|
HC IMPL GRAFT EPIFIX 2X2 CM
|
Facility
|
IP
|
$472.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101526
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.43 |
| Max. Negotiated Rate |
$354.00 |
| Rate for Payer: Adventist Health Commercial |
$94.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$303.97
|
| Rate for Payer: Cash Price |
$212.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$217.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$254.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$218.54
|
| Rate for Payer: Heritage Provider Network Senior |
$218.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$85.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$118.00
|
| Rate for Payer: Multiplan Commercial |
$354.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$170.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$156.28
|
|
|
HC IMPL GRAFT EPIFIX 2X4 CM
|
Facility
|
OP
|
$409.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101529
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$74.03 |
| Max. Negotiated Rate |
$306.75 |
| Rate for Payer: Adventist Health Commercial |
$81.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$252.76
|
| 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 |
$204.58
|
| Rate for Payer: Blue Shield of California Commercial |
$249.49
|
| Rate for Payer: Blue Shield of California EPN |
$199.59
|
| Rate for Payer: Cash Price |
$184.05
|
| Rate for Payer: Cash Price |
$184.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$188.14
|
| 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 |
$261.76
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$189.37
|
| Rate for Payer: Heritage Provider Network Senior |
$189.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$195.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$74.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$102.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.48
|
| Rate for Payer: Multiplan Commercial |
$306.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$163.60
|
| Rate for Payer: TriValley Medical Group Senior |
$163.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$147.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$135.42
|
| 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 IMPL GRAFT EPIFIX 2X4 CM
|
Facility
|
IP
|
$409.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101529
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$74.03 |
| Max. Negotiated Rate |
$306.75 |
| Rate for Payer: Adventist Health Commercial |
$81.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$263.40
|
| Rate for Payer: Cash Price |
$184.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$188.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$220.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$189.37
|
| Rate for Payer: Heritage Provider Network Senior |
$189.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$74.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$102.25
|
| Rate for Payer: Multiplan Commercial |
$306.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$147.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$135.42
|
|
|
HC IMPL GRAFT EPIFIX 3X4 CM
|
Facility
|
IP
|
$329.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101527
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.55 |
| Max. Negotiated Rate |
$246.75 |
| Rate for Payer: Adventist Health Commercial |
$65.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$211.88
|
| Rate for Payer: Cash Price |
$148.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$151.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$177.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$152.33
|
| Rate for Payer: Heritage Provider Network Senior |
$152.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$59.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.25
|
| Rate for Payer: Multiplan Commercial |
$246.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$118.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$108.93
|
|
|
HC IMPL GRAFT EPIFIX 3X4 CM
|
Facility
|
OP
|
$329.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101527
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.55 |
| Max. Negotiated Rate |
$246.75 |
| Rate for Payer: Adventist Health Commercial |
$65.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$203.32
|
| 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 |
$164.57
|
| Rate for Payer: Blue Shield of California Commercial |
$200.69
|
| Rate for Payer: Blue Shield of California EPN |
$160.55
|
| Rate for Payer: Cash Price |
$148.05
|
| Rate for Payer: Cash Price |
$148.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$151.34
|
| 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 |
$210.56
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$152.33
|
| Rate for Payer: Heritage Provider Network Senior |
$152.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$156.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$59.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.48
|
| Rate for Payer: Multiplan Commercial |
$246.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$131.60
|
| Rate for Payer: TriValley Medical Group Senior |
$131.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$118.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$108.93
|
| 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 IMPL GRAFT EPIFIX 4X4.5 CM MESH
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101528
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.25 |
| Max. Negotiated Rate |
$187.50 |
| Rate for Payer: Adventist Health Commercial |
$50.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$161.00
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$115.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$135.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$115.75
|
| Rate for Payer: Heritage Provider Network Senior |
$115.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$45.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.50
|
| Rate for Payer: Multiplan Commercial |
$187.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$90.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$82.78
|
|
|
HC IMPL GRAFT EPIFIX 4X4.5 CM MESH
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101528
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.25 |
| Max. Negotiated Rate |
$240.09 |
| Rate for Payer: Adventist Health Commercial |
$50.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$154.50
|
| 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 |
$125.05
|
| Rate for Payer: Blue Shield of California Commercial |
$152.50
|
| Rate for Payer: Blue Shield of California EPN |
$122.00
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$115.00
|
| 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 |
$160.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$115.75
|
| Rate for Payer: Heritage Provider Network Senior |
$115.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$119.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$45.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.48
|
| Rate for Payer: Multiplan Commercial |
$187.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$90.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$82.78
|
| 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 IMPL GRAFT EPIFIX 4X4 CM
|
Facility
|
OP
|
$329.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101530
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.55 |
| Max. Negotiated Rate |
$246.75 |
| Rate for Payer: Adventist Health Commercial |
$65.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$203.32
|
| 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 |
$164.57
|
| Rate for Payer: Blue Shield of California Commercial |
$200.69
|
| Rate for Payer: Blue Shield of California EPN |
$160.55
|
| Rate for Payer: Cash Price |
$148.05
|
| Rate for Payer: Cash Price |
$148.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$151.34
|
| 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 |
