|
HC S&I STENT COARCT INCL LSCA
|
Facility
|
IP
|
$2,270.00
|
|
|
Service Code
|
CPT 75956
|
| Hospital Charge Code |
906811484
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$410.87 |
| Max. Negotiated Rate |
$1,702.50 |
| Rate for Payer: Adventist Health Commercial |
$454.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,559.49
|
| Rate for Payer: Cash Price |
$1,021.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,536.79
|
| Rate for Payer: Heritage Provider Network Senior |
$1,536.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$410.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$567.50
|
| Rate for Payer: Multiplan Commercial |
$1,702.50
|
|
|
HC S&I STENT COARCT INCL LSCA
|
Facility
|
OP
|
$2,270.00
|
|
|
Service Code
|
CPT 75956
|
| Hospital Charge Code |
906811484
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$410.87 |
| Max. Negotiated Rate |
$3,319.81 |
| Rate for Payer: Adventist Health Commercial |
$454.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$747.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,559.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,929.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,248.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,702.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,319.81
|
| Rate for Payer: Blue Shield of California Commercial |
$1,409.67
|
| Rate for Payer: Blue Shield of California EPN |
$1,332.49
|
| Rate for Payer: Cash Price |
$1,021.50
|
| Rate for Payer: Cash Price |
$1,021.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,475.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,929.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,929.50
|
| Rate for Payer: Dignity Health Senior |
$1,929.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,475.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,405.13
|
| Rate for Payer: Heritage Provider Network Senior |
$1,405.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$508.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,094.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$410.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$567.50
|
| Rate for Payer: Multiplan Commercial |
$1,702.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,929.50
|
| Rate for Payer: Vantage Medical Group Senior |
$1,929.50
|
|
|
HC S&I STENT COARCT INCL LSCA
|
Facility
|
OP
|
$1,279.00
|
|
|
Service Code
|
CPT 75956
|
| Hospital Charge Code |
906820016
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$231.50 |
| Max. Negotiated Rate |
$3,319.81 |
| Rate for Payer: Adventist Health Commercial |
$255.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$747.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$878.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,087.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$703.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$959.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,319.81
|
| Rate for Payer: Blue Shield of California Commercial |
$794.26
|
| Rate for Payer: Blue Shield of California EPN |
$750.77
|
| Rate for Payer: Cash Price |
$575.55
|
| Rate for Payer: Cash Price |
$575.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$831.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,087.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,087.15
|
| Rate for Payer: Dignity Health Senior |
$1,087.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$831.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$791.70
|
| Rate for Payer: Heritage Provider Network Senior |
$791.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$508.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$616.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$231.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$319.75
|
| Rate for Payer: Multiplan Commercial |
$959.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,087.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1,087.15
|
|
|
HC S&I STENT COARCT INCL LSCA
|
Facility
|
IP
|
$1,279.00
|
|
|
Service Code
|
CPT 75956
|
| Hospital Charge Code |
906820016
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$231.50 |
| Max. Negotiated Rate |
$959.25 |
| Rate for Payer: Adventist Health Commercial |
$255.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$878.67
|
| Rate for Payer: Cash Price |
$575.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$865.88
|
| Rate for Payer: Heritage Provider Network Senior |
$865.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$231.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$319.75
|
| Rate for Payer: Multiplan Commercial |
$959.25
|
|
|
HC S&I STENT COARCT NOT INCL LSCA
|
Facility
|
IP
|
$1,096.00
|
|
|
Service Code
|
CPT 75957
|
| Hospital Charge Code |
906820017
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$198.38 |
| Max. Negotiated Rate |
$822.00 |
| Rate for Payer: Adventist Health Commercial |
$219.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$752.95
|
| Rate for Payer: Cash Price |
$493.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$741.99
|
| Rate for Payer: Heritage Provider Network Senior |
$741.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$198.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$274.00
|
| Rate for Payer: Multiplan Commercial |
$822.00
|
|
|
HC S&I STENT COARCT NOT INCL LSCA
|
Facility
|
OP
|
$1,096.00
|
|
|
Service Code
|
