|
HC IMPL GRAFT EPIFIX 3X4 CM
|
Facility
IP
|
$734.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101527
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$132.85 |
| Max. Negotiated Rate |
$550.50 |
| Rate for Payer: Adventist Health Commercial |
$146.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$504.26
|
| Rate for Payer: Cash Price |
$330.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$337.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$396.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$496.92
|
| Rate for Payer: Heritage Provider Network Senior |
$496.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$132.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$183.50
|
| Rate for Payer: Multiplan Commercial |
$550.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$267.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$245.23
|
|
|
HC IMPL GRAFT EPIFIX 3X4 CM
|
Facility
OP
|
$734.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101527
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$132.85 |
| Max. Negotiated Rate |
$623.90 |
| Rate for Payer: Adventist Health Commercial |
$146.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$372.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$504.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$623.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$403.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$550.50
|
| Rate for Payer: Blue Shield of California Commercial |
$455.81
|
| Rate for Payer: Blue Shield of California EPN |
$430.86
|
| Rate for Payer: Cash Price |
$330.30
|
| Rate for Payer: Cash Price |
$330.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$337.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$623.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$623.90
|
| Rate for Payer: Dignity Health Senior |
$623.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$469.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$339.84
|
| Rate for Payer: Heritage Provider Network Senior |
$339.84
|
| Rate for Payer: IEHP Medi-Cal |
$239.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$353.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$132.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$183.50
|
| Rate for Payer: Multiplan Commercial |
$550.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$267.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$245.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$623.90
|
| Rate for Payer: Vantage Medical Group Senior |
$623.90
|
|
|
HC IMPL GRAFT EPIFIX 4X4.5 CM MESH
|
Facility
IP
|
$814.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101528
|
|
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 4X4.5 CM MESH
|
Facility
OP
|
$814.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101528
|
|
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 4X4 CM
|
Facility
IP
|
$733.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101530
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$132.67 |
| Max. Negotiated Rate |
$549.75 |
| Rate for Payer: Adventist Health Commercial |
$146.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$503.57
|
| Rate for Payer: Cash Price |
$329.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$337.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$395.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$496.24
|
| Rate for Payer: Heritage Provider Network Senior |
$496.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$132.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$183.25
|
| Rate for Payer: Multiplan Commercial |
$549.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$267.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$244.90
|
|
|
HC IMPL GRAFT EPIFIX 4X4 CM
|
Facility
OP
|
$733.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101530
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$132.67 |
| Max. Negotiated Rate |
$623.05 |
| Rate for Payer: Adventist Health Commercial |
$146.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$372.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$503.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$623.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$403.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$549.75
|
| Rate for Payer: Blue Shield of California Commercial |
$455.19
|
| Rate for Payer: Blue Shield of California EPN |
$430.27
|
| Rate for Payer: Cash Price |
$329.85
|
| Rate for Payer: Cash Price |
$329.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$337.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$623.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$623.05
|
| Rate for Payer: Dignity Health Senior |
$623.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$469.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$339.38
|
| Rate for Payer: Heritage Provider Network Senior |
$339.38
|
| Rate for Payer: IEHP Medi-Cal |
$239.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$353.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$132.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$183.25
|
| Rate for Payer: Multiplan Commercial |
$549.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$267.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$244.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$623.05
|
| Rate for Payer: Vantage Medical Group Senior |
$623.05
|
|
|
HC IMPL GRAFT EPIFIX 5X6 CM
|
Facility
IP
|
$740.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101531
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$133.94 |
| Max. Negotiated Rate |
$555.00 |
| Rate for Payer: Adventist Health Commercial |
$148.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$508.38
|
| Rate for Payer: Cash Price |
$333.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$340.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$399.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$500.98
|
| Rate for Payer: Heritage Provider Network Senior |
$500.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$133.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$185.00
|
| Rate for Payer: Multiplan Commercial |
$555.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$269.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$247.23
|
|
|
HC IMPL GRAFT EPIFIX 5X6 CM
|
Facility
OP
|
$740.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101531
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$133.94 |
| Max. Negotiated Rate |
$629.00 |
| Rate for Payer: Adventist Health Commercial |
$148.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$372.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$508.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$629.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$407.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$555.00
|
| Rate for Payer: Blue Shield of California Commercial |
$459.54
|
