|
HC IMPLANTABLE PORT FOR MEDS
|
Facility
OP
|
$1,620.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
909081100
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$324.00 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$324.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$777.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,112.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,377.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$891.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,215.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,006.02
|
| Rate for Payer: Blue Shield of California EPN |
$950.94
|
| Rate for Payer: Cash Price |
$729.00
|
| Rate for Payer: Cash Price |
$729.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$745.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,377.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,377.00
|
| Rate for Payer: Dignity Health Senior |
$1,377.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,036.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$750.06
|
| Rate for Payer: Heritage Provider Network Senior |
$750.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$810.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$810.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$810.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$405.00
|
| Rate for Payer: Multiplan Commercial |
$1,215.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$590.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$541.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,377.00
|
| Rate for Payer: Vantage Medical Group Senior |
$1,377.00
|
|
|
HC IMPLANTED PERIONEAL PORT
|
Facility
IP
|
$21,819.00
|
|
|
Service Code
|
CPT 49419
|
| Hospital Charge Code |
909001457
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$3,949.24 |
| Max. Negotiated Rate |
$16,364.25 |
| Rate for Payer: Adventist Health Commercial |
$4,363.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14,989.65
|
| Rate for Payer: Cash Price |
$9,818.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$14,771.46
|
| Rate for Payer: Heritage Provider Network Senior |
$14,771.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,949.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,454.75
|
| Rate for Payer: Multiplan Commercial |
$16,364.25
|
|
|
HC IMPLANTED PERIONEAL PORT
|
Facility
OP
|
$21,819.00
|
|
|
Service Code
|
CPT 49419
|
| Hospital Charge Code |
909001457
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$331.27 |
| Max. Negotiated Rate |
$16,364.25 |
| Rate for Payer: Adventist Health Commercial |
$4,363.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14,989.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,299.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,552.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,866.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Blue Shield of California Commercial |
$14,131.19
|
| Rate for Payer: Blue Shield of California EPN |
$12,145.11
|
| Rate for Payer: Cash Price |
$9,818.55
|
| Rate for Payer: Cash Price |
$9,818.55
|
| Rate for Payer: Cash Price |
$9,818.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14,182.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,299.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,552.68
|
| Rate for Payer: Dignity Health Senior |
$6,866.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,866.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$13,505.96
|
| Rate for Payer: Heritage Provider Network Senior |
$8,445.27
|
| Rate for Payer: Humana Medicare |
$6,866.07
|
| Rate for Payer: IEHP Medi-Cal |
$331.27
|
| Rate for Payer: IEHP Medicare Advantage |
$6,866.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,045.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,949.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,101.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,454.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,651.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,651.25
|
| Rate for Payer: Multiplan Commercial |
$16,364.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,552.68
|
| Rate for Payer: TriValley Medical Group Senior |
$7,552.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13,479.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11,381.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,299.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,552.68
|
| Rate for Payer: Vantage Medical Group Senior |
$6,866.07
|
|
|
HC IMPL DRESSING WOUND 5X7CM OASIS ULTRA
|
Facility
OP
|
$90.00
|
|
|
Service Code
|
CPT Q4124
|
| Hospital Charge Code |
900101468
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.29 |
| Max. Negotiated Rate |
$76.50 |
| Rate for Payer: Adventist Health Commercial |
$18.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$61.83
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$76.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$49.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$67.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.29
|
| Rate for Payer: Blue Shield of California Commercial |
$55.89
|
| Rate for Payer: Blue Shield of California EPN |
$52.83
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$41.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$76.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$76.50
|
| Rate for Payer: Dignity Health Senior |
$76.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.67
|
| Rate for Payer: Heritage Provider Network Senior |
$41.67
|
| Rate for Payer: IEHP Medi-Cal |
$14.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$43.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.50
|
| Rate for Payer: Multiplan Commercial |
$67.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$32.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$30.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$76.50
|
| Rate for Payer: Vantage Medical Group Senior |
$76.50
|
|
|
HC IMPL DRESSING WOUND 5X7CM OASIS ULTRA
|
Facility
IP
|
$90.00
|
|
|
Service Code
|
CPT Q4124
|
| Hospital Charge Code |
900101468
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.29 |
| Max. Negotiated Rate |
$67.50 |
