|
HC S&I STENT COARCT INCL LSCA
|
Facility
|
IP
|
$1,215.00
|
|
|
Service Code
|
CPT 75956
|
| Hospital Charge Code |
906820016
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$219.91 |
| Max. Negotiated Rate |
$911.25 |
| Rate for Payer: Adventist Health Commercial |
$243.00
|
| Rate for Payer: Cash Price |
$668.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$822.55
|
| Rate for Payer: Heritage Provider Network Senior |
$822.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$219.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$303.75
|
| Rate for Payer: Multiplan Commercial |
$911.25
|
|
|
HC S&I STENT COARCT NOT INCL LSCA
|
Facility
|
OP
|
$1,041.00
|
|
|
Service Code
|
CPT 75957
|
| Hospital Charge Code |
906820017
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$188.42 |
| Max. Negotiated Rate |
$3,102.16 |
| Rate for Payer: Adventist Health Commercial |
$208.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$556.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$715.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$884.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$572.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$780.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,102.16
|
| Rate for Payer: Blue Shield of California Commercial |
$635.01
|
| Rate for Payer: Blue Shield of California EPN |
$508.01
|
| Rate for Payer: Cash Price |
$572.55
|
| Rate for Payer: Cash Price |
$572.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$676.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$884.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$884.85
|
| Rate for Payer: Dignity Health Senior |
$884.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$676.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$644.38
|
| Rate for Payer: Heritage Provider Network Senior |
$644.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$452.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$496.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$188.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$260.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$728.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$728.70
|
| Rate for Payer: Multiplan Commercial |
$780.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$520.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$520.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$884.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$884.85
|
| Rate for Payer: Vantage Medical Group Senior |
$884.85
|
|
|
HC S&I STENT COARCT NOT INCL LSCA
|
Facility
|
IP
|
$1,071.00
|
|
|
Service Code
|
CPT 75957
|
| Hospital Charge Code |
906811486
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$193.85 |
| Max. Negotiated Rate |
$803.25 |
| Rate for Payer: Adventist Health Commercial |
$214.20
|
| Rate for Payer: Cash Price |
$589.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$725.07
|
| Rate for Payer: Heritage Provider Network Senior |
$725.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$193.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$267.75
|
| Rate for Payer: Multiplan Commercial |
$803.25
|
|
|
HC S&I STENT COARCT NOT INCL LSCA
|
Facility
|
IP
|
$1,041.00
|
|
|
Service Code
|
CPT 75957
|
| Hospital Charge Code |
906820017
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$188.42 |
| Max. Negotiated Rate |
$780.75 |
| Rate for Payer: Adventist Health Commercial |
$208.20
|
| Rate for Payer: Cash Price |
$572.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$704.76
|
| Rate for Payer: Heritage Provider Network Senior |
$704.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$188.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$260.25
|
| Rate for Payer: Multiplan Commercial |
$780.75
|
|
|
HC S&I STENT COARCT NOT INCL LSCA
|
Facility
|
OP
|
$1,071.00
|
|
|
Service Code
|
CPT 75957
|
| Hospital Charge Code |
906811486
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$193.85 |
| Max. Negotiated Rate |
$3,102.16 |
| Rate for Payer: Adventist Health Commercial |
$214.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$572.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$735.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$910.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$589.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$803.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,102.16
|
| Rate for Payer: Blue Shield of California Commercial |
$653.31
|
| Rate for Payer: Blue Shield of California EPN |
$522.65
|
| Rate for Payer: Cash Price |
$589.05
|
| Rate for Payer: Cash Price |
$589.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$696.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$910.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$910.35
|
| Rate for Payer: Dignity Health Senior |
$910.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$696.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$662.95
|
| Rate for Payer: Heritage Provider Network Senior |
$662.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$452.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$510.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$193.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$267.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$749.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$749.70
|
| Rate for Payer: Multiplan Commercial |
$803.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$535.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$535.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$910.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$910.35
|
| Rate for Payer: Vantage Medical Group Senior |
$910.35
|
|
|
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: Cash Price |
$154.00
|
| 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 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 |
$170.80
|
| Rate for Payer: Blue Shield of California EPN |
$136.64
|
| Rate for Payer: Cash Price |
$154.00
|
| 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 |
$133.56
|
| 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: Molina Healthcare of CA Medi-Cal |
$196.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$196.00
|
| 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: United Healthcare All Other HMO/non HMO |
$140.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$140.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$238.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$238.00
|
| Rate for Payer: Vantage Medical Group Senior |
$238.00
|
|
|
HC SKIN SUB GRAFT TRUNK ARMS LEGS 1ST 100 SQ CM
|
Facility
|
OP
|
$11,524.00
|
|
|
Service Code
|
CPT 15273
|
| Hospital Charge Code |
