Payer: Blue Shield of California EPN |
$323.61
|
| Rate for Payer: Cash Price |
$362.25
|
| Rate for Payer: Cash Price |
$362.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$370.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$434.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$372.71
|
| Rate for Payer: Heritage Provider Network Senior |
$372.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$402.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$402.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$402.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$201.25
|
| Rate for Payer: Multiplan Commercial |
$603.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$290.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$266.54
|
|
|
HC VACCINE INFLUENZA VACCINE GT 3 YR
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
CPT 90656
|
| Hospital Charge Code |
910400052
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.04 |
| Max. Negotiated Rate |
$51.85 |
| Rate for Payer: Adventist Health Commercial |
$12.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$33.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$35.11
|
| Rate for Payer: Blue Shield of California Commercial |
$20.00
|
| Rate for Payer: Blue Shield of California EPN |
$20.00
|
| Rate for Payer: Cash Price |
$27.45
|
| Rate for Payer: Cash Price |
$27.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$51.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.24
|
| Rate for Payer: Heritage Provider Network Senior |
$28.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$29.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$42.70
|
| Rate for Payer: Multiplan Commercial |
$45.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.40
|
| Rate for Payer: TriValley Medical Group Senior |
$24.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$51.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.85
|
| Rate for Payer: Vantage Medical Group Senior |
$51.85
|
|
|
HC VACCINE INFLUENZA VACCINE GT 3 YR
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
CPT 90656
|
| Hospital Charge Code |
910400052
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.04 |
| Max. Negotiated Rate |
$45.75 |
| Rate for Payer: Adventist Health Commercial |
$12.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$39.28
|
| Rate for Payer: Cash Price |
$27.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.24
|
| Rate for Payer: Heritage Provider Network Senior |
$28.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.25
|
| Rate for Payer: Multiplan Commercial |
$45.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.20
|
|
|
HC VACCINE TDAP 7 YRS OR OLDER
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
900090715
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.41 |
| Max. Negotiated Rate |
$99.68 |
| Rate for Payer: Adventist Health Commercial |
$10.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$44.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$28.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$39.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$99.68
|
| Rate for Payer: Blue Shield of California Commercial |
$46.78
|
| Rate for Payer: Blue Shield of California EPN |
$46.78
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$44.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$44.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$44.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.08
|
| Rate for Payer: Heritage Provider Network Senior |
$24.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$24.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$36.40
|
| Rate for Payer: Multiplan Commercial |
$39.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$20.80
|
| Rate for Payer: TriValley Medical Group Senior |
$20.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$44.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$44.20
|
| Rate for Payer: Vantage Medical Group Senior |
$44.20
|
|
|
HC VACCINE TDAP 7 YRS OR OLDER
|
Facility
|
IP
|
$52.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
900090715
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.41 |
| Max. Negotiated Rate |
$39.00 |
| Rate for Payer: Adventist Health Commercial |
$10.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33.49
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.08
|
| Rate for Payer: Heritage Provider Network Senior |
$24.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.00
|
| Rate for Payer: Multiplan Commercial |
$39.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.22
|
|
|
HC VACCINIA VRS VAC 0.3 ML PERQ
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90622
|
| Hospital Charge Code |
948000201
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
|
|
HC VACCINIA VRS VAC 0.3 ML PERQ
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90622
|
| Hospital Charge Code |
948000201
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
HC VAD ABIOMED IMPELLA CP CATH
|
Facility
|
IP
|
$37,500.00
|
|
| Hospital Charge Code |
906812480
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,500.00 |
| Max. Negotiated Rate |
$28,125.00 |
| Rate for Payer: Adventist Health Commercial |
$7,500.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24,150.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,808.00
|
| Rate for Payer: Blue Shield of California Commercial |
$15,075.00
|
| Rate for Payer: Blue Shield of California EPN |
$15,075.00
|
| Rate for Payer: Cash Price |
$16,875.00
|
| Rate for Payer: Cash Price |
$16,875.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17,250.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$20,250.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$17,362.50
|
| Rate for Payer: Heritage Provider Network Senior |
$17,362.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$18,750.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18,750.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18,750.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9,375.00
|
| Rate for Payer: Multiplan Commercial |
$28,125.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13,548.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12,416.25