CPT 75957
|
| Hospital Charge Code |
906820017
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$198.38 |
| Max. Negotiated Rate |
$2,844.15 |
| Rate for Payer: Adventist Health Commercial |
$219.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$639.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$752.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$931.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$602.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$822.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,844.15
|
| Rate for Payer: Blue Shield of California Commercial |
$680.62
|
| Rate for Payer: Blue Shield of California EPN |
$643.35
|
| Rate for Payer: Cash Price |
$493.20
|
| Rate for Payer: Cash Price |
$493.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$712.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$931.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$931.60
|
| Rate for Payer: Dignity Health Senior |
$931.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$712.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$678.42
|
| Rate for Payer: Heritage Provider Network Senior |
$678.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$435.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$528.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$198.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$274.00
|
| Rate for Payer: Multiplan Commercial |
$822.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$931.60
|
| Rate for Payer: Vantage Medical Group Senior |
$931.60
|
|
|
HC S&I STENT COARCT NOT INCL LSCA
|
Facility
|
OP
|
$2,104.00
|
|
|
Service Code
|
CPT 75957
|
| Hospital Charge Code |
906811486
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$380.82 |
| Max. Negotiated Rate |
$2,844.15 |
| Rate for Payer: Adventist Health Commercial |
$420.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$639.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,445.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,788.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,157.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,578.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,844.15
|
| Rate for Payer: Blue Shield of California Commercial |
$1,306.58
|
| Rate for Payer: Blue Shield of California EPN |
$1,235.05
|
| Rate for Payer: Cash Price |
$946.80
|
| Rate for Payer: Cash Price |
$946.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,367.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,788.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,788.40
|
| Rate for Payer: Dignity Health Senior |
$1,788.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,367.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,302.38
|
| Rate for Payer: Heritage Provider Network Senior |
$1,302.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$435.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,014.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$380.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$526.00
|
| Rate for Payer: Multiplan Commercial |
$1,578.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,788.40
|
| Rate for Payer: Vantage Medical Group Senior |
$1,788.40
|
|
|
HC S&I STENT COARCT NOT INCL LSCA
|
Facility
|
IP
|
$2,104.00
|
|
|
Service Code
|
CPT 75957
|
| Hospital Charge Code |
906811486
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$380.82 |
| Max. Negotiated Rate |
$1,578.00 |
| Rate for Payer: Adventist Health Commercial |
$420.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,445.45
|
| Rate for Payer: Cash Price |
$946.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,424.41
|
| Rate for Payer: Heritage Provider Network Senior |
$1,424.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$380.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$526.00
|
| Rate for Payer: Multiplan Commercial |
$1,578.00
|
|
|
HC SITZMARKER CAPSULE
|
Facility
|
OP
|
$280.00
|
|
|
Service Code
|
CPT A9698
|
| Hospital Charge Code |
909009698
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$50.68 |
| Max. Negotiated Rate |
$238.00 |
| Rate for Payer: Adventist Health Commercial |
$56.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$238.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$154.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$210.00
|
| Rate for Payer: Blue Shield of California Commercial |
$173.88
|
| Rate for Payer: Blue Shield of California EPN |
$164.36
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$182.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$238.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$238.00
|
| Rate for Payer: Dignity Health Senior |
$238.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$179.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$173.32
|
| Rate for Payer: Heritage Provider Network Senior |
$173.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$134.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$50.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.00
|
| Rate for Payer: Multiplan Commercial |
$210.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$112.00
|
| Rate for Payer: TriValley Medical Group Senior |
$112.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$238.00
|
| Rate for Payer: Vantage Medical Group Senior |
$238.00
|
|
|
HC SITZMARKER CAPSULE
|
Facility
|
IP
|
$280.00
|
|
|
Service Code
|
CPT A9698
|