| Rate for Payer: Adventist Health Commercial |
$18.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$61.83
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$41.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.93
|
| Rate for Payer: Heritage Provider Network Senior |
$60.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.50
|
| Rate for Payer: Multiplan Commercial |
$67.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$32.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$30.07
|
|
|
HC IMPL DRSNG OASIS WND MATRIX 3X3.5CM
|
Facility
OP
|
$70.00
|
|
|
Service Code
|
CPT Q4102
|
| Hospital Charge Code |
900101458
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.23 |
| Max. Negotiated Rate |
$59.50 |
| Rate for Payer: Adventist Health Commercial |
$14.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$32.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$48.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$59.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$38.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$52.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.23
|
| Rate for Payer: Blue Shield of California Commercial |
$43.47
|
| Rate for Payer: Blue Shield of California EPN |
$41.09
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$59.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$59.50
|
| Rate for Payer: Dignity Health Senior |
$59.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.41
|
| Rate for Payer: Heritage Provider Network Senior |
$32.41
|
| Rate for Payer: IEHP Medi-Cal |
$15.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$33.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.50
|
| Rate for Payer: Multiplan Commercial |
$52.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$25.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$59.50
|
| Rate for Payer: Vantage Medical Group Senior |
$59.50
|
|
|
HC IMPL DRSNG OASIS WND MATRIX 3X3.5CM
|
Facility
IP
|
$70.00
|
|
|
Service Code
|
CPT Q4102
|
| Hospital Charge Code |
900101458
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.67 |
| Max. Negotiated Rate |
$52.50 |
| Rate for Payer: Adventist Health Commercial |
$14.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$48.09
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$47.39
|
| Rate for Payer: Heritage Provider Network Senior |
$47.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.50
|
| Rate for Payer: Multiplan Commercial |
$52.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$25.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.39
|
|
|
HC IMPL DRSNG OASIS WND MATRIX 3X7CM
|
Facility
OP
|
$74.00
|
|
|
Service Code
|
CPT Q4102
|
| Hospital Charge Code |
900101459
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.23 |
| Max. Negotiated Rate |
$62.90 |
| Rate for Payer: Adventist Health Commercial |
$14.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$32.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$50.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$62.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$40.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$55.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.23
|
| Rate for Payer: Blue Shield of California Commercial |
$45.95
|
| Rate for Payer: Blue Shield of California EPN |
$43.44
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$34.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$62.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$62.90
|
| Rate for Payer: Dignity Health Senior |
$62.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.26
|
| Rate for Payer: Heritage Provider Network Senior |
$34.26
|
| Rate for Payer: IEHP Medi-Cal |
$15.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$35.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.50
|
| Rate for Payer: Multiplan Commercial |
$55.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$62.90
|
| Rate for Payer: Vantage Medical Group Senior |
$62.90
|
|
|
HC IMPL DRSNG OASIS WND MATRIX 3X7CM
|
Facility
IP
|
$74.00
|
|
|
Service Code
|
CPT Q4102
|
| Hospital Charge Code |
900101459
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.39 |
| Max. Negotiated Rate |
$55.50 |
| Rate for Payer: Adventist Health Commercial |
$14.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$50.84
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$34.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.10
|
| Rate for Payer: Heritage Provider Network Senior |
$50.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.50
|
| Rate for Payer: Multiplan Commercial |
$55.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.72
|
|
|
HC IMPL GORE SEPTAL OCCL DEVICE
|
Facility
IP
|
$13,780.00
|
|
|
Service Code
|
CPT C1817
|
| Hospital Charge Code |
906812357
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,756.00 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$2,756.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6,614.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9,466.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$6,201.00
|
| Rate for Payer: Cash Price |
$6,201.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6,338.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,441.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$9,329.06
|
| Rate for Payer: Heritage Provider Network Senior |
$9,329.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6,890.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6,890.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6,890.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,445.00
|
| Rate for Payer: Multiplan Commercial |
$10,335.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5,024.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4,603.90
|
|
|
HC IMPL GORE SEPTAL OCCL DEVICE
|
Facility
OP
|
$13,780.00
|
|
|
Service Code
|
CPT C1817
|
| Hospital Charge Code |
906812357
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,756.00 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$2,756.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6,614.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9,466.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11,713.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,579.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,557.38