| Rate for Payer: Blue Shield of California EPN |
$434.38
|
| Rate for Payer: Cash Price |
$333.00
|
| Rate for Payer: Cash Price |
$333.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$340.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$629.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$629.00
|
| Rate for Payer: Dignity Health Senior |
$629.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$473.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$342.62
|
| Rate for Payer: Heritage Provider Network Senior |
$342.62
|
| Rate for Payer: IEHP Medi-Cal |
$239.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$356.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$133.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$185.00
|
| Rate for Payer: Multiplan Commercial |
$555.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$269.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$247.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$629.00
|
| Rate for Payer: Vantage Medical Group Senior |
$629.00
|
|
|
HC IMPL MED REVEAL ACT 6190
|
Facility
OP
|
$456.00
|
|
|
Service Code
|
CPT C1764
|
| Hospital Charge Code |
906813402
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$91.20 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$91.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$218.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$313.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$387.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$250.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$342.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$283.18
|
| Rate for Payer: Blue Shield of California EPN |
$267.67
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$209.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$387.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$387.60
|
| Rate for Payer: Dignity Health Senior |
$387.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$291.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$211.13
|
| Rate for Payer: Heritage Provider Network Senior |
$211.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$228.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$228.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$228.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$114.00
|
| Rate for Payer: Multiplan Commercial |
$342.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$166.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$152.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$387.60
|
| Rate for Payer: Vantage Medical Group Senior |
$387.60
|
|
|
HC IMPL MED REVEAL ACT 6190
|
Facility
IP
|
$456.00
|
|
|
Service Code
|
CPT C1764
|
| Hospital Charge Code |
906813402
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$91.20 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$91.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$218.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$313.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$209.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$246.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$308.71
|
| Rate for Payer: Heritage Provider Network Senior |
$308.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$228.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$228.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$228.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$114.00
|
| Rate for Payer: Multiplan Commercial |
$342.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$166.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$152.35
|
|
|
HC IMPL MED REVEAL DX 9528
|
Facility
IP
|
$9,987.50
|
|
|
Service Code
|
CPT C1764
|
| Hospital Charge Code |
906813619
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,997.50 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$1,997.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4,794.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,861.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$4,494.38
|
| Rate for Payer: Cash Price |
$4,494.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,594.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,393.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,761.54
|
| Rate for Payer: Heritage Provider Network Senior |
$6,761.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,993.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,993.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,993.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,496.88
|
| Rate for Payer: Multiplan Commercial |
$7,490.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,641.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,336.82
|
|
|
HC IMPL MED REVEAL DX 9528
|
Facility
OP
|
$9,987.50
|
|
|
Service Code
|
CPT C1764
|
| Hospital Charge Code |
906813619
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,997.50 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$1,997.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4,794.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,861.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8,489.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5,493.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,490.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$6,202.24
|
| Rate for Payer: Blue Shield of California EPN |
$5,862.66
|
| Rate for Payer: Cash Price |
$4,494.38
|
| Rate for Payer: Cash Price |
$4,494.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,594.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8,489.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,489.38
|
| Rate for Payer: Dignity Health Senior |
$8,489.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,392.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,624.21
|
| Rate for Payer: Heritage Provider Network Senior |
$4,624.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,993.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,993.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,993.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,496.88
|
| Rate for Payer: Multiplan Commercial |
$7,490.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,641.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,336.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,489.38
|
| Rate for Payer: Vantage Medical Group Senior |
$8,489.38
|
|
|
HC IMPL MED REVEAL XT 9529
|
Facility
OP
|
$10,987.50
|
|
|
Service Code
|
CPT C1764
|
| Hospital Charge Code |
906813636
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,197.50 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$2,197.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5,274.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,548.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,339.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6,043.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8,240.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$6,823.24
