|
HC SD PASSIVE RESTORATION
|
Facility
|
IP
|
$8,292.00
|
|
|
Service Code
|
CPT L6310
|
| Hospital Charge Code |
905356310
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,658.40 |
| Max. Negotiated Rate |
$7,462.80 |
| Rate for Payer: Blue Shield of California EPN |
$4,427.93
|
| Rate for Payer: Cash Price |
$3,731.40
|
| Rate for Payer: Central Health Plan Commercial |
$6,633.60
|
| Rate for Payer: Cigna of CA HMO |
$5,804.40
|
| Rate for Payer: Cigna of CA PPO |
$5,804.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,316.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,316.80
|
| Rate for Payer: Galaxy Health WC |
$7,048.20
|
| Rate for Payer: Global Benefits Group Commercial |
$4,975.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$7,462.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,530.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,159.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,658.40
|
| Rate for Payer: Multiplan Commercial |
$6,219.00
|
| Rate for Payer: Networks By Design Commercial |
$4,146.00
|
| Rate for Payer: Prime Health Services Commercial |
$7,048.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,131.06
|
| Rate for Payer: United Healthcare All Other HMO |
$3,058.09
|
| Rate for Payer: United Healthcare HMO Rider |
$2,991.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,736.36
|
|
|
HC SD PASSIVE RESTORATION
|
Facility
|
OP
|
$8,292.00
|
|
|
Service Code
|
CPT L6310
|
| Hospital Charge Code |
905356310
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$2,902.20 |
| Max. Negotiated Rate |
$7,462.80 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,048.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,560.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,560.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,014.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,898.91
|
| Rate for Payer: Blue Distinction Transplant |
$4,975.20
|
| Rate for Payer: Blue Shield of California Commercial |
$6,219.00
|
| Rate for Payer: Blue Shield of California EPN |
$4,510.85
|
| Rate for Payer: Cash Price |
$3,731.40
|
| Rate for Payer: Cash Price |
$3,731.40
|
| Rate for Payer: Central Health Plan Commercial |
$6,633.60
|
| Rate for Payer: Cigna of CA HMO |
$5,804.40
|
| Rate for Payer: Cigna of CA PPO |
$5,804.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,048.20
|
| Rate for Payer: Dignity Health Media |
$7,048.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,048.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,316.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,316.80
|
| Rate for Payer: Galaxy Health WC |
$7,048.20
|
| Rate for Payer: Global Benefits Group Commercial |
$4,975.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$7,462.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6,219.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$2,902.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,530.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,599.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,399.72
|
| Rate for Payer: Multiplan Commercial |
$6,219.00
|
| Rate for Payer: Networks By Design Commercial |
$4,146.00
|
| Rate for Payer: Prime Health Services Commercial |
$7,048.20
|
| Rate for Payer: Riverside University Health System MISP |
$3,316.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4,975.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4,975.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,146.00
|
| Rate for Payer: United Healthcare All Other HMO |
$4,146.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,146.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,146.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,048.20
|
| Rate for Payer: Vantage Medical Group Senior |
$7,048.20
|
|
|
HC SD PASSIVE RESTORATN CAP ONLY
|
Facility
|
IP
|
$2,418.00
|
|
|
Service Code
|
CPT L6320
|
| Hospital Charge Code |
905356320
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$483.60 |
| Max. Negotiated Rate |
$2,176.20 |
| Rate for Payer: Blue Shield of California EPN |
$1,291.21
|
| Rate for Payer: Cash Price |
$1,088.10
|
| Rate for Payer: Central Health Plan Commercial |
$1,934.40
|
| Rate for Payer: Cigna of CA HMO |
$1,692.60
|
| Rate for Payer: Cigna of CA PPO |
$1,692.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$967.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$967.20
|
| Rate for Payer: Galaxy Health WC |
$2,055.30
|
| Rate for Payer: Global Benefits Group Commercial |
$1,450.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,176.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,612.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$921.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$483.60
|
| Rate for Payer: Multiplan Commercial |
$1,813.50
|
| Rate for Payer: Networks By Design Commercial |
$1,209.00
|
| Rate for Payer: Prime Health Services Commercial |
$2,055.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$913.04
|
| Rate for Payer: United Healthcare All Other HMO |
$891.76
|
| Rate for Payer: United Healthcare HMO Rider |
$872.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$797.94
|
|
|
HC SD PASSIVE RESTORATN CAP ONLY
|
Facility
|
OP
|
$2,418.00
|
|
|
Service Code
|
CPT L6320
|
| Hospital Charge Code |
905356320
