|
04753D1
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04753D1
|
| Hospital Charge Code |
4163
|
| 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
|
|
|
04753D6
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04753D6
|
| Hospital Charge Code |
4164
|
| 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
|
|
|
04753DZ
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04753DZ
|
| Hospital Charge Code |
4165
|
| 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
|
|
|
04753EZ
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04753EZ
|
| Hospital Charge Code |
4166
|
| 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
|
|
|
04753FZ
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04753FZ
|
| Hospital Charge Code |
4167
|
| 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
|
|
|
04753GZ
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04753GZ
|
| Hospital Charge Code |
4168
|
| 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
|
|
|
0475441
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 0475441
|
| Hospital Charge Code |
2027
|
| 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
|
|
|
047544Z
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 047544Z
|
| Hospital Charge Code |
2028
|
| 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
|
|
|
047545Z
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 047545Z
|
| Hospital Charge Code |
2029
|
| 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
|
|
|
047546Z
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 047546Z
|
| Hospital Charge Code |
2030
|
| 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
|
|
|
047547Z
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 047547Z
|
| Hospital Charge Code |
2031
|
| 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
|
|
|
04754D1
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04754D1
|
| Hospital Charge Code |
4169
|
| 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
|
|
|
04754D6
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04754D6
|
| Hospital Charge Code |
4170
|
| 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
|
|
|
04754DZ
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04754DZ
|
| Hospital Charge Code |
4171
|
| 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
|
|
|
04754EZ
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04754EZ
|
| Hospital Charge Code |
4172
|
| 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
|
|
|
04754FZ
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04754FZ
|
| Hospital Charge Code |
4173
|
| 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
|
|
|
04754GZ
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04754GZ
|
| Hospital Charge Code |
4174
|
| 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
|
|
|
0476041
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 0476041
|
| Hospital Charge Code |
2032
|
| 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
|
|
|
047604Z
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 047604Z
|
| Hospital Charge Code |
2033
|
| 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
|
|
|
047605Z
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 047605Z
|
| Hospital Charge Code |
2034
|
| 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
|
|
|
047606Z
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 047606Z
|
| Hospital Charge Code |
2035
|
| 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
|
|
|
047607Z
|
Facility
|
IP
|
$8,623.00
|
|
|
Service Code
|
ICD 047607Z
|
| Hospital Charge Code |
2036
|
| 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
|
|
|
04760D1
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04760D1
|
| Hospital Charge Code |
4175
|
| 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
|
|
|
04760D6
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04760D6
|
| Hospital Charge Code |
4176
|
| 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
|
|
|
04760DZ
|
Facility
|
IP
|
$3,913.00
|
|
|
Service Code
|
ICD 04760DZ
|
| Hospital Charge Code |
4177
|
| 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
|
|