|
| Rate for Payer: Blue Shield of California EPN |
$8,088.86
|
| Rate for Payer: Cash Price |
$6,201.00
|
| Rate for Payer: Cash Price |
$6,201.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6,338.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11,713.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$11,713.00
|
| Rate for Payer: Dignity Health Senior |
$11,713.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,819.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,380.14
|
| Rate for Payer: Heritage Provider Network Senior |
$6,380.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6,890.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6,890.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6,890.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,445.00
|
| Rate for Payer: Multiplan Commercial |
$10,335.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5,024.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4,603.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11,713.00
|
| Rate for Payer: Vantage Medical Group Senior |
$11,713.00
|
|
|
HC IMPL GRAFIX CORE 2 X 3 CM 6 UNITS
|
Facility
OP
|
$678.00
|
|
|
Service Code
|
CPT Q4132
|
| Hospital Charge Code |
900101532
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$122.72 |
| Max. Negotiated Rate |
$576.30 |
| Rate for Payer: Adventist Health Commercial |
$135.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$388.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$465.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$576.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$372.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$508.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$314.29
|
| Rate for Payer: Blue Shield of California Commercial |
$421.04
|
| Rate for Payer: Blue Shield of California EPN |
$397.99
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$311.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$576.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$576.30
|
| Rate for Payer: Dignity Health Senior |
$576.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$433.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$313.91
|
| Rate for Payer: Heritage Provider Network Senior |
$313.91
|
| Rate for Payer: IEHP Medi-Cal |
$205.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$326.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$122.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$169.50
|
| Rate for Payer: Multiplan Commercial |
$508.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$247.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$226.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$576.30
|
| Rate for Payer: Vantage Medical Group Senior |
$576.30
|
|
|
HC IMPL GRAFIX CORE 2 X 3 CM 6 UNITS
|
Facility
IP
|
$678.00
|
|
|
Service Code
|
CPT Q4132
|
| Hospital Charge Code |
900101532
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$122.72 |
| Max. Negotiated Rate |
$508.50 |
| Rate for Payer: Adventist Health Commercial |
$135.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$465.79
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$311.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$366.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$459.01
|
| Rate for Payer: Heritage Provider Network Senior |
$459.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$122.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$169.50
|
| Rate for Payer: Multiplan Commercial |
$508.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$247.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$226.52
|
|
|
HC IMPL GRAFIX PRIME 2 X 3 CM 6 UNITS
|
Facility
OP
|
$339.00
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
900101533
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.36 |
| Max. Negotiated Rate |
$334.90 |
| Rate for Payer: Adventist Health Commercial |
$67.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$334.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$232.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$288.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$186.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$254.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$314.29
|
| Rate for Payer: Blue Shield of California Commercial |
$210.52
|
| Rate for Payer: Blue Shield of California EPN |
$198.99
|
| Rate for Payer: Cash Price |
$152.55
|
| Rate for Payer: Cash Price |
$152.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$155.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$288.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$288.15
|
| Rate for Payer: Dignity Health Senior |
$288.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$216.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$156.96
|
| Rate for Payer: Heritage Provider Network Senior |
$156.96
|
| Rate for Payer: IEHP Medi-Cal |
$209.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$163.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.75
|
| Rate for Payer: Multiplan Commercial |
$254.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$123.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$113.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$288.15
|
| Rate for Payer: Vantage Medical Group Senior |
$288.15
|
|
|
HC IMPL GRAFIX PRIME 2 X 3 CM 6 UNITS
|
Facility
IP
|
$339.00
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
900101533
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.36 |
| Max. Negotiated Rate |
$254.25 |
| Rate for Payer: Adventist Health Commercial |
$67.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$232.89
|
| Rate for Payer: Cash Price |
$152.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$155.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$183.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$229.50
|
| Rate for Payer: Heritage Provider Network Senior |
$229.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.75
|
| Rate for Payer: Multiplan Commercial |
$254.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$123.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$113.26
|
|
|