| Hospital Charge Code |
909009698
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$50.68 |
| Max. Negotiated Rate |
$210.00 |
| Rate for Payer: Adventist Health Commercial |
$56.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$192.36
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$151.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$189.56
|
| Rate for Payer: Heritage Provider Network Senior |
$189.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$50.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.00
|
| Rate for Payer: Multiplan Commercial |
$210.00
|
|
|
HC SKIN SUB GRAFT TRUNK ARMS LEGS 1ST 100 SQ CM
|
Facility
|
IP
|
$8,714.00
|
|
|
Service Code
|
CPT 15273
|
| Hospital Charge Code |
900101500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,577.23 |
| Max. Negotiated Rate |
$6,535.50 |
| Rate for Payer: Adventist Health Commercial |
$1,742.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,986.52
|
| Rate for Payer: Cash Price |
$3,921.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,899.38
|
| Rate for Payer: Heritage Provider Network Senior |
$5,899.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,577.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,178.50
|
| Rate for Payer: Multiplan Commercial |
$6,535.50
|
|
|
HC SKIN SUB GRAFT TRUNK ARMS LEGS 1ST 100 SQ CM
|
Facility
|
OP
|
$8,714.00
|
|
|
Service Code
|
CPT 15273
|
| Hospital Charge Code |
900101500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$268.27 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,742.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,986.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,482.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$5,411.39
|
| Rate for Payer: Blue Shield of California EPN |
$5,115.12
|
| Rate for Payer: Cash Price |
$3,921.30
|
| Rate for Payer: Cash Price |
$3,921.30
|
| Rate for Payer: Cash Price |
$3,921.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,664.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,930.75
|
| Rate for Payer: Dignity Health Senior |
$4,482.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,482.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,393.97
|
| Rate for Payer: Heritage Provider Network Senior |
$5,393.97
|
| Rate for Payer: Humana Medicare |
$4,482.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$268.27
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,482.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,516.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,577.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,289.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,178.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,647.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,647.95
|
| Rate for Payer: Multiplan Commercial |
$6,535.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,930.75
|
| Rate for Payer: TriValley Medical Group Senior |
$4,930.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4,482.50
|
|
|
HC SKIN SUB GRAFT TRUNK ARMS LEGS EACH ADDL 100 SQ CM
|
Facility
|
IP
|
$3,855.00
|
|
|
Service Code
|
CPT 15274
|
| Hospital Charge Code |
900101501
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$697.76 |
| Max. Negotiated Rate |
$2,891.25 |
| Rate for Payer: Adventist Health Commercial |
$771.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,648.38
|
| Rate for Payer: Cash Price |
$1,734.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,609.84
|
| Rate for Payer: Heritage Provider Network Senior |
$2,609.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$697.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$963.75
|
| Rate for Payer: Multiplan Commercial |
$2,891.25
|
|
|
HC SKIN SUB GRAFT TRUNK ARMS LEGS EACH ADDL 100 SQ CM
|
Facility
|
OP
|
$3,855.00
|
|
|
Service Code
|
CPT 15274
|
| Hospital Charge Code |
900101501
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$57.16 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$771.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,648.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,276.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,120.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,891.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,393.96
|
| Rate for Payer: Blue Shield of California EPN |
$2,262.88
|
| Rate for Payer: Cash Price |
$1,734.75
|
| Rate for Payer: Cash Price |
$1,734.75
|
| Rate for Payer: Cash Price |
$1,734.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,505.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,276.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,276.75
|
| Rate for Payer: Dignity Health Senior |
$3,276.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,386.24
|
| Rate for Payer: Heritage Provider Network Senior |
$2,386.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$57.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,858.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$697.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$963.75
|
| Rate for Payer: Multiplan Commercial |
$2,891.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,927.50
|
| Rate for Payer: TriValley Medical Group Senior |
$1,927.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,276.75
|
| Rate for Payer: Vantage Medical Group Senior |
$3,276.75
|
|
|
HC SKIN SUB GRAFT TRUNK ARMS LEGS EACH ADDL 25 SQ CM
|
Facility
|
IP
|
