|
FRACTURE OF FEMUR
|
Facility
|
IP
|
$14,141.62
|
|
|
Service Code
|
APR-DRG 3403
|
| Min. Negotiated Rate |
$8,931.55 |
| Max. Negotiated Rate |
$14,141.62 |
| Rate for Payer: Adventist Health Medi-Cal |
$8,931.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$10,643.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14,141.62
|
|
|
FRACTURE OF FEMUR
|
Facility
|
IP
|
$21,126.84
|
|
|
Service Code
|
APR-DRG 3404
|
| Min. Negotiated Rate |
$13,343.27 |
| Max. Negotiated Rate |
$21,126.84 |
| Rate for Payer: Adventist Health Medi-Cal |
$13,343.27
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$15,900.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21,126.84
|
|
|
FRACTURE OF FEMUR
|
Facility
|
IP
|
$7,754.64
|
|
|
Service Code
|
APR-DRG 3401
|
| Min. Negotiated Rate |
$4,897.67 |
| Max. Negotiated Rate |
$7,754.64 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,897.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$5,836.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7,754.64
|
|
|
FRACTURE OF PELVIS OR DISLOCATION OF HIP
|
Facility
|
IP
|
$15,269.58
|
|
|
Service Code
|
APR-DRG 3413
|
| Min. Negotiated Rate |
$9,643.94 |
| Max. Negotiated Rate |
$15,269.58 |
| Rate for Payer: Adventist Health Medi-Cal |
$9,643.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$11,492.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15,269.58
|
|
|
FRACTURE OF PELVIS OR DISLOCATION OF HIP
|
Facility
|
IP
|
$10,427.47
|
|
|
Service Code
|
APR-DRG 3412
|
| Min. Negotiated Rate |
$6,585.77 |
| Max. Negotiated Rate |
$10,427.47 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,585.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$7,848.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10,427.47
|
|
|
FRACTURE OF PELVIS OR DISLOCATION OF HIP
|
Facility
|
IP
|
$26,770.60
|
|
|
Service Code
|
APR-DRG 3414
|
| Min. Negotiated Rate |
$16,907.75 |
| Max. Negotiated Rate |
$26,770.60 |
| Rate for Payer: Adventist Health Medi-Cal |
$16,907.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$20,148.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26,770.60
|
|
|
FRACTURE OF PELVIS OR DISLOCATION OF HIP
|
Facility
|
IP
|
$8,397.16
|
|
|
Service Code
|
APR-DRG 3411
|
| Min. Negotiated Rate |
$5,303.47 |
| Max. Negotiated Rate |
$8,397.16 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,303.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$6,319.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8,397.16
|
|
|
FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK
|
Facility
|
IP
|
$15,968.49
|
|
|
Service Code
|
APR-DRG 3423
|
| Min. Negotiated Rate |
$10,085.36 |
| Max. Negotiated Rate |
$15,968.49 |
| Rate for Payer: Adventist Health Medi-Cal |
$10,085.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$12,018.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15,968.49
|
|
|
FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK
|
Facility
|
IP
|
$8,209.84
|
|
|
Service Code
|
APR-DRG 3421
|
| Min. Negotiated Rate |
$5,185.16 |
| Max. Negotiated Rate |
$8,209.84 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,185.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$6,178.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8,209.84
|
|
|
FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK
|
Facility
|
IP
|
$11,003.53
|
|
|
Service Code
|
APR-DRG 3422
|
| Min. Negotiated Rate |
$6,949.60 |
| Max. Negotiated Rate |
$11,003.53 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,949.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$8,281.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11,003.53
|
|
|
FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK
|
Facility
|
IP
|
$28,647.82
|
|
|
Service Code
|
APR-DRG 3424
|
| Min. Negotiated Rate |
$18,093.36 |
| Max. Negotiated Rate |
$28,647.82 |
| Rate for Payer: Adventist Health Medi-Cal |
$18,093.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$21,561.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$28,647.82
|
|
|
FRACTURES OF FEMUR WITH MCC
|
Facility
|
IP
|
$41,260.30
|
|
|
Service Code
|
MSDRG 533
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$41,260.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$41,260.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$26,652.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37,314.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$37,163.59
|
| Rate for Payer: EPIC Health Plan Senior |
$24,775.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$22,523.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$31,532.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$30,181.34
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$22,523.39
|
| Rate for Payer: Prime Health Services Medicare |
$23,874.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
FRACTURES OF FEMUR WITHOUT MCC
|
Facility
|
IP
|
$21,215.75
|
|
|
Service Code
|
MSDRG 534
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$21,215.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$21,215.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13,704.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19,186.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$19,831.96
|
| Rate for Payer: EPIC Health Plan Senior |
$13,221.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12,019.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16,827.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16,105.96
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$12,019.37
|
| Rate for Payer: Prime Health Services Medicare |
$12,740.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
FRACTURES OF HIP AND PELVIS WITH MCC
|
Facility
|
IP
|
$33,740.96
|
|
|
Service Code
|
MSDRG 535
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$33,740.96 |
| Rate for Payer: Aetna of CA HMO/PPO |
$33,740.96
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$21,795.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30,514.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$30,661.95
|
| Rate for Payer: EPIC Health Plan Senior |
$20,441.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18,583.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$26,016.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$24,901.22
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$18,583.00
|
| Rate for Payer: Prime Health Services Medicare |
$19,697.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
FRACTURES OF HIP AND PELVIS WITHOUT MCC
|
Facility
|
IP
|
$21,255.22
|
|
|
Service Code
|
MSDRG 536
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$21,255.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$21,255.22
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13,730.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19,222.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$19,866.10
|
| Rate for Payer: EPIC Health Plan Senior |
$13,244.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12,040.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16,856.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16,133.68
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$12,040.06
|
| Rate for Payer: Prime Health Services Medicare |
$12,762.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC
|
Facility
|
IP
|
$37,499.31
|
|
|
Service Code
|
MSDRG 562
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$37,499.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$37,499.31
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$24,223.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33,913.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$33,911.64
|
| Rate for Payer: EPIC Health Plan Senior |
$22,607.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20,552.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$28,773.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$27,540.36
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$20,552.51
|
| Rate for Payer: Prime Health Services Medicare |
$21,785.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC
|
Facility
|
IP
|
$23,568.66
|
|
|
Service Code
|
MSDRG 563
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$23,568.66 |
| Rate for Payer: Aetna of CA HMO/PPO |
$23,568.66
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$15,224.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21,314.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$21,866.43
|
| Rate for Payer: EPIC Health Plan Senior |
$14,577.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13,252.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18,553.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17,758.19
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$13,252.38
