|
HC DRAIN JP
|
Facility
|
OP
|
$35.09
|
|
| Hospital Charge Code |
909020083
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.35 |
| Max. Negotiated Rate |
$29.83 |
| Rate for Payer: Adventist Health Commercial |
$7.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.55
|
| Rate for Payer: Blue Shield of California Commercial |
$21.40
|
| Rate for Payer: Blue Shield of California EPN |
$17.12
|
| Rate for Payer: Cash Price |
$15.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$29.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.72
|
| Rate for Payer: Heritage Provider Network Senior |
$21.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$16.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$24.56
|
| Rate for Payer: Multiplan Commercial |
$26.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.83
|
| Rate for Payer: Vantage Medical Group Senior |
$29.83
|
|
|
HC DRES & OR DEB OF BURN INT/SUB LG
|
Facility
|
OP
|
$1,298.00
|
|
|
Service Code
|
CPT 16030
|
| Hospital Charge Code |
900501048
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$234.94 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$259.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$802.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$784.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$575.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$522.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$616.55
|
| Rate for Payer: Blue Shield of California EPN |
$490.64
|
| Rate for Payer: Cash Price |
$584.10
|
| Rate for Payer: Cash Price |
$584.10
|
| Rate for Payer: Cash Price |
$584.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$843.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$784.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$575.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$522.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$522.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$878.75
|
| Rate for Payer: Heritage Provider Network Senior |
$878.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$522.85
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$619.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$234.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$601.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$324.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$700.62
|
| Rate for Payer: Multiplan Commercial |
$973.50
|
| Rate for Payer: Multiplan WC |
$808.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$778.80
|
| Rate for Payer: TriValley Medical Group Senior |
$778.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$784.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$575.13
|
| Rate for Payer: Vantage Medical Group Senior |
$522.85
|
|
|
HC DRES & OR DEB OF BURN INT/SUB LG
|
Facility
|
IP
|
$1,298.00
|
|
|
Service Code
|
CPT 16030
|
| Hospital Charge Code |
900501048
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$234.94 |
| Max. Negotiated Rate |
$973.50 |
| Rate for Payer: Adventist Health Commercial |
$259.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$835.91
|
| Rate for Payer: Cash Price |
$584.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$878.75
|
| Rate for Payer: Heritage Provider Network Senior |
$878.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$234.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$324.50
|
| Rate for Payer: Multiplan Commercial |
$973.50
|
|
|
HC DRES & OR DEB OF BURN INT/SUB MED
|
Facility
|
IP
|
$996.00
|
|
|
Service Code
|
CPT 16025
|
| Hospital Charge Code |
900501047
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$180.28 |
| Max. Negotiated Rate |
$747.00 |
| Rate for Payer: Adventist Health Commercial |
$199.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$641.42
|
| Rate for Payer: Cash Price |
$448.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$674.29
|
| Rate for Payer: Heritage Provider Network Senior |
$674.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$180.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$249.00
|
| Rate for Payer: Multiplan Commercial |
$747.00
|
|
|
HC DRES & OR DEB OF BURN INT/SUB MED
|
Facility
|
OP
|
$996.00
|
|
|
Service Code
|
CPT 16025
|
| Hospital Charge Code |
900501047
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$180.28 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$199.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$615.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$387.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$283.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$258.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$473.10
|
| Rate for Payer: Blue Shield of California EPN |
$376.49
|
| Rate for Payer: Cash Price |
$448.20
|
| Rate for Payer: Cash Price |
$448.20
|
| Rate for Payer: Cash Price |
$448.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$647.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$387.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$283.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$258.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$258.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$674.29
|
| Rate for Payer: Heritage Provider Network Senior |
$674.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$258.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$475.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$180.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$296.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$249.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$345.79
|
| Rate for Payer: Multiplan Commercial |
$747.00
|
