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Type

Price

Percutaneous Cardiovascular Procedure (PTCA)

Facility IP

$14,669.00

Service Code	ICD 02724ZZ
Min. Negotiated Rate	$10,527.00
Max. Negotiated Rate	$14,669.00
Rate for Payer: Blue Shield of California Commercial	$14,669.00
Rate for Payer: Blue Shield of California EPN	$10,527.00

Percutaneous Cardiovascular Procedure (PTCA)

Facility IP

$14,669.00

Service Code	ICD 027J4ZZ
Min. Negotiated Rate	$10,527.00
Max. Negotiated Rate	$14,669.00
Rate for Payer: Blue Shield of California Commercial	$14,669.00
Rate for Payer: Blue Shield of California EPN	$10,527.00

Percutaneous Cardiovascular Procedure (PTCA)

Facility IP

$14,669.00

Service Code	ICD 02713T6
Min. Negotiated Rate	$10,527.00
Max. Negotiated Rate	$14,669.00
Rate for Payer: Blue Shield of California Commercial	$14,669.00
Rate for Payer: Blue Shield of California EPN	$10,527.00

Percutaneous Cardiovascular Procedure (PTCA)

Facility IP

$14,669.00

Service Code	ICD 02713DZ
Min. Negotiated Rate	$10,527.00
Max. Negotiated Rate	$14,669.00
Rate for Payer: Blue Shield of California Commercial	$14,669.00
Rate for Payer: Blue Shield of California EPN	$10,527.00

Percutaneous Cardiovascular Procedure (PTCA)

Facility IP

$14,669.00

Service Code	ICD 02704ZZ
Min. Negotiated Rate	$10,527.00
Max. Negotiated Rate	$14,669.00
Rate for Payer: Blue Shield of California Commercial	$14,669.00
Rate for Payer: Blue Shield of California EPN	$10,527.00

Percutaneous Cardiovascular Procedure (PTCA)

Facility IP

$14,669.00

Service Code	ICD 027144Z
Min. Negotiated Rate	$10,527.00
Max. Negotiated Rate	$14,669.00
Rate for Payer: Blue Shield of California Commercial	$14,669.00
Rate for Payer: Blue Shield of California EPN	$10,527.00

Percutaneous Cardiovascular Procedure (PTCA)

Facility IP

$14,669.00

Service Code	ICD 02723ZZ
Min. Negotiated Rate	$10,527.00
Max. Negotiated Rate	$14,669.00
Rate for Payer: Blue Shield of California Commercial	$14,669.00
Rate for Payer: Blue Shield of California EPN	$10,527.00

Percutaneous Cardiovascular Procedure (PTCA)

Facility IP

$14,669.00

Service Code	ICD 02733ZZ
Min. Negotiated Rate	$10,527.00
Max. Negotiated Rate	$14,669.00
Rate for Payer: Blue Shield of California Commercial	$14,669.00
Rate for Payer: Blue Shield of California EPN	$10,527.00

Percutaneous Cardiovascular Procedure (PTCA)

Facility IP

$14,669.00

Service Code	ICD 027044Z
Min. Negotiated Rate	$10,527.00
Max. Negotiated Rate	$14,669.00
Rate for Payer: Blue Shield of California Commercial	$14,669.00
Rate for Payer: Blue Shield of California EPN	$10,527.00

Percutaneous Cardiovascular Procedure (PTCA)

Facility IP

$14,669.00

Service Code	ICD 0273446
Min. Negotiated Rate	$10,527.00
Max. Negotiated Rate	$14,669.00
Rate for Payer: Blue Shield of California Commercial	$14,669.00
Rate for Payer: Blue Shield of California EPN	$10,527.00

Percutaneous Cardiovascular Procedure (PTCA)

Facility IP

$14,669.00

Service Code	ICD 0272446
Min. Negotiated Rate	$10,527.00
Max. Negotiated Rate	$14,669.00
Rate for Payer: Blue Shield of California Commercial	$14,669.00
Rate for Payer: Blue Shield of California EPN	$10,527.00

Percutaneous Cardiovascular Procedure (PTCA)

Facility IP

$14,669.00

Service Code	ICD 027244Z
Min. Negotiated Rate	$10,527.00
Max. Negotiated Rate	$14,669.00
Rate for Payer: Blue Shield of California Commercial	$14,669.00
Rate for Payer: Blue Shield of California EPN	$10,527.00

Percutaneous Cardiovascular Procedure (PTCA)