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$846.30 |
| Max. Negotiated Rate |
$2,309.58 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,055.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,329.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,329.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,170.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,428.55
|
| Rate for Payer: Blue Distinction Transplant |
$1,450.80
|
| Rate for Payer: Blue Shield of California Commercial |
$1,813.50
|
| Rate for Payer: Blue Shield of California EPN |
$1,315.39
|
| Rate for Payer: Cash Price |
$1,088.10
|
| Rate for Payer: Cash Price |
$1,088.10
|
| Rate for Payer: Central Health Plan Commercial |
$1,934.40
|
| Rate for Payer: Cigna of CA HMO |
$1,692.60
|
| Rate for Payer: Cigna of CA PPO |
$1,692.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,055.30
|
| Rate for Payer: Dignity Health Media |
$2,055.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,055.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$967.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$967.20
|
| Rate for Payer: Galaxy Health WC |
$2,055.30
|
| Rate for Payer: Global Benefits Group Commercial |
$1,450.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,176.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,813.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$846.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,612.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,309.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$991.38
|
| Rate for Payer: Multiplan Commercial |
$1,813.50
|
| Rate for Payer: Networks By Design Commercial |
$1,209.00
|
| Rate for Payer: Prime Health Services Commercial |
$2,055.30
|
| Rate for Payer: Riverside University Health System MISP |
$967.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,450.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,450.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,209.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,209.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,209.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,209.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,055.30
|
| Rate for Payer: Vantage Medical Group Senior |
$2,055.30
|
|
|
HC SD RECOVERY ADDL 30 MIN
|
Facility
|
IP
|
$817.00
|
|
| Hospital Charge Code |
907201508
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$163.40 |
| Max. Negotiated Rate |
$735.30 |
| Rate for Payer: Cash Price |
$367.65
|
| Rate for Payer: Central Health Plan Commercial |
$653.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$326.80
|
| Rate for Payer: Galaxy Health WC |
$694.45
|
| Rate for Payer: Global Benefits Group Commercial |
$490.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$735.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$544.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$311.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$163.40
|
| Rate for Payer: Multiplan Commercial |
$612.75
|
| Rate for Payer: Networks By Design Commercial |
$531.05
|
| Rate for Payer: Prime Health Services Commercial |
$694.45
|
|
|
HC SD RECOVERY ADDL 30 MIN
|
Facility
|
OP
|
$817.00
|
|
| Hospital Charge Code |
907201508
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$163.40 |
| Max. Negotiated Rate |
$735.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$496.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$694.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$449.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$449.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$395.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$482.68
|
| Rate for Payer: Blue Distinction Transplant |
$490.20
|
| Rate for Payer: Blue Shield of California Commercial |
$513.89
|
| Rate for Payer: Blue Shield of California EPN |
$399.51
|
| Rate for Payer: Cash Price |
$367.65
|
| Rate for Payer: Central Health Plan Commercial |
$653.60
|
| Rate for Payer: Cigna of CA HMO |
$522.88
|
| Rate for Payer: Cigna of CA PPO |
$604.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$694.45
|
| Rate for Payer: Dignity Health Media |
$694.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$694.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$326.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$326.80
|
| Rate for Payer: Galaxy Health WC |
$694.45
|
| Rate for Payer: Global Benefits Group Commercial |
$490.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$735.30
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$612.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$285.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$544.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$311.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$163.40
|
| Rate for Payer: Multiplan Commercial |
$612.75
|
| Rate for Payer: Networks By Design Commercial |
$531.05
|
| Rate for Payer: Prime Health Services Commercial |
$694.45
|
| Rate for Payer: Riverside University Health System MISP |
$326.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$490.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$490.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$408.50
|
| Rate for Payer: United Healthcare All Other HMO |
$408.50
|
| Rate for Payer: United Healthcare HMO Rider |