|
| Rate for Payer: Prime Health Services Medicare |
$14,047.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
FULL TERM NEONATE WITH MAJOR PROBLEMS
|
Facility
|
IP
|
$109,739.70
|
|
|
Service Code
|
MSDRG 793
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$109,739.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$109,739.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$70,887.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$99,244.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$96,374.70
|
| Rate for Payer: EPIC Health Plan Senior |
$64,249.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$58,408.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$81,772.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$78,267.94
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$58,408.91
|
| Rate for Payer: Prime Health Services Medicare |
$61,913.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,809.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,601.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY
|
Facility
|
IP
|
$58,180.78
|
|
|
Service Code
|
MSDRG 934
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$58,180.78 |
| Rate for Payer: Aetna of CA HMO/PPO |
$58,180.78
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$37,582.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52,616.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$51,794.01
|
| Rate for Payer: EPIC Health Plan Senior |
$34,529.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$31,390.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$43,946.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$42,063.02
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$31,390.31
|
| Rate for Payer: Prime Health Services Medicare |
$33,273.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC
|
Facility
|
IP
|
$188,778.29
|
|
|
Service Code
|
MSDRG 928
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$188,778.29 |
| Rate for Payer: EPIC Health Plan Senior |
$109,810.59
|
| Rate for Payer: Aetna of CA HMO/PPO |
$188,778.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$121,943.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$170,724.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$164,715.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$99,827.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$139,758.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$133,769.27
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$99,827.81
|
| Rate for Payer: Prime Health Services Medicare |
$105,817.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC
|
Facility
|
IP
|
$84,768.24
|
|
|
Service Code
|
MSDRG 929
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$84,768.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$84,768.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$54,756.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$76,661.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$74,782.98
|
| Rate for Payer: EPIC Health Plan Senior |
$49,855.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$45,323.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$63,452.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$60,732.85
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$45,323.02
|
| Rate for Payer: Prime Health Services Medicare |
$48,042.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 15240
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$115.91 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,653.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,653.72
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,074.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$3,703.23
|
| Rate for Payer: Blue Shield of California Commercial |
$5,036.70
|
| Rate for Payer: Blue Shield of California EPN |
$3,165.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,919.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,653.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,378.64
|
| Rate for Payer: EPIC Health Plan Senior |
$2,919.09
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$4,352.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$115.91
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$128.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,715.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,555.98
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Preferred Health Network WC |
$3,778.81
|
| Rate for Payer: Prime Health Services Medicare |
$2,812.94
|
| Rate for Payer: Prime Health Services WC |
$3,665.45
|
| Rate for Payer: Riverside University Health System MISP |
$2,919.09
|
| Rate for Payer: United Healthcare All Other HMO |
$7,378.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,428.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,122.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$2,653.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2,653.72
|
|
|
FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 15260
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$145.36 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,653.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,653.72
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,587.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$3,703.23
|
| Rate for Payer: Blue Shield of California Commercial |
$4,407.11
|
| Rate for Payer: Blue Shield of California EPN |
$3,165.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,919.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,653.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,378.64
|
| Rate for Payer: EPIC Health Plan Senior |
$2,919.09
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$4,352.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$145.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$160.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,715.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,555.98
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Preferred Health Network WC |
$3,778.81
|
| Rate for Payer: Prime Health Services Medicare |
$2,812.94
|
| Rate for Payer: Prime Health Services WC |
$3,665.45
|
| Rate for Payer: Riverside University Health System MISP |
$2,919.09
|
| Rate for Payer: United Healthcare All Other HMO |
$7,378.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,428.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,122.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$2,653.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2,653.72
|
|
|
FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 15220
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$101.17 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,653.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,653.72
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,587.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$3,703.23
|
| Rate for Payer: Blue Shield of California Commercial |
$4,407.11
|
| Rate for Payer: Blue Shield of California EPN |
$3,165.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,919.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,653.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,378.64
|
| Rate for Payer: EPIC Health Plan Senior |
$2,919.09
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$4,352.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$101.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$111.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,715.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,555.98
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Preferred Health Network WC |
$3,778.81
|
| Rate for Payer: Prime Health Services Medicare |
$2,812.94
|
| Rate for Payer: Prime Health Services WC |
$3,665.45
|
| Rate for Payer: Riverside University Health System MISP |
$2,919.09
|
| Rate for Payer: United Healthcare All Other HMO |
$7,378.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,428.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,122.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$2,653.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2,653.72
|
|
|
FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 15221
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$192.11 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3,974.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,523.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,407.11
|
| Rate for Payer: Blue Shield of California EPN |
$3,165.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$192.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$212.21
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
|