| Rate for Payer: Multiplan WC |
$402.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$597.60
|
| Rate for Payer: TriValley Medical Group Senior |
$597.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$387.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$283.86
|
| Rate for Payer: Vantage Medical Group Senior |
$258.05
|
|
|
HC DRES & OR DEB OF BURN INT/SUB SMALL
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
CPT 16020
|
| Hospital Charge Code |
900501046
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$135.75 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$150.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$463.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$387.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$283.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$258.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$356.25
|
| Rate for Payer: Blue Shield of California EPN |
$283.50
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$487.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$387.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$283.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$258.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$258.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$507.75
|
| Rate for Payer: Heritage Provider Network Senior |
$507.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$258.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$357.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$135.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$296.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$187.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$345.79
|
| Rate for Payer: Multiplan Commercial |
$562.50
|
| Rate for Payer: Multiplan WC |
$402.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$450.00
|
| Rate for Payer: TriValley Medical Group Senior |
$450.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$387.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$283.86
|
| Rate for Payer: Vantage Medical Group Senior |
$258.05
|
|
|
HC DRES & OR DEB OF BURN INT/SUB SMALL
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
CPT 16020
|
| Hospital Charge Code |
900501046
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$135.75 |
| Max. Negotiated Rate |
$562.50 |
| Rate for Payer: Adventist Health Commercial |
$150.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$483.00
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$507.75
|
| Rate for Payer: Heritage Provider Network Senior |
$507.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$135.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$187.50
|
| Rate for Payer: Multiplan Commercial |
$562.50
|
|
|
HC DRESSING CHANGE UNDER ANESTH
|
Facility
|
OP
|
$555.00
|
|
|
Service Code
|
CPT 15852
|
| Hospital Charge Code |
907201139
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$100.45 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$111.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$342.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,045.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$950.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$263.62
|
| Rate for Payer: Blue Shield of California EPN |
$209.79
|
| Rate for Payer: Cash Price |
$249.75
|
| Rate for Payer: Cash Price |
$249.75
|
| Rate for Payer: Cash Price |
$249.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$360.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,045.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$950.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$950.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$375.74
|
| Rate for Payer: Heritage Provider Network Senior |
$375.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$950.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$264.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$100.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,093.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$138.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,273.76
|
| Rate for Payer: Multiplan Commercial |
$416.25
|
| Rate for Payer: Multiplan WC |
$1,239.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$333.00
|
| Rate for Payer: TriValley Medical Group Senior |
$333.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,045.63
|
| Rate for Payer: Vantage Medical Group Senior |
$950.57
|
|
|
HC DRESSING CHANGE UNDER ANESTH
|
Facility
|
IP
|
$555.00
|
|
|
Service Code
|
CPT 15852
|
| Hospital Charge Code |
907201139
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$100.45 |
| Max. Negotiated Rate |
$416.25 |
| Rate for Payer: Adventist Health Commercial |
$111.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$357.42
|
| Rate for Payer: Cash Price |
$249.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$375.74
|
| Rate for Payer: Heritage Provider Network Senior |
$375.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$100.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$138.75
|
| Rate for Payer: Multiplan Commercial |
$416.25
|
|
|
HC DRIED BLOOD SPOT SCREEN DUKE
|
Facility
|
OP
|
$145.00
|
|
|
Service Code
|
CPT 84311
|
| Hospital Charge Code |
900914678
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$108.75 |
| Rate for Payer: Adventist Health Commercial |
$29.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$89.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$66.41
|
| Rate for Payer: Blue Shield of California Commercial |
$56.28
|
| Rate for Payer: Blue Shield of California EPN |
$45.14
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$94.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.55