|
| Rate for Payer: Blue Shield of California EPN |
$6,449.66
|
| Rate for Payer: Cash Price |
$4,944.38
|
| Rate for Payer: Cash Price |
$4,944.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,054.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,339.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,339.38
|
| Rate for Payer: Dignity Health Senior |
$9,339.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,032.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,087.21
|
| Rate for Payer: Heritage Provider Network Senior |
$5,087.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,493.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,493.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,493.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,746.88
|
| Rate for Payer: Multiplan Commercial |
$8,240.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,006.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,670.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,339.38
|
| Rate for Payer: Vantage Medical Group Senior |
$9,339.38
|
|
|
HC IMPL MED REVEAL XT 9529
|
Facility
IP
|
$10,987.50
|
|
|
Service Code
|
CPT C1764
|
| Hospital Charge Code |
906813636
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,197.50 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$2,197.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5,274.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,548.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$4,944.38
|
| Rate for Payer: Cash Price |
$4,944.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,054.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,933.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,438.54
|
| Rate for Payer: Heritage Provider Network Senior |
$7,438.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,493.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,493.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,493.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,746.88
|
| Rate for Payer: Multiplan Commercial |
$8,240.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,006.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,670.92
|
|
|
HC IMPL PRIMATRIX 4CM X 4CM MESH
|
Facility
OP
|
$156.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101517
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.24 |
| Max. Negotiated Rate |
$132.60 |
| Rate for Payer: Adventist Health Commercial |
$31.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$95.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$107.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$132.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$85.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$117.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$74.80
|
| Rate for Payer: Blue Shield of California Commercial |
$96.88
|
| Rate for Payer: Blue Shield of California EPN |
$91.57
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$71.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$132.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$132.60
|
| Rate for Payer: Dignity Health Senior |
$132.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$99.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$72.23
|
| Rate for Payer: Heritage Provider Network Senior |
$72.23
|
| Rate for Payer: IEHP Medi-Cal |
$66.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$75.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.00
|
| Rate for Payer: Multiplan Commercial |
$117.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$56.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$52.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$132.60
|
| Rate for Payer: Vantage Medical Group Senior |
$132.60
|
|
|
HC IMPL PRIMATRIX 4CM X 4CM MESH
|
Facility
IP
|
$156.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101517
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.24 |
| Max. Negotiated Rate |
$117.00 |
| Rate for Payer: Adventist Health Commercial |
$31.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$107.17
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$71.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$105.61
|
| Rate for Payer: Heritage Provider Network Senior |
$105.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.00
|
| Rate for Payer: Multiplan Commercial |
$117.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$56.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$52.12
|
|
|
HC IMPL PRIMATRIX 5CM X 5CM MESH
|
Facility
OP
|
$183.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.12 |
| Max. Negotiated Rate |
$155.55 |
| Rate for Payer: Adventist Health Commercial |
$36.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$95.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$125.72
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$155.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$100.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$137.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$74.80
|
| Rate for Payer: Blue Shield of California Commercial |
$113.64
|
| Rate for Payer: Blue Shield of California EPN |
$107.42
|
| Rate for Payer: Cash Price |
$82.35
|
| Rate for Payer: Cash Price |
$82.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$84.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$155.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$155.55
|
| Rate for Payer: Dignity Health Senior |
$155.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$117.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$84.73
|
| Rate for Payer: Heritage Provider Network Senior |
$84.73
|
| Rate for Payer: IEHP Medi-Cal |
$66.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$88.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.75
|
| Rate for Payer: Multiplan Commercial |
$137.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$66.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$61.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$155.55
|
| Rate for Payer: Vantage Medical Group Senior |
$155.55
|
|
|
HC IMPL PRIMATRIX 5CM X 5CM MESH
|
Facility
IP
|
$183.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.12 |
| Max. Negotiated Rate |
$137.25 |
| Rate for Payer: Adventist Health Commercial |
$36.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$125.72
|
| Rate for Payer: Cash Price |
$82.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$84.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$98.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$123.89
|
| Rate for Payer: Heritage Provider Network Senior |
$123.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.75
|
| Rate for Payer: Multiplan Commercial |
$137.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$66.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$61.14
|
|
|
HC IMPL PRIMATRIX 6CM X 6CM FENESTRATED
|
Facility
OP
|