HC IMPL GRAFT DERMAGRAFT 5CM X 7.5CM
|
Facility
IP
|
$133.00
|
|
|
Service Code
|
CPT Q4106
|
| Hospital Charge Code |
900101460
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.07 |
| Max. Negotiated Rate |
$99.75 |
| Rate for Payer: Adventist Health Commercial |
$26.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$91.37
|
| Rate for Payer: Cash Price |
$59.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$61.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$90.04
|
| Rate for Payer: Heritage Provider Network Senior |
$90.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.25
|
| Rate for Payer: Multiplan Commercial |
$99.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$48.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$44.44
|
|
|
HC IMPL GRAFT DERMAGRAFT 5CM X 7.5CM
|
Facility
OP
|
$133.00
|
|
|
Service Code
|
CPT Q4106
|
| Hospital Charge Code |
900101460
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.07 |
| Max. Negotiated Rate |
$113.05 |
| Rate for Payer: Adventist Health Commercial |
$26.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$110.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$91.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$113.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$73.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$99.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$76.05
|
| Rate for Payer: Blue Shield of California Commercial |
$82.59
|
| Rate for Payer: Blue Shield of California EPN |
$78.07
|
| Rate for Payer: Cash Price |
$59.85
|
| Rate for Payer: Cash Price |
$59.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$61.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$113.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$113.05
|
| Rate for Payer: Dignity Health Senior |
$113.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$61.58
|
| Rate for Payer: Heritage Provider Network Senior |
$61.58
|
| Rate for Payer: IEHP Medi-Cal |
$25.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$64.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.25
|
| Rate for Payer: Multiplan Commercial |
$99.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$48.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$44.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$113.05
|
| Rate for Payer: Vantage Medical Group Senior |
$113.05
|
|
|
HC IMPL GRAFT EPIFIX 14MM DISK
|
Facility
OP
|
$829.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101524
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$150.05 |
| Max. Negotiated Rate |
$704.65 |
| Rate for Payer: Adventist Health Commercial |
$165.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$372.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$569.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$704.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$455.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$621.75
|
| Rate for Payer: Blue Shield of California Commercial |
$514.81
|
| Rate for Payer: Blue Shield of California EPN |
$486.62
|
| Rate for Payer: Cash Price |
$373.05
|
| Rate for Payer: Cash Price |
$373.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$381.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$704.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$704.65
|
| Rate for Payer: Dignity Health Senior |
$704.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$530.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$383.83
|
| Rate for Payer: Heritage Provider Network Senior |
$383.83
|
| Rate for Payer: IEHP Medi-Cal |
$239.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$399.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$150.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$207.25
|
| Rate for Payer: Multiplan Commercial |
$621.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$302.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$276.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$704.65
|
| Rate for Payer: Vantage Medical Group Senior |
$704.65
|
|
|
HC IMPL GRAFT EPIFIX 14MM DISK
|
Facility
IP
|
$829.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101524
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$150.05 |
| Max. Negotiated Rate |
$621.75 |
| Rate for Payer: Adventist Health Commercial |
$165.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$569.52
|
| Rate for Payer: Cash Price |
$373.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$381.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$447.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$561.23
|
| Rate for Payer: Heritage Provider Network Senior |
$561.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$150.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$207.25
|
| Rate for Payer: Multiplan Commercial |
$621.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$302.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$276.97
|
|
|
HC IMPL GRAFT EPIFIX 18MM DISK
|
Facility
IP
|
$814.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101525
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$147.33 |
| Max. Negotiated Rate |
$610.50 |
| Rate for Payer: Adventist Health Commercial |
$162.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$559.22
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$374.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$439.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$551.08
|
| Rate for Payer: Heritage Provider Network Senior |
$551.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$147.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$203.50
|
| Rate for Payer: Multiplan Commercial |
$610.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$296.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$271.96
|
|
|
HC IMPL GRAFT EPIFIX 18MM DISK
|
Facility
OP
|
$814.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101525
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$147.33 |
| Max. Negotiated Rate |
$691.90 |
| Rate for Payer: Adventist Health Commercial |
$162.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$372.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$559.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$691.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$447.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$610.50