$408.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$408.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$694.45
|
| Rate for Payer: Vantage Medical Group Senior |
$694.45
|
|
|
HC SD RECOVERY LEVEL IV FIRST HR
|
Facility
|
OP
|
$1,536.00
|
|
| Hospital Charge Code |
906500107
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$307.20 |
| Max. Negotiated Rate |
$1,382.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$932.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,305.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$844.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$844.80
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$743.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$907.47
|
| Rate for Payer: Blue Distinction Transplant |
$921.60
|
| Rate for Payer: Blue Shield of California Commercial |
$966.14
|
| Rate for Payer: Blue Shield of California EPN |
$751.10
|
| Rate for Payer: Cash Price |
$691.20
|
| Rate for Payer: Central Health Plan Commercial |
$1,228.80
|
| Rate for Payer: Cigna of CA HMO |
$983.04
|
| Rate for Payer: Cigna of CA PPO |
$1,136.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,305.60
|
| Rate for Payer: Dignity Health Media |
$1,305.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,305.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$614.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$614.40
|
| Rate for Payer: Galaxy Health WC |
$1,305.60
|
| Rate for Payer: Global Benefits Group Commercial |
$921.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,382.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,152.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$537.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,024.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$585.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$307.20
|
| Rate for Payer: Multiplan Commercial |
$1,152.00
|
| Rate for Payer: Networks By Design Commercial |
$998.40
|
| Rate for Payer: Prime Health Services Commercial |
$1,305.60
|
| Rate for Payer: Riverside University Health System MISP |
$614.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$921.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$921.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Other HMO |
$768.00
|
| Rate for Payer: United Healthcare HMO Rider |
$768.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$768.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,305.60
|
| Rate for Payer: Vantage Medical Group Senior |
$1,305.60
|
|
|
HC SD RECOVERY LEVEL IV FIRST HR
|
Facility
|
IP
|
$1,536.00
|
|
| Hospital Charge Code |
906500107
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$307.20 |
| Max. Negotiated Rate |
$1,382.40 |
| Rate for Payer: Cash Price |
$691.20
|
| Rate for Payer: Central Health Plan Commercial |
$1,228.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$614.40
|
| Rate for Payer: Galaxy Health WC |
$1,305.60
|
| Rate for Payer: Global Benefits Group Commercial |
$921.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,382.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,024.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$585.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$307.20
|
| Rate for Payer: Multiplan Commercial |
$1,152.00
|
| Rate for Payer: Networks By Design Commercial |
$998.40
|
| Rate for Payer: Prime Health Services Commercial |
$1,305.60
|
|
|
HC SEALANT COSEAL 2ML
|
Facility
|
IP
|
$1,928.69
|
|
| Hospital Charge Code |
901605215
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$385.74 |
| Max. Negotiated Rate |
$1,735.82 |
| Rate for Payer: Blue Shield of California EPN |
$1,029.92
|
| Rate for Payer: Cash Price |
$867.91
|
| Rate for Payer: Central Health Plan Commercial |
$1,542.95
|
| Rate for Payer: Cigna of CA HMO |
$1,350.08
|
| Rate for Payer: Cigna of CA PPO |
$1,350.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$771.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$771.48
|
| Rate for Payer: Galaxy Health WC |
$1,639.39
|
| Rate for Payer: Global Benefits Group Commercial |
$1,157.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,735.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,286.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$734.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$385.74
|
| Rate for Payer: Multiplan Commercial |
$1,446.52
|
| Rate for Payer: Prime Health Services Commercial |
$1,639.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$728.27
|
| Rate for Payer: United Healthcare All Other HMO |
$711.30
|
| Rate for Payer: United Healthcare HMO Rider |
$695.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$636.47
|
|
|
HC SEALANT COSEAL 2ML
|
Facility
|
OP
|
$1,928.69
|
|
| Hospital Charge Code |
901605215
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$385.74 |
| Max. Negotiated Rate |
$1,735.82 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,639.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,060.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,060.78
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$880.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,074.28
|
| Rate for Payer: Blue Distinction Transplant |
$1,157.21
|
| Rate for Payer: Blue Shield of California Commercial |
$1,446.52
|
| Rate for Payer: Blue Shield of California EPN |