$126.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.81 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Adventist Health Commercial |
$25.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$95.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$86.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$107.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$69.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$94.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$74.80
|
| Rate for Payer: Blue Shield of California Commercial |
$78.25
|
| Rate for Payer: Blue Shield of California EPN |
$73.96
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$107.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$107.10
|
| Rate for Payer: Dignity Health Senior |
$107.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.34
|
| Rate for Payer: Heritage Provider Network Senior |
$58.34
|
| Rate for Payer: IEHP Medi-Cal |
$66.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$60.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$94.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$42.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$107.10
|
| Rate for Payer: Vantage Medical Group Senior |
$107.10
|
|
|
HC IMPL PRIMATRIX 6CM X 6CM FENESTRATED
|
Facility
IP
|
$126.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.81 |
| Max. Negotiated Rate |
$94.50 |
| Rate for Payer: Adventist Health Commercial |
$25.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$86.56
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$85.30
|
| Rate for Payer: Heritage Provider Network Senior |
$85.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$94.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$42.10
|
|
|
HC IMPL PRIMATRIX 6CM X 6CM MESH
|
Facility
IP
|
$126.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101520
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.81 |
| Max. Negotiated Rate |
$94.50 |
| Rate for Payer: Adventist Health Commercial |
$25.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$86.56
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$85.30
|
| Rate for Payer: Heritage Provider Network Senior |
$85.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$94.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$42.10
|
|
|
HC IMPL PRIMATRIX 6CM X 6CM MESH
|
Facility
OP
|
$126.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101520
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.81 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Adventist Health Commercial |
$25.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$95.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$86.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$107.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$69.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$94.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$74.80
|
| Rate for Payer: Blue Shield of California Commercial |
$78.25
|
| Rate for Payer: Blue Shield of California EPN |
$73.96
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$107.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$107.10
|
| Rate for Payer: Dignity Health Senior |
$107.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.34
|
| Rate for Payer: Heritage Provider Network Senior |
$58.34
|
| Rate for Payer: IEHP Medi-Cal |
$66.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$60.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$94.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$42.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$107.10
|
| Rate for Payer: Vantage Medical Group Senior |
$107.10
|
|
|
HC IMPL PRIMATRIX AG 4CM X 4CM FENESTRATED
|
Facility
OP
|
$166.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101521
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.05 |
| Max. Negotiated Rate |
$141.10 |
| Rate for Payer: Adventist Health Commercial |
$33.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$95.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$114.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$141.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$91.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$124.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$74.80
|
| Rate for Payer: Blue Shield of California Commercial |
$103.09
|
| Rate for Payer: Blue Shield of California EPN |
$97.44
|
| Rate for Payer: Cash Price |
$74.70
|
| Rate for Payer: Cash Price |
$74.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$76.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$141.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$141.10
|
| Rate for Payer: Dignity Health Senior |
$141.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$106.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$76.86
|
| Rate for Payer: Heritage Provider Network Senior |
$76.86
|
| Rate for Payer: IEHP Medi-Cal |
$66.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$80.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.50
|
| Rate for Payer: Multiplan Commercial |
$124.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$60.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$55.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$141.10
|
| Rate for Payer: Vantage Medical Group Senior |
$141.10
|
|
|
HC IMPL PRIMATRIX AG 4CM X 4CM FENESTRATED
|
Facility
IP
|
$166.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101521
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.05 |
| Max. Negotiated Rate |
$124.50 |
| Rate for Payer: Adventist Health Commercial |
$33.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$114.04
|
| Rate for Payer: Cash Price |
$74.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$76.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$89.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$112.38
|
| Rate for Payer: Heritage Provider Network Senior |
$112.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.50
|
| Rate for Payer: Multiplan Commercial |
$124.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$60.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$55.46
|
|
|
HC IMPL PRIMATRIX AG 4CM X 4CM MESH
|
Facility
IP
|
$166.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101522
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.05 |
| Max. Negotiated Rate |
$124.50 |
| Rate for Payer: Adventist Health Commercial |
$33.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$114.04
|
| Rate for Payer: Cash Price |
$74.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$76.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$89.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$112.38
|
| Rate for Payer: Heritage Provider Network Senior |
$112.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.50
|
| Rate for Payer: Multiplan Commercial |
$124.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$60.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$55.46
|
|