|
| Rate for Payer: Blue Shield of California Commercial |
$505.49
|
| Rate for Payer: Blue Shield of California EPN |
$477.82
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$374.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$691.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$691.90
|
| Rate for Payer: Dignity Health Senior |
$691.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$520.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$376.88
|
| Rate for Payer: Heritage Provider Network Senior |
$376.88
|
| Rate for Payer: IEHP Medi-Cal |
$239.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$392.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$147.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$203.50
|
| Rate for Payer: Multiplan Commercial |
$610.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$296.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$271.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$691.90
|
| Rate for Payer: Vantage Medical Group Senior |
$691.90
|
|
|
HC IMPL GRAFT EPIFIX 2X2 CM
|
Facility
IP
|
$985.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101526
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$178.28 |
| Max. Negotiated Rate |
$738.75 |
| Rate for Payer: Adventist Health Commercial |
$197.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$676.70
|
| Rate for Payer: Cash Price |
$443.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$453.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$531.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$666.84
|
| Rate for Payer: Heritage Provider Network Senior |
$666.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$178.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$246.25
|
| Rate for Payer: Multiplan Commercial |
$738.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$359.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$329.09
|
|
|
HC IMPL GRAFT EPIFIX 2X2 CM
|
Facility
OP
|
$985.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101526
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$178.28 |
| Max. Negotiated Rate |
$837.25 |
| Rate for Payer: Adventist Health Commercial |
$197.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$372.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$676.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$837.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$541.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$738.75
|
| Rate for Payer: Blue Shield of California Commercial |
$611.68
|
| Rate for Payer: Blue Shield of California EPN |
$578.20
|
| Rate for Payer: Cash Price |
$443.25
|
| Rate for Payer: Cash Price |
$443.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$453.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$837.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$837.25
|
| Rate for Payer: Dignity Health Senior |
$837.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$630.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$456.06
|
| Rate for Payer: Heritage Provider Network Senior |
$456.06
|
| Rate for Payer: IEHP Medi-Cal |
$239.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$474.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$178.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$246.25
|
| Rate for Payer: Multiplan Commercial |
$738.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$359.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$329.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$837.25
|
| Rate for Payer: Vantage Medical Group Senior |
$837.25
|
|
|
HC IMPL GRAFT EPIFIX 2X4 CM
|
Facility
IP
|
$624.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101529
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$112.94 |
| Max. Negotiated Rate |
$468.00 |
| Rate for Payer: Adventist Health Commercial |
$124.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$428.69
|
| Rate for Payer: Cash Price |
$280.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$287.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$336.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$422.45
|
| Rate for Payer: Heritage Provider Network Senior |
$422.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$112.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$156.00
|
| Rate for Payer: Multiplan Commercial |
$468.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$227.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$208.48
|
|
|
HC IMPL GRAFT EPIFIX 2X4 CM
|
Facility
OP
|
$624.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101529
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$112.94 |
| Max. Negotiated Rate |
$530.40 |
| Rate for Payer: Adventist Health Commercial |
$124.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$372.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$428.69
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$530.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$343.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$468.00
|
| Rate for Payer: Blue Shield of California Commercial |
$387.50
|
| Rate for Payer: Blue Shield of California EPN |
$366.29
|
| Rate for Payer: Cash Price |
$280.80
|
| Rate for Payer: Cash Price |
$280.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$287.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$530.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$530.40
|
| Rate for Payer: Dignity Health Senior |
$530.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$399.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$288.91
|
| Rate for Payer: Heritage Provider Network Senior |
$288.91
|
| Rate for Payer: IEHP Medi-Cal |
$239.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$300.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$112.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$156.00
|
| Rate for Payer: Multiplan Commercial |
$468.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$227.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$208.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$530.40
|
| Rate for Payer: Vantage Medical Group Senior |
$530.40
|
|