Facility IP

$14,669.00

Service Code	ICD 02C23ZZ
Min. Negotiated Rate	$10,527.00
Max. Negotiated Rate	$14,669.00
Rate for Payer: Blue Shield of California Commercial	$14,669.00
Rate for Payer: Blue Shield of California EPN	$10,527.00

Percutaneous Cardiovascular Procedure (PTCA)

Facility IP

$14,669.00

Service Code	ICD 02733DZ
Min. Negotiated Rate	$10,527.00
Max. Negotiated Rate	$14,669.00
Rate for Payer: Blue Shield of California Commercial	$14,669.00
Rate for Payer: Blue Shield of California EPN	$10,527.00

Percutaneous Cardiovascular Procedure (PTCA)

Facility IP

$14,669.00

Service Code	ICD 027H44Z
Min. Negotiated Rate	$10,527.00
Max. Negotiated Rate	$14,669.00
Rate for Payer: Blue Shield of California Commercial	$14,669.00
Rate for Payer: Blue Shield of California EPN	$10,527.00

Percutaneous Cardiovascular Procedure (PTCA)

Facility IP

$14,669.00

Service Code	ICD 02734T6
Min. Negotiated Rate	$10,527.00
Max. Negotiated Rate	$14,669.00
Rate for Payer: Blue Shield of California Commercial	$14,669.00
Rate for Payer: Blue Shield of California EPN	$10,527.00

Percutaneous Cardiovascular Procedure (PTCA)

Facility IP

$14,669.00

Service Code	ICD 027J3ZZ
Min. Negotiated Rate	$10,527.00
Max. Negotiated Rate	$14,669.00
Rate for Payer: Blue Shield of California Commercial	$14,669.00
Rate for Payer: Blue Shield of California EPN	$10,527.00

Percutaneous implantation of neurostimulator electrode array, epidural

Facility OP

$30,248.00

Service Code	CPT 63650
Hospital Revenue Code	360
Min. Negotiated Rate	$2,960.28
Max. Negotiated Rate	$30,248.00
Rate for Payer: Adventist Health Medi-Cal	$8,545.06
Rate for Payer: Aetna of CA HMO/PPO	$6,248.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$12,817.59
Rate for Payer: AlphaCare Medical Group Medi-Cal	$9,399.57
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$8,545.06
Rate for Payer: Anthem Blue Cross of CA Exchange	$4,736.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$30,248.00
Rate for Payer: Anthem Blue Cross of CA Workers' Comp	$11,682.32
Rate for Payer: Blue Shield of California Commercial	$4,121.55
Rate for Payer: Blue Shield of California EPN	$2,960.28
Rate for Payer: Caremore Medicare Advantage	$8,545.06
Rate for Payer: Dignity Health Commercial/Exchange	$12,817.59
Rate for Payer: EPIC Health Plan Commercial	$11,535.83
Rate for Payer: EPIC Health Plan Medicare/Senior	$8,545.06
Rate for Payer: EPIC Health Plan Transplant	$8,545.06
Rate for Payer: Heritage Provider Network Commercial/Senior	$14,013.90
Rate for Payer: IEHP medi-cal	$14,099.35
Rate for Payer: IEHP Medicare Advantage	$8,545.06
Rate for Payer: Innovage PACE Commercial	$12,817.59
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$8,545.06
Rate for Payer: Molina Healthcare of CA Medi-Cal	$11,450.38
Rate for Payer: Molina Healthcare of CA Medicare	$11,450.38
Rate for Payer: Multiplan WC	$11,682.32
Rate for Payer: Preferred Health Network WC	$11,920.73
Rate for Payer: Prime Health Services Medicare	$9,057.76
Rate for Payer: Prime Health Services WC	$11,563.11
Rate for Payer: Riverside University Health MISP	$9,399.57
Rate for Payer: United Healthcare All Other Commercial	$16,813.00
Rate for Payer: United Healthcare All Other HMO	$27,445.00
Rate for Payer: United Healthcare HMO Rider	$17,214.00
Rate for Payer: United Healthcare Select/Navigate/Core	$15,742.00
Rate for Payer: Vantage Medical Group Commercial/Exchange	$12,817.59
Rate for Payer: Vantage Medical Group Medi-Cal	$9,399.57
Rate for Payer: Vantage Medical Group Senior	$8,545.06

Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed

Facility OP

$27,445.00

Service Code	CPT 64561
Hospital Revenue Code	360
Min. Negotiated Rate	$4,736.00
Max. Negotiated Rate	$27,445.00
Rate for Payer: Adventist Health Medi-Cal	$8,545.06
Rate for Payer: Aetna of CA HMO/PPO	$8,114.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$12,817.59
Rate for Payer: AlphaCare Medical Group Medi-Cal	$9,399.57
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$8,545.06
Rate for Payer: Anthem Blue Cross of CA Exchange	$4,736.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$12,379.00
Rate for Payer: Anthem Blue Cross of CA Workers' Comp	$11,682.32
Rate for Payer: Blue Shield of California Commercial	$12,373.72
Rate for Payer: Blue Shield of California EPN	$8,887.36
Rate for Payer: Caremore Medicare Advantage	$8,545.06
Rate for Payer: Dignity Health Commercial/Exchange	$12,817.59
Rate for Payer: EPIC Health Plan Commercial	$11,535.83
Rate for Payer: EPIC Health Plan Medicare/Senior	$8,545.06
Rate for Payer: EPIC Health Plan Transplant	$8,545.06
Rate for Payer: Heritage Provider Network Commercial/Senior	$14,013.90
Rate for Payer: IEHP medi-cal	$14,099.35
Rate for Payer: IEHP Medicare Advantage	$8,545.06
Rate for Payer: Innovage PACE Commercial	$12,817.59
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$8,545.06
Rate for Payer: Molina Healthcare of CA Medi-Cal	$11,450.38
Rate for Payer: Molina Healthcare of CA Medicare	$11,450.38
Rate for Payer: Multiplan WC	$11,682.32
Rate for Payer: Preferred Health Network WC	$11,920.73
Rate for Payer: Prime Health Services Medicare	$9,057.76
Rate for Payer: Prime Health Services WC	$11,563.11
Rate for Payer: Riverside University Health MISP	$9,399.57
Rate for Payer: United Healthcare All Other Commercial	$16,813.00
Rate for Payer: United Healthcare All Other HMO	$27,445.00
Rate for Payer: United Healthcare HMO Rider	$17,214.00
Rate for Payer: United Healthcare Select/Navigate/Core	$15,742.00
Rate for Payer: Vantage Medical Group Commercial/Exchange	$12,817.59
Rate for Payer: Vantage Medical Group Medi-Cal	$9,399.57
Rate for Payer: Vantage Medical Group Senior	$8,545.06

PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES

Facility IP

$29,734.49

Service Code	APR-DRG 0302
Min. Negotiated Rate	$24,952.02
Max. Negotiated Rate	$29,734.49
Rate for Payer: Adventist Health Medi-Cal	$24,952.02
Rate for Payer: IEHP medi-cal	$29,734.49

PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES

Facility IP

$53,782.90

Service Code	APR-DRG 0304
Min. Negotiated Rate	$45,132.50
Max. Negotiated Rate	$53,782.90
Rate for Payer: Adventist Health Medi-Cal	$45,132.50
Rate for Payer: IEHP medi-cal	$53,782.90

PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES

Facility IP

$40,736.94

Service Code	APR-DRG 0303
Min. Negotiated Rate	$34,184.84
Max. Negotiated Rate	$40,736.94
Rate for Payer: Adventist Health Medi-Cal	$34,184.84
Rate for Payer: IEHP medi-cal	$40,736.94

PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES

Facility IP

$22,190.43

Service Code	APR-DRG 0301
Min. Negotiated Rate	$18,621.34
Max. Negotiated Rate	$22,190.43
Rate for Payer: Adventist Health Medi-Cal	$18,621.34
Rate for Payer: IEHP medi-cal	$22,190.43

Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar

Facility OP

$27,445.00

Service Code	CPT 0275T
Hospital Revenue Code	360
Min. Negotiated Rate	$4,736.00
Max. Negotiated Rate	$27,445.00
Rate for Payer: Adventist Health Medi-Cal	$8,938.53
Rate for Payer: Aetna of CA HMO/PPO	$5,509.18
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$13,407.80
Rate for Payer: AlphaCare Medical Group Medi-Cal	$9,832.38
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$8,938.53
Rate for Payer: Anthem Blue Cross of CA Exchange	$4,736.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$5,779.00
Rate for Payer: Anthem Blue Cross of CA Workers' Comp	$12,220.24
Rate for Payer: Blue Shield of California Commercial	$9,194.24
Rate for Payer: Blue Shield of California EPN	$6,603.71
Rate for Payer: Caremore Medicare Advantage	$8,938.53
Rate for Payer: Dignity Health Commercial/Exchange	$13,407.80
Rate for Payer: EPIC Health Plan Commercial	$12,067.02
Rate for Payer: EPIC Health Plan Medicare/Senior	$8,938.53
Rate for Payer: EPIC Health Plan Transplant	$8,938.53
Rate for Payer: Heritage Provider Network Commercial/Senior	$14,659.19
Rate for Payer: IEHP medi-cal	$14,748.57
Rate for Payer: IEHP Medicare Advantage	$8,938.53
Rate for Payer: Innovage PACE Commercial	$13,407.80
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$8,938.53
Rate for Payer: Molina Healthcare of CA Medi-Cal	$11,977.63
Rate for Payer: Molina Healthcare of CA Medicare	$11,977.63
Rate for Payer: Multiplan WC	$12,220.24
Rate for Payer: Preferred Health Network WC	$12,469.63
Rate for Payer: Prime Health Services Medicare	$9,474.84
Rate for Payer: Prime Health Services WC	$12,095.54
Rate for Payer: Riverside University Health MISP	$9,832.38
Rate for Payer: United Healthcare All Other Commercial	$16,813.00
Rate for Payer: United Healthcare All Other HMO	$27,445.00
Rate for Payer: United Healthcare HMO Rider	$17,214.00
Rate for Payer: United Healthcare Select/Navigate/Core	$15,742.00
Rate for Payer: Vantage Medical Group Commercial/Exchange	$13,407.80
Rate for Payer: Vantage Medical Group Medi-Cal	$9,832.38
Rate for Payer: Vantage Medical Group Senior	$8,938.53

Percutaneous nephrolithotomy or pyelolithotomy, lithotripsy, stone extraction, antegrade ureteroscopy, antegrade stent placement and nephrostomy tube placement, when performed, including imaging guidance; complex (eg, stone[s] > 2 cm, branching stones, stones in multiple locations, ureter stones, complicated anatomy)

Facility OP

$25,512.00

Service Code	CPT 50081
Hospital Revenue Code	360
Min. Negotiated Rate	$5,806.00
Max. Negotiated Rate	$25,512.00
Rate for Payer: Adventist Health Medi-Cal	$11,510.17
Rate for Payer: Aetna of CA HMO/PPO	$11,071.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$17,265.26
Rate for Payer: AlphaCare Medical Group Medi-Cal	$12,661.19
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$11,510.17
Rate for Payer: Anthem Blue Cross of CA Exchange	$5,806.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$7,084.00
Rate for Payer: Anthem Blue Cross of CA Workers' Comp	$15,736.05
Rate for Payer: Blue Shield of California Commercial	$9,194.24
Rate for Payer: Blue Shield of California EPN	$6,603.71
Rate for Payer: Caremore Medicare Advantage	$11,510.17
Rate for Payer: Dignity Health Commercial/Exchange	$17,265.26
Rate for Payer: EPIC Health Plan Commercial	$15,538.73
Rate for Payer: EPIC Health Plan Medicare/Senior	$11,510.17
Rate for Payer: EPIC Health Plan Transplant	$11,510.17
Rate for Payer: Heritage Provider Network Commercial/Senior	$18,876.68
Rate for Payer: IEHP medi-cal	$18,991.78
Rate for Payer: IEHP Medicare Advantage	$11,510.17
Rate for Payer: Innovage PACE Commercial	$17,265.26
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$11,510.17
Rate for Payer: Molina Healthcare of CA Medi-Cal	$15,423.63
Rate for Payer: Molina Healthcare of CA Medicare	$15,423.63
Rate for Payer: Multiplan WC	$15,736.05
Rate for Payer: Preferred Health Network WC	$16,057.19
Rate for Payer: Prime Health Services Medicare	$12,200.78
Rate for Payer: Prime Health Services WC	$15,575.47
Rate for Payer: Riverside University Health MISP	$12,661.19
Rate for Payer: United Healthcare All Other Commercial	$14,836.00
Rate for Payer: United Healthcare All Other HMO	$25,512.00
Rate for Payer: United Healthcare HMO Rider	$16,069.00
Rate for Payer: United Healthcare Select/Navigate/Core	$14,692.00
Rate for Payer: Vantage Medical Group Commercial/Exchange	$17,265.26
Rate for Payer: Vantage Medical Group Medi-Cal	$12,661.19
Rate for Payer: Vantage Medical Group Senior	$11,510.17