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$89.75
|
| Rate for Payer: Heritage Provider Network Senior |
$89.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$69.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.85
|
| Rate for Payer: Multiplan Commercial |
$108.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.10
|
| Rate for Payer: TriValley Medical Group Senior |
$8.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.91
|
| Rate for Payer: Vantage Medical Group Senior |
$8.10
|
|
|
HC DRIED BLOOD SPOT SCREEN DUKE
|
Facility
|
IP
|
$145.00
|
|
|
Service Code
|
CPT 84311
|
| Hospital Charge Code |
900914678
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$108.75 |
| Rate for Payer: Adventist Health Commercial |
$29.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$93.38
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$98.17
|
| Rate for Payer: Heritage Provider Network Senior |
$98.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.25
|
| Rate for Payer: Multiplan Commercial |
$108.75
|
|
|
HC DRILL SKULL FOR IMPLANTATION
|
Facility
|
IP
|
$11,512.00
|
|
|
Service Code
|
CPT 61107
|
| Hospital Charge Code |
900501647
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,083.67 |
| Max. Negotiated Rate |
$8,634.00 |
| Rate for Payer: Adventist Health Commercial |
$2,302.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,413.73
|
| Rate for Payer: Cash Price |
$5,180.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,793.62
|
| Rate for Payer: Heritage Provider Network Senior |
$7,793.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,083.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,878.00
|
| Rate for Payer: Multiplan Commercial |
$8,634.00
|
|
|
HC DRILL SKULL FOR IMPLANTATION
|
Facility
|
OP
|
$11,512.00
|
|
|
Service Code
|
CPT 61107
|
| Hospital Charge Code |
900501647
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,083.67 |
| Max. Negotiated Rate |
$9,785.20 |
| Rate for Payer: Adventist Health Commercial |
$2,302.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,114.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9,785.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6,331.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,634.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,245.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$5,180.40
|
| Rate for Payer: Cash Price |
$5,180.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,482.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,785.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,785.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9,785.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,907.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,125.93
|
| Rate for Payer: Heritage Provider Network Senior |
$7,125.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,491.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,083.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,878.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8,058.40
|
| Rate for Payer: Multiplan Commercial |
$8,634.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,785.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,785.20
|
| Rate for Payer: Vantage Medical Group Senior |
$9,785.20
|
|
|
HC DRSNG CAL AG MELGISORB+ 4X4"
|
Facility
|
IP
|
$15.76
|
|
|
Service Code
|
CPT A6196
|
| Hospital Charge Code |
901698367
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$11.82 |
| Rate for Payer: Adventist Health Commercial |
$3.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.15
|
| Rate for Payer: Cash Price |
$7.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.67
|
| Rate for Payer: Heritage Provider Network Senior |
$10.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.94
|
| Rate for Payer: Multiplan Commercial |
$11.82
|
|
|
HC DRSNG CAL AG MELGISORB+ 4X4"
|
Facility
|
OP
|
$15.76
|
|
|
Service Code
|
CPT A6196
|
| Hospital Charge Code |
901698367
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$13.40 |
| Rate for Payer: Adventist Health Commercial |
$3.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.88
|
| Rate for Payer: Blue Shield of California Commercial |
$9.61
|
| Rate for Payer: Blue Shield of California EPN |
$7.69
|
| Rate for Payer: Cash Price |
$7.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.76
|
| Rate for Payer: Heritage Provider Network Senior |
$9.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11.03
|
| Rate for Payer: Multiplan Commercial |
$11.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.40
|
| Rate for Payer: Vantage Medical Group Senior |
$13.40
|
|
|
HC DRSNG KERECIS OMEGA 3 WOUND 1.75X1.75CM
|
Facility
|
IP
|
$826.00
|
|
|
Service Code
|
CPT Q4158
|
| Hospital Charge Code |
900102212
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$149.51 |
| Max. Negotiated Rate |
$619.50 |
| Rate for Payer: Adventist Health Commercial |
$165.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$531.94
|
| Rate for Payer: Cash Price |
$371.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$379.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$446.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$382.44
|
| Rate for Payer: Heritage Provider Network Senior |
$382.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.50
|
| Rate for Payer: Multiplan Commercial |
$619.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$298.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$273.49
|
|
|
HC DRSNG KERECIS OMEGA 3 WOUND 1.75X1.75CM
|
Facility
|
OP
|
$826.00
|
|
|
Service Code
|
CPT Q4158
|
| Hospital Charge Code |
900102212
