|
04734GZ
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04734GZ
|
| Hospital Charge Code |
4138
|
| Min. Negotiated Rate |
$3,913.00 |
| Max. Negotiated Rate |
$3,913.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,913.00
|
|
|
0474041
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 0474041
|
| Hospital Charge Code |
2002
|
| Min. Negotiated Rate |
$8,623.00 |
| Max. Negotiated Rate |
$8,623.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,623.00
|
|
|
047404Z
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 047404Z
|
| Hospital Charge Code |
2003
|
| Min. Negotiated Rate |
$8,623.00 |
| Max. Negotiated Rate |
$8,623.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,623.00
|
|
|
047405Z
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 047405Z
|
| Hospital Charge Code |
2004
|
| Min. Negotiated Rate |
$8,623.00 |
| Max. Negotiated Rate |
$8,623.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,623.00
|
|
|
047406Z
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 047406Z
|
| Hospital Charge Code |
2005
|
| Min. Negotiated Rate |
$8,623.00 |
| Max. Negotiated Rate |
$8,623.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,623.00
|
|
|
047407Z
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 047407Z
|
| Hospital Charge Code |
2006
|
| Min. Negotiated Rate |
$8,623.00 |
| Max. Negotiated Rate |
$8,623.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,623.00
|
|
|
04740D1
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04740D1
|
| Hospital Charge Code |
4139
|
| Min. Negotiated Rate |
$3,913.00 |
| Max. Negotiated Rate |
$3,913.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,913.00
|
|
|
04740D6
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04740D6
|
| Hospital Charge Code |
4140
|
| Min. Negotiated Rate |
$3,913.00 |
| Max. Negotiated Rate |
$3,913.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,913.00
|
|
|
04740DZ
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04740DZ
|
| Hospital Charge Code |
4141
|
| Min. Negotiated Rate |
$3,913.00 |
| Max. Negotiated Rate |
$3,913.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,913.00
|
|
|
04740EZ
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04740EZ
|
| Hospital Charge Code |
4142
|
| Min. Negotiated Rate |
$3,913.00 |
| Max. Negotiated Rate |
$3,913.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,913.00
|
|
|
04740FZ
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04740FZ
|
| Hospital Charge Code |
4143
|
| Min. Negotiated Rate |
$3,913.00 |
| Max. Negotiated Rate |
$3,913.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,913.00
|
|
|
04740GZ
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04740GZ
|
| Hospital Charge Code |
4144
|
| Min. Negotiated Rate |
$3,913.00 |
| Max. Negotiated Rate |
$3,913.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,913.00
|
|
|
0474341
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 0474341
|
| Hospital Charge Code |
2007
|
| Min. Negotiated Rate |
$8,623.00 |
| Max. Negotiated Rate |
$8,623.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,623.00
|
|
|
047434Z
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 047434Z
|
| Hospital Charge Code |
2008
|
| Min. Negotiated Rate |
$8,623.00 |
| Max. Negotiated Rate |
$8,623.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,623.00
|
|
|
047435Z
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 047435Z
|
| Hospital Charge Code |
2009
|
| Min. Negotiated Rate |
$8,623.00 |
| Max. Negotiated Rate |
$8,623.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,623.00
|
|
|
047436Z
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 047436Z
|
| Hospital Charge Code |
2010
|
| Min. Negotiated Rate |
$8,623.00 |
| Max. Negotiated Rate |
$8,623.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,623.00
|
|
|
047437Z
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 047437Z
|
| Hospital Charge Code |
2011
|
| Min. Negotiated Rate |
$8,623.00 |
| Max. Negotiated Rate |
$8,623.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,623.00
|
|
|
04743D1
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04743D1
|
| Hospital Charge Code |
4145
|
| Min. Negotiated Rate |
$3,913.00 |
| Max. Negotiated Rate |
$3,913.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,913.00
|
|
|
04743D6
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04743D6
|
| Hospital Charge Code |
4146
|
| Min. Negotiated Rate |
$3,913.00 |
| Max. Negotiated Rate |
$3,913.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,913.00
|
|
|
04743DZ
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04743DZ
|
| Hospital Charge Code |
4147
|
| Min. Negotiated Rate |
$3,913.00 |
| Max. Negotiated Rate |
$3,913.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,913.00
|
|
|
04743EZ
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04743EZ
|
| Hospital Charge Code |
4148
|
| Min. Negotiated Rate |
$3,913.00 |
| Max. Negotiated Rate |
$3,913.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,913.00
|
|
|
04743FZ
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04743FZ
|
| Hospital Charge Code |
4149
|
| Min. Negotiated Rate |
$3,913.00 |
| Max. Negotiated Rate |
$3,913.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,913.00
|
|
|
04743GZ
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04743GZ
|
| Hospital Charge Code |
4150
|
| Min. Negotiated Rate |
$3,913.00 |
| Max. Negotiated Rate |
$3,913.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,913.00
|
|
|
0474441
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 0474441
|
| Hospital Charge Code |
2012
|
| Min. Negotiated Rate |
$8,623.00 |
| Max. Negotiated Rate |
$8,623.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,623.00
|
|
|
047444Z
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 047444Z
|
| Hospital Charge Code |
2013
|
| Min. Negotiated Rate |
$8,623.00 |
| Max. Negotiated Rate |
$8,623.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,623.00
|
|