$1,049.21
|
| Rate for Payer: Cash Price |
$867.91
|
| Rate for Payer: Central Health Plan Commercial |
$1,542.95
|
| Rate for Payer: Cigna of CA HMO |
$1,350.08
|
| Rate for Payer: Cigna of CA PPO |
$1,350.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,639.39
|
| Rate for Payer: Dignity Health Media |
$1,639.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,639.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$771.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$771.48
|
| Rate for Payer: Galaxy Health WC |
$1,639.39
|
| Rate for Payer: Global Benefits Group Commercial |
$1,157.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,735.82
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,446.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$675.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,286.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$734.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$385.74
|
| Rate for Payer: Multiplan Commercial |
$1,446.52
|
| Rate for Payer: Networks By Design Commercial |
$964.34
|
| Rate for Payer: Prime Health Services Commercial |
$1,639.39
|
| Rate for Payer: Riverside University Health System MISP |
$771.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,157.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,157.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$964.34
|
| Rate for Payer: United Healthcare All Other HMO |
$964.34
|
| Rate for Payer: United Healthcare HMO Rider |
$964.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$964.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,639.39
|
| Rate for Payer: Vantage Medical Group Senior |
$1,639.39
|
|
|
HC SEALANT FIBRIN TISSEEL 4ML
|
Facility
|
OP
|
$782.55
|
|
| Hospital Charge Code |
901605213
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$156.51 |
| Max. Negotiated Rate |
$704.30 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$665.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$430.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$430.40
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$357.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$435.88
|
| Rate for Payer: Blue Distinction Transplant |
$469.53
|
| Rate for Payer: Blue Shield of California Commercial |
$586.91
|
| Rate for Payer: Blue Shield of California EPN |
$425.71
|
| Rate for Payer: Cash Price |
$352.15
|
| Rate for Payer: Central Health Plan Commercial |
$626.04
|
| Rate for Payer: Cigna of CA HMO |
$547.78
|
| Rate for Payer: Cigna of CA PPO |
$547.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$665.17
|
| Rate for Payer: Dignity Health Media |
$665.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$665.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$313.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$313.02
|
| Rate for Payer: Galaxy Health WC |
$665.17
|
| Rate for Payer: Global Benefits Group Commercial |
$469.53
|
| Rate for Payer: Health Management Network EPO/PPO |
$704.30
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$586.91
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$273.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$521.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$298.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$156.51
|
| Rate for Payer: Multiplan Commercial |
$586.91
|
| Rate for Payer: Networks By Design Commercial |
$391.28
|
| Rate for Payer: Prime Health Services Commercial |
$665.17
|
| Rate for Payer: Riverside University Health System MISP |
$313.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$469.53
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$469.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$391.28
|
| Rate for Payer: United Healthcare All Other HMO |
$391.28
|
| Rate for Payer: United Healthcare HMO Rider |
$391.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$391.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$665.17
|
| Rate for Payer: Vantage Medical Group Senior |
$665.17
|
|
|
HC SEALANT FIBRIN TISSEEL 4ML
|
Facility
|
IP
|
$782.55
|
|
| Hospital Charge Code |
901605213
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$156.51 |
| Max. Negotiated Rate |
$704.30 |
| Rate for Payer: Blue Shield of California EPN |
$417.88
|
| Rate for Payer: Cash Price |
$352.15
|
| Rate for Payer: Central Health Plan Commercial |
$626.04
|
| Rate for Payer: Cigna of CA HMO |
$547.78
|
| Rate for Payer: Cigna of CA PPO |
$547.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$313.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$313.02
|
| Rate for Payer: Galaxy Health WC |
$665.17
|
| Rate for Payer: Global Benefits Group Commercial |
$469.53
|
| Rate for Payer: Health Management Network EPO/PPO |
$704.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$521.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$298.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$156.51
|
| Rate for Payer: Multiplan Commercial |
$586.91
|
| Rate for Payer: Prime Health Services Commercial |
$665.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$295.49
|
| Rate for Payer: United Healthcare All Other HMO |
$288.60
|
| Rate for Payer: United Healthcare HMO Rider |
$282.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$258.24
|
|
|
HC SEALANT FLOSEAL 10ML PLUS
|
Facility