$210.56
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$152.33
|
| Rate for Payer: Heritage Provider Network Senior |
$152.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$156.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$59.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.48
|
| Rate for Payer: Multiplan Commercial |
$246.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$131.60
|
| Rate for Payer: TriValley Medical Group Senior |
$131.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$118.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$108.93
|
| 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 IMPL GRAFT EPIFIX 4X4 CM
|
Facility
|
IP
|
$329.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101530
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.55 |
| Max. Negotiated Rate |
$246.75 |
| Rate for Payer: Adventist Health Commercial |
$65.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$211.88
|
| Rate for Payer: Cash Price |
$148.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$151.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$177.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$152.33
|
| Rate for Payer: Heritage Provider Network Senior |
$152.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$59.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.25
|
| Rate for Payer: Multiplan Commercial |
$246.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$118.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$108.93
|
|
|
HC IMPL GRAFT EPIFIX 5X6 CM
|
Facility
|
OP
|
$329.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101531
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.55 |
| Max. Negotiated Rate |
$246.75 |
| Rate for Payer: Cash Price |
$148.05
|
| Rate for Payer: Adventist Health Commercial |
$65.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$203.32
|
| 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 |
$164.57
|
| Rate for Payer: Blue Shield of California Commercial |
$200.69
|
| Rate for Payer: Blue Shield of California EPN |
$160.55
|
| Rate for Payer: Cash Price |
$148.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$151.34
|
| 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 |
$210.56
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$152.33
|
| Rate for Payer: Heritage Provider Network Senior |
$152.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$156.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$59.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.48
|
| Rate for Payer: Multiplan Commercial |
$246.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$131.60
|
| Rate for Payer: TriValley Medical Group Senior |
$131.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$118.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$108.93
|
| 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 IMPL GRAFT EPIFIX 5X6 CM
|
Facility
|
IP
|
$329.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
900101531
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.55 |
| Max. Negotiated Rate |
$246.75 |
| Rate for Payer: Adventist Health Commercial |
$65.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$211.88
|
| Rate for Payer: Cash Price |
$148.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$151.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$177.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$152.33
|
| Rate for Payer: Heritage Provider Network Senior |
$152.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$59.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.25
|
| Rate for Payer: Multiplan Commercial |
$246.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$118.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$108.93
|
|
|
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 |
$13,770.00 |
| Rate for Payer: Adventist Health Commercial |
$91.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$281.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$387.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$250.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$342.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,770.00
|
| Rate for Payer: Blue Shield of California Commercial |
$183.31
|
| Rate for Payer: Blue Shield of California EPN |
$183.31
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$228.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$228.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$228.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$114.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$319.20
|
| Rate for Payer: Multiplan Commercial |
$342.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$164.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$150.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$387.60
|
| 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 |
$13,808.00 |
| Rate for Payer: Adventist Health Commercial |
$91.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$293.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,808.00
|
| Rate for Payer: Blue Shield of California Commercial |
$183.31
|
| Rate for Payer: Blue Shield of California EPN |
$183.31
|
| 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 |
$211.13
|
| Rate for Payer: Heritage Provider Network Senior |
$211.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$228.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$228.00
|
| Rate for Payer: Kaiser Foundation Hospitals 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 |
$164.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$150.98
|
|
|
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 |
$13,770.00 |
| Rate for Payer: Adventist Health Commercial |
$1,997.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,172.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8,489.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,493.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,490.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,770.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,014.97
|
| Rate for Payer: Blue Shield of California EPN |
$4,014.97
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$4,993.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4,993.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,993.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,496.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6,991.25
|
| Rate for Payer: Multiplan Commercial |
$7,490.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,608.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,306.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8,489.38
|
| 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 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 |
$13,808.00 |
| Rate for Payer: Adventist Health Commercial |
$1,997.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,431.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,808.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,014.97
|
| Rate for Payer: Blue Shield of California EPN |
$4,014.97
|
| 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 |
$4,624.21
|
| Rate for Payer: Heritage Provider Network Senior |
$4,624.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4,993.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4,993.75
|
| Rate for Payer: Kaiser Foundation Hospitals 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 |
$3,608.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,306.86
|
|
|
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 |
$13,770.00 |
| Rate for Payer: Adventist Health Commercial |
$2,197.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,790.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9,339.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6,043.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,240.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,770.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,416.98
|
| Rate for Payer: Blue Shield of California EPN |