900101500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$2,304.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,916.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,977.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,116.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,651.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| Rate for Payer: Blue Shield of California Commercial |
$7,029.64
|
| Rate for Payer: Blue Shield of California EPN |
$5,623.71
|
| Rate for Payer: Cash Price |
$6,338.20
|
| Rate for Payer: Cash Price |
$6,338.20
|
| Rate for Payer: Cash Price |
$6,338.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,490.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,977.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,116.79
|
| Rate for Payer: Dignity Health Senior |
$4,651.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,651.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,133.36
|
| Rate for Payer: Heritage Provider Network Senior |
$7,133.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$278.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,651.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,496.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,085.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,349.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,881.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,861.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,861.05
|
| Rate for Payer: Multiplan Commercial |
$8,643.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,116.79
|
| Rate for Payer: TriValley Medical Group Senior |
$5,116.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5,762.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5,762.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,977.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,116.79
|
| Rate for Payer: Vantage Medical Group Senior |
$4,651.63
|
|
|
HC SKIN SUB GRAFT TRUNK ARMS LEGS 1ST 100 SQ CM
|
Facility
|
IP
|
$11,524.00
|
|
|
Service Code
|
CPT 15273
|
| Hospital Charge Code |
900101500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,085.84 |
| Max. Negotiated Rate |
$8,643.00 |
| Rate for Payer: Adventist Health Commercial |
$2,304.80
|
| Rate for Payer: Cash Price |
$6,338.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,801.75
|
| Rate for Payer: Heritage Provider Network Senior |
$7,801.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,085.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,881.00
|
| Rate for Payer: Multiplan Commercial |
$8,643.00
|
|
|
HC SKIN SUB GRAFT TRUNK ARMS LEGS EACH ADDL 100 SQ CM
|
Facility
|
OP
|
$5,098.00
|
|
|
Service Code
|
CPT 15274
|
| Hospital Charge Code |
900101501
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,019.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,502.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,333.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,803.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,823.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,109.78
|
| Rate for Payer: Blue Shield of California EPN |
$2,487.82
|
| Rate for Payer: Cash Price |
$2,803.90
|
| Rate for Payer: Cash Price |
$2,803.90
|
| Rate for Payer: Cash Price |
$2,803.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,313.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,333.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,333.30
|
| Rate for Payer: Dignity Health Senior |
$4,333.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,155.66
|
| Rate for Payer: Heritage Provider Network Senior |
$3,155.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$59.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,431.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$922.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,274.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,568.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,568.60
|
| Rate for Payer: Multiplan Commercial |
$3,823.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,549.00
|
| Rate for Payer: TriValley Medical Group Senior |
$2,549.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,549.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,549.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,333.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,333.30
|
| Rate for Payer: Vantage Medical Group Senior |
$4,333.30
|
|
|
HC SKIN SUB GRAFT TRUNK ARMS LEGS EACH ADDL 100 SQ CM
|
Facility
|
IP
|
$5,098.00
|
|
|
Service Code
|
CPT 15274
|
| Hospital Charge Code |
900101501
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$922.74 |
| Max. Negotiated Rate |
$3,823.50 |
| Rate for Payer: Adventist Health Commercial |
$1,019.60
|
| Rate for Payer: Cash Price |
$2,803.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,451.35
|
| Rate for Payer: Heritage Provider Network Senior |
$3,451.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$922.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,274.50
|
| Rate for Payer: Multiplan Commercial |
$3,823.50
|
|
|
HC SKIN SUB GRAFT TRUNK ARMS LEGS EACH ADDL 25 SQ CM
|
Facility
|
IP
|
$3,059.00
|
|
|
Service Code
|
CPT 15272
|
| Hospital Charge Code |
900101499
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$553.68 |
| Max. Negotiated Rate |
$2,294.25 |
| Rate for Payer: Adventist Health Commercial |
$611.80
|
| Rate for Payer: Cash Price |
$1,682.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,070.94
|
| Rate for Payer: Heritage Provider Network Senior |
$2,070.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$553.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$764.75
|
| Rate for Payer: Multiplan Commercial |
$2,294.25
|
|
|
HC SKIN SUB GRAFT TRUNK ARMS LEGS EACH ADDL 25 SQ CM
|
Facility
|
OP
|
$3,059.00
|
|
|
Service Code
|
CPT 15272
|
| Hospital Charge Code |
900101499
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$611.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,101.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,600.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,682.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,294.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,865.99
|
| Rate for Payer: Blue Shield of California EPN |
$1,492.79
|
| Rate for Payer: Cash Price |
$1,682.45
|
| Rate for Payer: Cash Price |
$1,682.45
|
| Rate for Payer: Cash Price |
$1,682.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,988.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,600.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,600.15
|
| Rate for Payer: Dignity Health Senior |
$2,600.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,893.52
|
| Rate for Payer: Heritage Provider Network Senior |