|
|
|
HC VAD ABIOMED IMPELLA CP CATH
|
Facility
|
OP
|
$37,500.00
|
|
| Hospital Charge Code |
906812480
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,500.00 |
| Max. Negotiated Rate |
$31,875.00 |
| Rate for Payer: Adventist Health Commercial |
$7,500.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23,175.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31,875.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20,625.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$28,125.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,770.00
|
| Rate for Payer: Blue Shield of California Commercial |
$15,075.00
|
| Rate for Payer: Blue Shield of California EPN |
$15,075.00
|
| Rate for Payer: Cash Price |
$16,875.00
|
| Rate for Payer: Cash Price |
$16,875.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17,250.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31,875.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$31,875.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31,875.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$24,000.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$17,362.50
|
| Rate for Payer: Heritage Provider Network Senior |
$17,362.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$18,750.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18,750.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18,750.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9,375.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$26,250.00
|
| Rate for Payer: Multiplan Commercial |
$28,125.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13,548.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12,416.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31,875.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31,875.00
|
| Rate for Payer: Vantage Medical Group Senior |
$31,875.00
|
|
|
HC VAD/CATH DECLOT THROMBOLYTIC AGENT
|
Facility
|
OP
|
$1,230.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
907201300
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$222.63 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$246.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$760.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$637.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$467.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$424.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$584.25
|
| Rate for Payer: Blue Shield of California EPN |
$464.94
|
| Rate for Payer: Cash Price |
$553.50
|
| Rate for Payer: Cash Price |
$553.50
|
| Rate for Payer: Cash Price |
$553.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$799.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$637.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$467.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$424.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$424.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$832.71
|
| Rate for Payer: Heritage Provider Network Senior |
$832.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$424.83
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$586.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$222.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$488.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$307.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$569.27
|
| Rate for Payer: Multiplan Commercial |
$922.50
|
| Rate for Payer: Multiplan WC |
$671.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$738.00
|
| Rate for Payer: TriValley Medical Group Senior |
$738.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$637.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$467.31
|
| Rate for Payer: Vantage Medical Group Senior |
$424.83
|
|
|
HC VAD/CATH DECLOT THROMBOLYTIC AGENT
|
Facility
|
IP
|
$1,230.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
907201300
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$222.63 |
| Max. Negotiated Rate |
$922.50 |
| Rate for Payer: Adventist Health Commercial |
$246.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$792.12
|
| Rate for Payer: Cash Price |
$553.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$832.71
|
| Rate for Payer: Heritage Provider Network Senior |
$832.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$222.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$307.50
|
| Rate for Payer: Multiplan Commercial |
$922.50
|
|
|
HC VAD/CATH DECLOT THROMBOLYTIC AGENT
|
Facility
|
OP
|
$1,230.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
907201300
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$222.63 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$246.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$760.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$637.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$467.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$424.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| 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 |
$553.50
|
| Rate for Payer: Cash Price |
$553.50
|
| Rate for Payer: Cash Price |
$553.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$799.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$637.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$467.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$424.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$424.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$761.37
|
| Rate for Payer: Heritage Provider Network Senior |
$522.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$424.83
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$807.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$222.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$488.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$307.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$569.27
|
| Rate for Payer: Multiplan Commercial |
$922.50
|
| Rate for Payer: Multiplan WC |
$671.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$467.31
|
| Rate for Payer: TriValley Medical Group Senior |
$467.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,093.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$637.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$467.31