$2,313.00
|
|
|
Service Code
|
CPT 15272
|
| Hospital Charge Code |
900101499
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$418.65 |
| Max. Negotiated Rate |
$1,734.75 |
| Rate for Payer: Adventist Health Commercial |
$462.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,589.03
|
| Rate for Payer: Cash Price |
$1,040.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,565.90
|
| Rate for Payer: Heritage Provider Network Senior |
$1,565.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$418.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$578.25
|
| Rate for Payer: Multiplan Commercial |
$1,734.75
|
|
|
HC SKIN SUB GRAFT TRUNK ARMS LEGS EACH ADDL 25 SQ CM
|
Facility
|
OP
|
$2,313.00
|
|
|
Service Code
|
CPT 15272
|
| Hospital Charge Code |
900101499
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$22.32 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$462.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,589.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,966.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,272.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,734.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,436.37
|
| Rate for Payer: Blue Shield of California EPN |
$1,357.73
|
| Rate for Payer: Cash Price |
$1,040.85
|
| Rate for Payer: Cash Price |
$1,040.85
|
| Rate for Payer: Cash Price |
$1,040.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,503.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,966.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,966.05
|
| Rate for Payer: Dignity Health Senior |
$1,966.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,431.75
|
| Rate for Payer: Heritage Provider Network Senior |
$1,431.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,114.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$418.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$578.25
|
| Rate for Payer: Multiplan Commercial |
$1,734.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,156.50
|
| Rate for Payer: TriValley Medical Group Senior |
$1,156.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,966.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1,966.05
|
|
|
HC SKIN SUB GRFT DIGIT 1ST 25 SQ
|
Facility
|
OP
|
$5,287.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
900501784
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$129.62 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,057.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,632.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,283.23
|
| Rate for Payer: Blue Shield of California EPN |
$3,103.47
|
| Rate for Payer: Cash Price |
$2,379.15
|
| Rate for Payer: Cash Price |
$2,379.15
|
| Rate for Payer: Cash Price |
$2,379.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,436.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,272.65
|
| Rate for Payer: Heritage Provider Network Senior |
$3,272.65
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$129.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,329.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$956.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,321.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: Multiplan Commercial |
$3,965.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,506.34
|
| Rate for Payer: TriValley Medical Group Senior |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
HC SKIN SUB GRFT DIGIT 1ST 25 SQ
|
Facility
|
OP
|
$5,287.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
900501784
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$936.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,057.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,632.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$2,379.15
|
| Rate for Payer: Cash Price |
$2,379.15
|
| Rate for Payer: Cash Price |
$2,379.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,436.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,579.30
|
| Rate for Payer: Heritage Provider Network Senior |
$3,579.30
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$936.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,548.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$956.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,321.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: Multiplan Commercial |
$3,965.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,919.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,766.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
HC SKIN SUB GRFT DIGIT 1ST 25 SQ
|
Facility
|
IP
|
$5,287.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
900501784
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$956.95 |
| Max. Negotiated Rate |
$3,965.25 |
| Rate for Payer: Adventist Health Commercial |
$1,057.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,632.17
|
| Rate for Payer: Cash Price |
$2,379.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,579.30
|
| Rate for Payer: Heritage Provider Network Senior |
$3,579.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$956.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,321.75
|
| Rate for Payer: Multiplan Commercial |
$3,965.25
|
|
|
HC SKIN SUB GRFT DIGIT 1ST 25 SQ
|
Facility
|
IP
|
$5,287.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
900501784
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$956.95 |
| Max. Negotiated Rate |
$3,965.25 |