|
IP
|
$1,701.08
|
|
| Hospital Charge Code |
901698427
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$340.22 |
| Max. Negotiated Rate |
$1,530.97 |
| Rate for Payer: Blue Shield of California EPN |
$908.38
|
| Rate for Payer: Cash Price |
$765.49
|
| Rate for Payer: Central Health Plan Commercial |
$1,360.86
|
| Rate for Payer: Cigna of CA HMO |
$1,190.76
|
| Rate for Payer: Cigna of CA PPO |
$1,190.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$680.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$680.43
|
| Rate for Payer: Galaxy Health WC |
$1,445.92
|
| Rate for Payer: Global Benefits Group Commercial |
$1,020.65
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,530.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,134.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$648.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$340.22
|
| Rate for Payer: Multiplan Commercial |
$1,275.81
|
| Rate for Payer: Prime Health Services Commercial |
$1,445.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$642.33
|
| Rate for Payer: United Healthcare All Other HMO |
$627.36
|
| Rate for Payer: United Healthcare HMO Rider |
$613.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$561.36
|
|
|
HC SEALANT FLOSEAL 10ML PLUS
|
Facility
|
IP
|
$1,158.74
|
|
| Hospital Charge Code |
901607982
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$231.75 |
| Max. Negotiated Rate |
$1,042.87 |
| Rate for Payer: Blue Shield of California EPN |
$618.77
|
| Rate for Payer: Cash Price |
$521.43
|
| Rate for Payer: Central Health Plan Commercial |
$926.99
|
| Rate for Payer: Cigna of CA HMO |
$811.12
|
| Rate for Payer: Cigna of CA PPO |
$811.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$463.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$463.50
|
| Rate for Payer: Galaxy Health WC |
$984.93
|
| Rate for Payer: Global Benefits Group Commercial |
$695.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,042.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$772.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$441.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$231.75
|
| Rate for Payer: Multiplan Commercial |
$869.06
|
| Rate for Payer: Prime Health Services Commercial |
$984.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$437.54
|
| Rate for Payer: United Healthcare All Other HMO |
$427.34
|
| Rate for Payer: United Healthcare HMO Rider |
$418.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$382.38
|
|
|
HC SEALANT FLOSEAL 10ML PLUS
|
Facility
|
OP
|
$1,701.08
|
|
| Hospital Charge Code |
901698427
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$340.22 |
| Max. Negotiated Rate |
$1,530.97 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,445.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$935.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$935.59
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$776.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$947.50
|
| Rate for Payer: Blue Distinction Transplant |
$1,020.65
|
| Rate for Payer: Blue Shield of California Commercial |
$1,275.81
|
| Rate for Payer: Blue Shield of California EPN |
$925.39
|
| Rate for Payer: Cash Price |
$765.49
|
| Rate for Payer: Central Health Plan Commercial |
$1,360.86
|
| Rate for Payer: Cigna of CA HMO |
$1,190.76
|
| Rate for Payer: Cigna of CA PPO |
$1,190.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,445.92
|
| Rate for Payer: Dignity Health Media |
$1,445.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,445.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$680.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$680.43
|
| Rate for Payer: Galaxy Health WC |
$1,445.92
|
| Rate for Payer: Global Benefits Group Commercial |
$1,020.65
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,530.97
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,275.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$595.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,134.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$648.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$340.22
|
| Rate for Payer: Multiplan Commercial |
$1,275.81
|
| Rate for Payer: Networks By Design Commercial |
$850.54
|
| Rate for Payer: Prime Health Services Commercial |
$1,445.92
|
| Rate for Payer: Riverside University Health System MISP |
$680.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,020.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,020.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$850.54
|
| Rate for Payer: United Healthcare All Other HMO |
$850.54
|
| Rate for Payer: United Healthcare HMO Rider |
$850.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$850.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,445.92
|
| Rate for Payer: Vantage Medical Group Senior |
$1,445.92
|
|
|
HC SEALANT FLOSEAL 10ML PLUS
|
Facility
|
OP
|
$1,158.74
|
|
| Hospital Charge Code |
901607982
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$231.75 |
| Max. Negotiated Rate |
$1,042.87 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$984.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$637.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$637.31
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$529.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$645.42