|
| Rate for Payer: Vantage Medical Group Senior |
$424.83
|
|
|
HC VAD/CATH DECLOT THROMBOLYTIC AGENT
|
Facility
|
IP
|
$1,230.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
907201300
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$222.63 |
| Max. Negotiated Rate |
$922.50 |
| Rate for Payer: Adventist Health Commercial |
$246.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$792.12
|
| Rate for Payer: Cash Price |
$553.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$832.71
|
| Rate for Payer: Heritage Provider Network Senior |
$832.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$222.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$307.50
|
| Rate for Payer: Multiplan Commercial |
$922.50
|
|
|
HC VAG DEL PLUS ANTE/POST PARTUM
|
Facility
|
OP
|
$3,724.00
|
|
|
Service Code
|
CPT 59400
|
| Hospital Charge Code |
902400310
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$483.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$744.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,301.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,165.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,048.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,793.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,656.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,271.64
|
| Rate for Payer: Blue Shield of California EPN |
$1,817.31
|
| Rate for Payer: Cash Price |
$1,675.80
|
| Rate for Payer: Cash Price |
$1,675.80
|
| Rate for Payer: Cash Price |
$1,675.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,420.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,165.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,165.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,165.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,305.16
|
| Rate for Payer: Heritage Provider Network Senior |
$2,305.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,776.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$674.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$931.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,606.80
|
| Rate for Payer: Multiplan Commercial |
$2,793.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$575.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$483.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,165.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,165.40
|
| Rate for Payer: Vantage Medical Group Senior |
$3,165.40
|
|
|
HC VAG DEL PLUS ANTE/POST PARTUM
|
Facility
|
IP
|
$3,724.00
|
|
|
Service Code
|
CPT 59400
|
| Hospital Charge Code |
902400310
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$674.04 |
| Max. Negotiated Rate |
$2,793.00 |
| Rate for Payer: Adventist Health Commercial |
$744.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,398.26
|
| Rate for Payer: Cash Price |
$1,675.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,521.15
|
| Rate for Payer: Heritage Provider Network Senior |
$2,521.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$674.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$931.00
|
| Rate for Payer: Multiplan Commercial |
$2,793.00
|
|
|
HC VAGINAL DELIVERY ONLY
|
Facility
|
OP
|
$7,016.00
|
|
|
Service Code
|
CPT 59409
|
| Hospital Charge Code |
900501171
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,269.90 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,403.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,335.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,579.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,163.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,656.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,332.60
|
| Rate for Payer: Blue Shield of California EPN |
$2,652.05
|
| Rate for Payer: Cash Price |
$3,157.20
|
| Rate for Payer: Cash Price |
$3,157.20
|
| Rate for Payer: Cash Price |
$3,157.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,560.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,579.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,163.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,163.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,749.83
|
| Rate for Payer: Heritage Provider Network Senior |
$4,749.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,163.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3,346.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,269.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,788.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,754.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,579.06
|
| Rate for Payer: Multiplan Commercial |
$5,262.00
|
| Rate for Payer: Multiplan WC |
$6,436.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,209.60
|
| Rate for Payer: TriValley Medical Group Senior |
$4,209.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,579.83
|
| Rate for Payer: Vantage Medical Group Senior |
$4,163.48
|
|
|
HC VAGINAL DELIVERY ONLY
|
Facility
|
IP
|
$7,016.00
|
|
|
Service Code
|
CPT 59409
|
| Hospital Charge Code |
900501171
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,269.90 |
| Max. Negotiated Rate |
$5,262.00 |
| Rate for Payer: Adventist Health Commercial |
$1,403.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,518.30
|
| Rate for Payer: Cash Price |
$3,157.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,749.83
|
| Rate for Payer: Heritage Provider Network Senior |
$4,749.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,269.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,754.00
|
| Rate for Payer: Multiplan Commercial |
$5,262.00
|
|
|
HC VALPROIC ACID (DEPAKENE)
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT 80164
|
| Hospital Charge Code |
900910927
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$39.46 |
| Max. Negotiated Rate |
$163.50 |
| Rate for Payer: Adventist Health Commercial |
$43.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$140.39
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$147.59
|
| Rate for Payer: Heritage Provider Network Senior |
$147.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$39.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54.50
|
| Rate for Payer: Multiplan Commercial |
$163.50
|
|