$1,893.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,459.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$553.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$764.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,141.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,141.30
|
| Rate for Payer: Multiplan Commercial |
$2,294.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,529.50
|
| Rate for Payer: TriValley Medical Group Senior |
$1,529.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,529.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,529.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,600.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,600.15
|
| Rate for Payer: Vantage Medical Group Senior |
$2,600.15
|
|
|
HC SKIN SUB GRFT DIGIT 1ST 25 SQ
|
Facility
|
IP
|
$4,357.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
900501784
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$788.62 |
| Max. Negotiated Rate |
$3,267.75 |
| Rate for Payer: Adventist Health Commercial |
$871.40
|
| Rate for Payer: Cash Price |
$2,396.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,949.69
|
| Rate for Payer: Heritage Provider Network Senior |
$2,949.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$788.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,089.25
|
| Rate for Payer: Multiplan Commercial |
$3,267.75
|
|
|
HC SKIN SUB GRFT DIGIT 1ST 25 SQ
|
Facility
|
IP
|
$4,357.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
900501784
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$788.62 |
| Max. Negotiated Rate |
$3,267.75 |
| Rate for Payer: Adventist Health Commercial |
$871.40
|
| Rate for Payer: Cash Price |
$2,396.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,949.69
|
| Rate for Payer: Heritage Provider Network Senior |
$2,949.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$788.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,089.25
|
| Rate for Payer: Multiplan Commercial |
$3,267.75
|
|
|
HC SKIN SUB GRFT DIGIT 1ST 25 SQ
|
Facility
|
OP
|
$4,357.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
900501784
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$871.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,993.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,486.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,556.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,324.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| Rate for Payer: Cash Price |
$2,396.35
|
| Rate for Payer: Cash Price |
$2,396.35
|
| Rate for Payer: Cash Price |
$2,396.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,832.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,486.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,556.64
|
| Rate for Payer: Dignity Health Senior |
$2,324.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,324.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,949.69
|
| Rate for Payer: Heritage Provider Network Senior |
$2,949.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$973.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,324.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,078.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$788.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,672.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,089.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,928.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,928.52
|
| Rate for Payer: Multiplan Commercial |
$3,267.75
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,567.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,442.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,486.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,556.64
|
| Rate for Payer: Vantage Medical Group Senior |
$2,324.22
|
|
|
HC SKIN SUB GRFT DIGIT 1ST 25 SQ
|
Facility
|
OP
|
$4,357.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
900501784
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$871.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,993.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,486.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,556.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,324.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,657.77
|
| Rate for Payer: Blue Shield of California EPN |
$2,126.22
|
| Rate for Payer: Cash Price |
$2,396.35
|
| Rate for Payer: Cash Price |
$2,396.35
|
| Rate for Payer: Cash Price |
$2,396.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,832.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,486.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,556.64
|
| Rate for Payer: Dignity Health Senior |
$2,324.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,324.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,696.98
|
| Rate for Payer: Heritage Provider Network Senior |
$2,696.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$134.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,324.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,078.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$788.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,672.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,089.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,928.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,928.52
|
| Rate for Payer: Multiplan Commercial |
$3,267.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,556.64
|
| Rate for Payer: TriValley Medical Group Senior |
$2,556.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,178.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,178.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,486.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,556.64
|
| Rate for Payer: Vantage Medical Group Senior |
$2,324.22
|
|
|
HC SKIN SUB GRFT HEAD HANDS DIGITS FEET 1ST 100 SQ CM
|
Facility
|
OP
|
$6,118.00
|
|
|
Service Code
|
CPT 15277
|
| Hospital Charge Code |
900101503
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,223.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,203.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,486.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,556.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,324.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,731.98
|
| Rate for Payer: Blue Shield of California EPN |
$2,985.58
|
| Rate for Payer: Cash Price |
$3,364.90
|
| Rate for Payer: Cash Price |
$3,364.90
|
| Rate for Payer: Cash Price |
$3,364.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,976.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,486.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,556.64
|
| Rate for Payer: Dignity Health Senior |