|
| Rate for Payer: Blue Distinction Transplant |
$695.24
|
| Rate for Payer: Blue Shield of California Commercial |
$869.06
|
| Rate for Payer: Blue Shield of California EPN |
$630.35
|
| Rate for Payer: Cash Price |
$521.43
|
| Rate for Payer: Central Health Plan Commercial |
$926.99
|
| Rate for Payer: Cigna of CA HMO |
$811.12
|
| Rate for Payer: Cigna of CA PPO |
$811.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$984.93
|
| Rate for Payer: Dignity Health Media |
$984.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$984.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$463.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$463.50
|
| Rate for Payer: Galaxy Health WC |
$984.93
|
| Rate for Payer: Global Benefits Group Commercial |
$695.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,042.87
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$869.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$405.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$772.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$441.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$231.75
|
| Rate for Payer: Multiplan Commercial |
$869.06
|
| Rate for Payer: Networks By Design Commercial |
$579.37
|
| Rate for Payer: Prime Health Services Commercial |
$984.93
|
| Rate for Payer: Riverside University Health System MISP |
$463.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$695.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$695.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$579.37
|
| Rate for Payer: United Healthcare All Other HMO |
$579.37
|
| Rate for Payer: United Healthcare HMO Rider |
$579.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$579.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$984.93
|
| Rate for Payer: Vantage Medical Group Senior |
$984.93
|
|
|
HC SEALANT FLOSEAL 5ML PLUS
|
Facility
|
OP
|
$670.08
|
|
| Hospital Charge Code |
901607981
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.02 |
| Max. Negotiated Rate |
$603.07 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$569.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$368.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$368.54
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$305.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$373.23
|
| Rate for Payer: Blue Distinction Transplant |
$402.05
|
| Rate for Payer: Blue Shield of California Commercial |
$502.56
|
| Rate for Payer: Blue Shield of California EPN |
$364.52
|
| Rate for Payer: Cash Price |
$301.54
|
| Rate for Payer: Central Health Plan Commercial |
$536.06
|
| Rate for Payer: Cigna of CA HMO |
$469.06
|
| Rate for Payer: Cigna of CA PPO |
$469.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$569.57
|
| Rate for Payer: Dignity Health Media |
$569.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$569.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$268.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$268.03
|
| Rate for Payer: Galaxy Health WC |
$569.57
|
| Rate for Payer: Global Benefits Group Commercial |
$402.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$603.07
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$502.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$234.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$446.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$255.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.02
|
| Rate for Payer: Multiplan Commercial |
$502.56
|
| Rate for Payer: Networks By Design Commercial |
$335.04
|
| Rate for Payer: Prime Health Services Commercial |
$569.57
|
| Rate for Payer: Riverside University Health System MISP |
$268.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$402.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$402.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$335.04
|
| Rate for Payer: United Healthcare All Other HMO |
$335.04
|
| Rate for Payer: United Healthcare HMO Rider |
$335.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$335.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$569.57
|
| Rate for Payer: Vantage Medical Group Senior |
$569.57
|
|
|
HC SEALANT FLOSEAL 5ML PLUS
|
Facility
|
IP
|
$670.08
|
|
| Hospital Charge Code |
901607981
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.02 |
| Max. Negotiated Rate |
$603.07 |
| Rate for Payer: Blue Shield of California EPN |
$357.82
|
| Rate for Payer: Cash Price |
$301.54
|
| Rate for Payer: Central Health Plan Commercial |
$536.06
|
| Rate for Payer: Cigna of CA HMO |
$469.06
|
| Rate for Payer: Cigna of CA PPO |
$469.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$268.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$268.03
|
| Rate for Payer: Galaxy Health WC |
$569.57
|
| Rate for Payer: Global Benefits Group Commercial |
$402.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$603.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$446.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$255.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.02
|
| Rate for Payer: Multiplan Commercial |
$502.56
|
| Rate for Payer: Prime Health Services Commercial |
$569.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$253.02
|
| Rate for Payer: United Healthcare All Other HMO |
$247.13
|
| Rate for Payer: United Healthcare HMO Rider |