| Rate for Payer: Adventist Health Commercial |
$1,057.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,632.17
|
| Rate for Payer: Cash Price |
$2,379.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,579.30
|
| Rate for Payer: Heritage Provider Network Senior |
$3,579.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$956.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,321.75
|
| Rate for Payer: Multiplan Commercial |
$3,965.25
|
|
|
HC SKIN SUB GRFT HEAD HANDS DIGITS FEET 1ST 100 SQ CM
|
Facility
|
IP
|
$4,626.00
|
|
|
Service Code
|
CPT 15277
|
| Hospital Charge Code |
900101503
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$837.31 |
| Max. Negotiated Rate |
$3,469.50 |
| Rate for Payer: Adventist Health Commercial |
$925.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,178.06
|
| Rate for Payer: Cash Price |
$2,081.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,131.80
|
| Rate for Payer: Heritage Provider Network Senior |
$3,131.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$837.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,156.50
|
| Rate for Payer: Multiplan Commercial |
$3,469.50
|
|
|
HC SKIN SUB GRFT HEAD HANDS DIGITS FEET 1ST 100 SQ CM
|
Facility
|
OP
|
$4,626.00
|
|
|
Service Code
|
CPT 15277
|
| Hospital Charge Code |
900101503
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$276.35 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$925.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,178.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,872.75
|
| Rate for Payer: Blue Shield of California EPN |
$2,715.46
|
| Rate for Payer: Cash Price |
$2,081.70
|
| Rate for Payer: Cash Price |
$2,081.70
|
| Rate for Payer: Cash Price |
$2,081.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,006.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,863.49
|
| Rate for Payer: Heritage Provider Network Senior |
$2,863.49
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$276.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,329.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$837.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,156.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: Multiplan Commercial |
$3,469.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,506.34
|
| Rate for Payer: TriValley Medical Group Senior |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
HC SKIN SUB GRFT HEAD HANDS DIGITS FEET ADDL 100 SQ CM
|
Facility
|
OP
|
$2,313.00
|
|
|
Service Code
|
CPT 15278
|
| Hospital Charge Code |
900101504
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.86 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$462.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,589.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,966.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,272.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,734.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,436.37
|
| Rate for Payer: Blue Shield of California EPN |
$1,357.73
|
| Rate for Payer: Cash Price |
$1,040.85
|
| Rate for Payer: Cash Price |
$1,040.85
|
| Rate for Payer: Cash Price |
$1,040.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,503.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,966.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,966.05
|
| Rate for Payer: Dignity Health Senior |
$1,966.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,431.75
|
| Rate for Payer: Heritage Provider Network Senior |
$1,431.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$70.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,114.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$418.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$578.25
|
| Rate for Payer: Multiplan Commercial |
$1,734.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,156.50
|
| Rate for Payer: TriValley Medical Group Senior |
$1,156.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,966.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1,966.05
|
|
|
HC SKIN SUB GRFT HEAD HANDS DIGITS FEET ADDL 100 SQ CM
|
Facility
|
IP
|
$2,313.00
|
|
|
Service Code
|
CPT 15278
|
| Hospital Charge Code |
900101504
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$418.65 |
| Max. Negotiated Rate |
$1,734.75 |
| Rate for Payer: Adventist Health Commercial |
$462.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,589.03
|
| Rate for Payer: Cash Price |
$1,040.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,565.90
|
| Rate for Payer: Heritage Provider Network Senior |
$1,565.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$418.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$578.25
|
| Rate for Payer: Multiplan Commercial |
$1,734.75
|
|
|
HC SKIN SUB GRFT HEAD HANDS DIGITS FEET ADDL 25 SQ CM
|
Facility
|
IP
|
$2,313.00
|
|
|
Service Code
|
CPT 15276
|
| Hospital Charge Code |
900101502
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$418.65 |
| Max. Negotiated Rate |
$1,734.75 |
| Rate for Payer: Adventist Health Commercial |
$462.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,589.03
|
| Rate for Payer: Cash Price |
$1,040.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,565.90
|
| Rate for Payer: Heritage Provider Network Senior |
$1,565.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$418.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$578.25
|
| Rate for Payer: Multiplan Commercial |
$1,734.75
|
|