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$149.51 |
| Max. Negotiated Rate |
$619.50 |
| Rate for Payer: Adventist Health Commercial |
$165.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$510.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$240.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$176.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$160.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$372.29
|
| Rate for Payer: Blue Shield of California Commercial |
$503.86
|
| Rate for Payer: Blue Shield of California EPN |
$403.09
|
| Rate for Payer: Cash Price |
$371.70
|
| Rate for Payer: Cash Price |
$371.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$379.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$240.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$176.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$160.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$528.64
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$382.44
|
| Rate for Payer: Heritage Provider Network Senior |
$382.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$394.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.48
|
| Rate for Payer: Multiplan Commercial |
$619.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$330.40
|
| Rate for Payer: TriValley Medical Group Senior |
$330.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$298.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$273.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$240.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$176.07
|
| Rate for Payer: Vantage Medical Group Senior |
$160.06
|
|
|
HC DRSNG KERECIS OMEGA 3 WOUND 3 X 3.5CM
|
Facility
|
OP
|
$332.00
|
|
|
Service Code
|
CPT Q4158
|
| Hospital Charge Code |
900102213
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.09 |
| Max. Negotiated Rate |
$372.29 |
| Rate for Payer: Adventist Health Commercial |
$66.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$205.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$240.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$176.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$160.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$372.29
|
| Rate for Payer: Blue Shield of California Commercial |
$202.52
|
| Rate for Payer: Blue Shield of California EPN |
$162.02
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$152.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$240.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$176.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$160.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$212.48
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$153.72
|
| Rate for Payer: Heritage Provider Network Senior |
$153.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$158.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$60.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.48
|
| Rate for Payer: Multiplan Commercial |
$249.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$132.80
|
| Rate for Payer: TriValley Medical Group Senior |
$132.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$119.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$109.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$240.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$176.07
|
| Rate for Payer: Vantage Medical Group Senior |
$160.06
|
|
|
HC DRSNG KERECIS OMEGA 3 WOUND 3 X 3.5CM
|
Facility
|
IP
|
$332.00
|
|
|
Service Code
|
CPT Q4158
|
| Hospital Charge Code |
900102213
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.09 |
| Max. Negotiated Rate |
$249.00 |
| Rate for Payer: Adventist Health Commercial |
$66.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$213.81
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$152.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$179.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$153.72
|
| Rate for Payer: Heritage Provider Network Senior |
$153.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$60.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.00
|
| Rate for Payer: Multiplan Commercial |
$249.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$119.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$109.93
|
|
|
HC DRSNG KERECIS OMEGA 3 WOUND 3 X 7CM
|
Facility
|
IP
|
$213.00
|
|
|
Service Code
|
CPT Q4158
|
| Hospital Charge Code |
900102214
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.55 |
| Max. Negotiated Rate |
$159.75 |
| Rate for Payer: Adventist Health Commercial |
$42.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$137.17
|
| Rate for Payer: Cash Price |
$95.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$97.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$115.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$98.62
|
| Rate for Payer: Heritage Provider Network Senior |
$98.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$38.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.25
|
| Rate for Payer: Multiplan Commercial |
$159.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$76.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$70.52
|
|
|
HC DRSNG KERECIS OMEGA 3 WOUND 3 X 7CM
|
Facility
|
OP
|
$213.00
|
|
|
Service Code
|
CPT Q4158
|
| Hospital Charge Code |
900102214
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.55 |
| Max. Negotiated Rate |
$372.29 |
| Rate for Payer: Adventist Health Commercial |
$42.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$131.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$240.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$176.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$160.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$372.29