$241.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$221.13
|
|
|
HC SEALANT FLOSEAL 5ML PLUS
|
Facility
|
OP
|
$1,064.07
|
|
| Hospital Charge Code |
901698426
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$212.81 |
| Max. Negotiated Rate |
$957.66 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$904.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$585.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$585.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$485.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$592.69
|
| Rate for Payer: Blue Distinction Transplant |
$638.44
|
| Rate for Payer: Blue Shield of California Commercial |
$798.05
|
| Rate for Payer: Blue Shield of California EPN |
$578.85
|
| Rate for Payer: Cash Price |
$478.83
|
| Rate for Payer: Central Health Plan Commercial |
$851.26
|
| Rate for Payer: Cigna of CA HMO |
$744.85
|
| Rate for Payer: Cigna of CA PPO |
$744.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$904.46
|
| Rate for Payer: Dignity Health Media |
$904.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$904.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$425.63
|
| Rate for Payer: EPIC Health Plan Transplant |
$425.63
|
| Rate for Payer: Galaxy Health WC |
$904.46
|
| Rate for Payer: Global Benefits Group Commercial |
$638.44
|
| Rate for Payer: Health Management Network EPO/PPO |
$957.66
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$798.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$372.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$709.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$405.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$212.81
|
| Rate for Payer: Multiplan Commercial |
$798.05
|
| Rate for Payer: Networks By Design Commercial |
$532.04
|
| Rate for Payer: Prime Health Services Commercial |
$904.46
|
| Rate for Payer: Riverside University Health System MISP |
$425.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$638.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$638.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$532.04
|
| Rate for Payer: United Healthcare All Other HMO |
$532.04
|
| Rate for Payer: United Healthcare HMO Rider |
$532.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$532.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$904.46
|
| Rate for Payer: Vantage Medical Group Senior |
$904.46
|
|
|
HC SEALANT FLOSEAL 5ML PLUS
|
Facility
|
IP
|
$1,064.07
|
|
| Hospital Charge Code |
901698426
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$212.81 |
| Max. Negotiated Rate |
$957.66 |
| Rate for Payer: Blue Shield of California EPN |
$568.21
|
| Rate for Payer: Cash Price |
$478.83
|
| Rate for Payer: Central Health Plan Commercial |
$851.26
|
| Rate for Payer: Cigna of CA HMO |
$744.85
|
| Rate for Payer: Cigna of CA PPO |
$744.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$425.63
|
| Rate for Payer: EPIC Health Plan Transplant |
$425.63
|
| Rate for Payer: Galaxy Health WC |
$904.46
|
| Rate for Payer: Global Benefits Group Commercial |
$638.44
|
| Rate for Payer: Health Management Network EPO/PPO |
$957.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$709.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$405.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$212.81
|
| Rate for Payer: Multiplan Commercial |
$798.05
|
| Rate for Payer: Prime Health Services Commercial |
$904.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$401.79
|
| Rate for Payer: United Healthcare All Other HMO |
$392.43
|
| Rate for Payer: United Healthcare HMO Rider |
$383.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$351.14
|
|
|
HC SECONDARY ART M-THROMB ADD-ON
|
Facility
|
OP
|
$12,452.00
|
|
|
Service Code
|
CPT 37186
|
| Hospital Charge Code |
906820199
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$677.65 |
| Max. Negotiated Rate |
$11,206.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,584.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6,848.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6,848.60
|
| 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: Blue Distinction Transplant |
$7,471.20
|
| Rate for Payer: Blue Shield of California Commercial |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Cash Price |
$5,603.40
|
| Rate for Payer: Cash Price |
$5,603.40
|
| Rate for Payer: Central Health Plan Commercial |
$9,961.60
|
| Rate for Payer: Cigna of CA PPO |
$9,214.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,584.20
|
| Rate for Payer: Dignity Health Media |
$10,584.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$10,584.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,980.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,980.80
|
| Rate for Payer: Galaxy Health WC |
$10,584.20
|
| Rate for Payer: Global Benefits Group Commercial |
$7,471.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$11,206.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$9,339.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$4,358.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8,305.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$677.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,490.40
|
| Rate for Payer: Multiplan Commercial |
$9,339.00
|
| Rate for Payer: Networks By Design Commercial |
$8,093.80
|