$4,416.98
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$5,493.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5,493.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,493.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,746.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$7,691.25
|
| Rate for Payer: Multiplan Commercial |
$8,240.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,969.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,637.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,339.38
|
| 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 |
$13,808.00 |
| Rate for Payer: Adventist Health Commercial |
$2,197.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,075.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,808.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,416.98
|
| Rate for Payer: Blue Shield of California EPN |
$4,416.98
|
| 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 |
$5,087.21
|
| Rate for Payer: Heritage Provider Network Senior |
$5,087.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,493.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5,493.75
|
| Rate for Payer: Kaiser Foundation Hospitals 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 |
$3,969.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,637.96
|
|
|
HC IMPL PRIMATRIX 3CM X 3CM MESH
|
Facility
|
IP
|
$326.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900103303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.01 |
| Max. Negotiated Rate |
$244.50 |
| Rate for Payer: Adventist Health Commercial |
$65.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$209.94
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$149.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$176.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$150.94
|
| Rate for Payer: Heritage Provider Network Senior |
$150.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$59.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$81.50
|
| Rate for Payer: Multiplan Commercial |
$244.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$117.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$107.94
|
|
|
HC IMPL PRIMATRIX 3CM X 3CM MESH
|
Facility
|
OP
|
$326.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900103303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.01 |
| Max. Negotiated Rate |
$244.50 |
| Rate for Payer: Adventist Health Commercial |
$65.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$201.47
|
| 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 |
$84.85
|
| Rate for Payer: Blue Shield of California Commercial |
$198.86
|
| Rate for Payer: Blue Shield of California EPN |
$159.09
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$149.96
|
| 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 |
$208.64
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$150.94
|
| Rate for Payer: Heritage Provider Network Senior |
$150.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$155.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$59.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$81.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.48
|
| Rate for Payer: Multiplan Commercial |
$244.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$130.40
|
| Rate for Payer: TriValley Medical Group Senior |
$130.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$117.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$107.94
|
| 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 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 |
$100.46
|
| 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 |
$72.23
|
| Rate for Payer: Heritage Provider Network Senior |
$72.23
|
| Rate for Payer: Kaiser Foundation Hospitals 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 |
$56.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$51.65
|
|
|
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 |
$240.09 |
| Rate for Payer: Adventist Health Commercial |
$31.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$96.41
|
| 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 |
$84.85
|
| Rate for Payer: Blue Shield of California Commercial |
$95.16
|
| Rate for Payer: Blue Shield of California EPN |
$76.13
|
| 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 |
$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 |
$99.84
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$72.23
|
| Rate for Payer: Heritage Provider Network Senior |
$72.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$74.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$28.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.48
|
| Rate for Payer: Multiplan Commercial |
$117.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$62.40
|
| Rate for Payer: TriValley Medical Group Senior |
$62.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$56.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$51.65
|
| 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 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 |
$117.85
|
| 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 |
$84.73
|
| Rate for Payer: Heritage Provider Network Senior |
$84.73
|
| Rate for Payer: Kaiser Foundation Hospitals 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 |
$66.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$60.59
|
|
|
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 |
$240.09 |
| Rate for Payer: Adventist Health Commercial |
$36.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$113.09
|
| 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 |
$84.85
|
| Rate for Payer: Blue Shield of California Commercial |
$111.63
|
| Rate for Payer: Blue Shield of California EPN |
$89.30
|
| 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 |
$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 |
$117.12
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$84.73
|
| Rate for Payer: Heritage Provider Network Senior |
$84.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$87.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$33.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.48
|
| Rate for Payer: Multiplan Commercial |
$137.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$73.20
|
| Rate for Payer: TriValley Medical Group Senior |
$73.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$66.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$60.59
|
| 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 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 |
$81.14
|
| 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 |
$58.34
|
| Rate for Payer: Heritage Provider Network Senior |
$58.34
|
| Rate for Payer: Kaiser Foundation Hospitals 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 |
$45.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$41.72
|
|
|
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 |
$240.09 |
| Rate for Payer: Adventist Health Commercial |
$25.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.87
|
| 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 |
$84.85
|
| Rate for Payer: Blue Shield of California Commercial |
$76.86
|
| Rate for Payer: Blue Shield of California EPN |
$61.49
|
| 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 |
$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 |
$80.64
|
| Rate for Payer: EPIC Health Plan Medicare |
$160.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.34
|
| Rate for Payer: Heritage Provider Network Senior |
$58.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$160.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$60.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$22.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$214.48
|
| Rate for Payer: Multiplan Commercial |
$94.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$50.40
|
| Rate for Payer: TriValley Medical Group Senior |
$50.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$41.72
|
| 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
|
|