|
| Rate for Payer: Blue Shield of California Commercial |
$129.93
|
| Rate for Payer: Blue Shield of California EPN |
$103.94
|
| Rate for Payer: Cash Price |
$95.85
|
| Rate for Payer: Cash Price |
$95.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$97.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$240.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$176.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$160.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$136.32
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$98.62
|
| Rate for Payer: Heritage Provider Network Senior |
$98.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$101.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$38.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.48
|
| Rate for Payer: Multiplan Commercial |
$159.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$85.20
|
| Rate for Payer: TriValley Medical Group Senior |
$85.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$76.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$70.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$240.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$176.07
|
| Rate for Payer: Vantage Medical Group Senior |
$160.06
|
|
|
HC DRSNG KERECIS OMEGA 3X3.5CM FENESTRATED
|
Facility
|
IP
|
$429.00
|
|
|
Service Code
|
CPT Q4158
|
| Hospital Charge Code |
900103302
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.65 |
| Max. Negotiated Rate |
$321.75 |
| Rate for Payer: Adventist Health Commercial |
$85.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$276.28
|
| Rate for Payer: Cash Price |
$193.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$197.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$231.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$198.63
|
| Rate for Payer: Heritage Provider Network Senior |
$198.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$77.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.25
|
| Rate for Payer: Multiplan Commercial |
$321.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$155.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$142.04
|
|
|
HC DRSNG KERECIS OMEGA 3X3.5CM FENESTRATED
|
Facility
|
OP
|
$429.00
|
|
|
Service Code
|
CPT Q4158
|
| Hospital Charge Code |
900103302
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.65 |
| Max. Negotiated Rate |
$372.29 |
| Rate for Payer: Adventist Health Commercial |
$85.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$265.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$240.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$176.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$160.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$372.29
|
| Rate for Payer: Blue Shield of California Commercial |
$261.69
|
| Rate for Payer: Blue Shield of California EPN |
$209.35
|
| Rate for Payer: Cash Price |
$193.05
|
| Rate for Payer: Cash Price |
$193.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$197.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$240.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$176.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$160.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$274.56
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$198.63
|
| Rate for Payer: Heritage Provider Network Senior |
$198.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$204.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$77.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.48
|
| Rate for Payer: Multiplan Commercial |
$321.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$171.60
|
| Rate for Payer: TriValley Medical Group Senior |
$171.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$155.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$142.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$240.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$176.07
|
| Rate for Payer: Vantage Medical Group Senior |
$160.06
|
|
|
HC DRSNG OPTIFOAM AG 4X4" NO BRDR
|
Facility
|
IP
|
$50.08
|
|
|
Service Code
|
CPT A6209
|
| Hospital Charge Code |
901698381
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.06 |
| Max. Negotiated Rate |
$37.56 |
| Rate for Payer: Adventist Health Commercial |
$10.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.25
|
| Rate for Payer: Cash Price |
$22.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.90
|
| Rate for Payer: Heritage Provider Network Senior |
$33.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.52
|
| Rate for Payer: Multiplan Commercial |
$37.56
|
|
|
HC DRSNG OPTIFOAM AG 4X4" NO BRDR
|
Facility
|
OP
|
$50.08
|
|
|
Service Code
|
CPT A6209
|
| Hospital Charge Code |
901698381
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.06 |
| Max. Negotiated Rate |
$42.57 |
| Rate for Payer: Adventist Health Commercial |
$10.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$25.05
|
| Rate for Payer: Blue Shield of California Commercial |
$30.55
|
| Rate for Payer: Blue Shield of California EPN |
$24.44
|
| Rate for Payer: Cash Price |
$22.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$42.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.00
|
| Rate for Payer: Heritage Provider Network Senior |
$31.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$23.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$35.06
|
| Rate for Payer: Multiplan Commercial |
$37.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$25.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$25.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.57
|
| Rate for Payer: Vantage Medical Group Senior |
$42.57
|
|