| Rate for Payer: Prime Health Services Commercial |
$10,584.20
|
| Rate for Payer: Riverside University Health System MISP |
$4,980.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7,471.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,834.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,517.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,041.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$951.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10,584.20
|
| Rate for Payer: Vantage Medical Group Senior |
$10,584.20
|
|
|
HC SECONDARY ART M-THROMB ADD-ON
|
Facility
|
IP
|
$12,452.00
|
|
|
Service Code
|
CPT 37186
|
| Hospital Charge Code |
906820199
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,490.40 |
| Max. Negotiated Rate |
$11,206.80 |
| Rate for Payer: Cash Price |
$5,603.40
|
| Rate for Payer: Central Health Plan Commercial |
$9,961.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,980.80
|
| Rate for Payer: Galaxy Health WC |
$10,584.20
|
| Rate for Payer: Global Benefits Group Commercial |
$7,471.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$11,206.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8,305.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,744.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,490.40
|
| Rate for Payer: Multiplan Commercial |
$9,339.00
|
| Rate for Payer: Networks By Design Commercial |
$8,093.80
|
| Rate for Payer: Prime Health Services Commercial |
$10,584.20
|
|
|
HC SECONDARY ART M-THROMB ADD-ON
|
Facility
|
OP
|
$12,452.00
|
|
|
Service Code
|
CPT 37186
|
| Hospital Charge Code |
909081845
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$677.65 |
| Max. Negotiated Rate |
$11,206.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,584.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6,848.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6,848.60
|
| 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: Blue Distinction Transplant |
$7,471.20
|
| Rate for Payer: Blue Shield of California Commercial |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Cash Price |
$5,603.40
|
| Rate for Payer: Cash Price |
$5,603.40
|
| Rate for Payer: Central Health Plan Commercial |
$9,961.60
|
| Rate for Payer: Cigna of CA PPO |
$9,214.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,584.20
|
| Rate for Payer: Dignity Health Media |
$10,584.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$10,584.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,980.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,980.80
|
| Rate for Payer: Galaxy Health WC |
$10,584.20
|
| Rate for Payer: Global Benefits Group Commercial |
$7,471.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$11,206.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$9,339.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$4,358.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8,305.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$677.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,490.40
|
| Rate for Payer: Multiplan Commercial |
$9,339.00
|
| Rate for Payer: Networks By Design Commercial |
$8,093.80
|
| Rate for Payer: Prime Health Services Commercial |
$10,584.20
|
| Rate for Payer: Riverside University Health System MISP |
$4,980.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7,471.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,834.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,517.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,041.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$951.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10,584.20
|
| Rate for Payer: Vantage Medical Group Senior |
$10,584.20
|
|
|
HC SECONDARY ART M-THROMB ADD-ON
|
Facility
|
IP
|
$12,452.00
|
|
|
Service Code
|
CPT 37186
|
| Hospital Charge Code |
909081845
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,490.40 |
| Max. Negotiated Rate |
$11,206.80 |
| Rate for Payer: Cash Price |
$5,603.40
|
| Rate for Payer: Central Health Plan Commercial |
$9,961.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,980.80
|
| Rate for Payer: Galaxy Health WC |
$10,584.20
|
| Rate for Payer: Global Benefits Group Commercial |
$7,471.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$11,206.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8,305.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,744.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,490.40
|
| Rate for Payer: Multiplan Commercial |
$9,339.00
|
| Rate for Payer: Networks By Design Commercial |
$8,093.80
|
| Rate for Payer: Prime Health Services Commercial |
$10,584.20
|
|
|
HC SECURPORT IV CATH ADHESIVE
|
Facility
|
IP
|
$42.89
|
|
| Hospital Charge Code |
901698214
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$38.60 |
| Rate for Payer: Cash Price |
$19.30
|
| Rate for Payer: Central Health Plan Commercial |
$34.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.16
|
| Rate for Payer: Galaxy Health WC |
$36.46
|
| Rate for Payer: Global Benefits Group Commercial |
$25.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$38.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.58
|
| Rate for Payer: Multiplan Commercial |
$32.17
|
| Rate for Payer: Networks By Design Commercial |
$27.88
|
| Rate for Payer: Prime Health Services Commercial |
$36.46
|
|