$2,324.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,324.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,787.04
|
| Rate for Payer: Heritage Provider Network Senior |
$3,787.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$287.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,324.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,918.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,107.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,672.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,529.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,928.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,928.52
|
| Rate for Payer: Multiplan Commercial |
$4,588.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,556.64
|
| Rate for Payer: TriValley Medical Group Senior |
$2,556.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,059.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,059.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,486.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,556.64
|
| Rate for Payer: Vantage Medical Group Senior |
$2,324.22
|
|
|
HC SKIN SUB GRFT HEAD HANDS DIGITS FEET 1ST 100 SQ CM
|
Facility
|
IP
|
$6,118.00
|
|
|
Service Code
|
CPT 15277
|
| Hospital Charge Code |
900101503
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,107.36 |
| Max. Negotiated Rate |
$4,588.50 |
| Rate for Payer: Adventist Health Commercial |
$1,223.60
|
| Rate for Payer: Cash Price |
$3,364.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,141.89
|
| Rate for Payer: Heritage Provider Network Senior |
$4,141.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,107.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,529.50
|
| Rate for Payer: Multiplan Commercial |
$4,588.50
|
|
|
HC SKIN SUB GRFT HEAD HANDS DIGITS FEET ADDL 100 SQ CM
|
Facility
|
IP
|
$3,059.00
|
|
|
Service Code
|
CPT 15278
|
| Hospital Charge Code |
900101504
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$553.68 |
| Max. Negotiated Rate |
$2,294.25 |
| Rate for Payer: Adventist Health Commercial |
$611.80
|
| Rate for Payer: Cash Price |
$1,682.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,070.94
|
| Rate for Payer: Heritage Provider Network Senior |
$2,070.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$553.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$764.75
|
| Rate for Payer: Multiplan Commercial |
$2,294.25
|
|
|
HC SKIN SUB GRFT HEAD HANDS DIGITS FEET ADDL 100 SQ CM
|
Facility
|
OP
|
$3,059.00
|
|
|
Service Code
|
CPT 15278
|
| Hospital Charge Code |
900101504
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$611.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,101.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,600.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,682.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,294.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,865.99
|
| Rate for Payer: Blue Shield of California EPN |
$1,492.79
|
| Rate for Payer: Cash Price |
$1,682.45
|
| Rate for Payer: Cash Price |
$1,682.45
|
| Rate for Payer: Cash Price |
$1,682.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,988.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,600.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,600.15
|
| Rate for Payer: Dignity Health Senior |
$2,600.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,893.52
|
| Rate for Payer: Heritage Provider Network Senior |
$1,893.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$73.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,459.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$553.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$764.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,141.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,141.30
|
| Rate for Payer: Multiplan Commercial |
$2,294.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,529.50
|
| Rate for Payer: TriValley Medical Group Senior |
$1,529.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,529.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,529.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,600.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,600.15
|
| Rate for Payer: Vantage Medical Group Senior |
$2,600.15
|
|
|
HC SKIN SUB GRFT HEAD HANDS DIGITS FEET ADDL 25 SQ CM
|
Facility
|
IP
|
$3,059.00
|
|
|
Service Code
|
CPT 15276
|
| Hospital Charge Code |
900101502
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$553.68 |
| Max. Negotiated Rate |
$2,294.25 |
| Rate for Payer: Adventist Health Commercial |
$611.80
|
| Rate for Payer: Cash Price |
$1,682.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,070.94
|
| Rate for Payer: Heritage Provider Network Senior |
$2,070.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$553.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$764.75
|
| Rate for Payer: Multiplan Commercial |
$2,294.25
|
|
|
HC SKIN SUB GRFT HEAD HANDS DIGITS FEET ADDL 25 SQ CM
|
Facility
|
OP
|
$3,059.00
|
|
|
Service Code
|
CPT 15276
|
| Hospital Charge Code |
900101502
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$611.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,101.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,600.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,682.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,294.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,865.99
|
| Rate for Payer: Blue Shield of California EPN |
$1,492.79
|
| Rate for Payer: Cash Price |
$1,682.45
|
| Rate for Payer: Cash Price |
$1,682.45
|
| Rate for Payer: Cash Price |
$1,682.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,988.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,600.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,600.15
|
| Rate for Payer: Dignity Health Senior |
$2,600.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,893.52
|
| Rate for Payer: Heritage Provider Network Senior |
$1,893.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$33.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,459.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$553.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$764.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,141.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,141.30
|
| Rate for Payer: Multiplan Commercial |
$2,294.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,529.50
|
| Rate for Payer: TriValley Medical Group Senior |
$1,529.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,529.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,529.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,600.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,600.15
|
| Rate for Payer: Vantage Medical Group Senior |
$2,600.15
|
|
|
HC SKIN SUBSTITUTE PRIMATRIX 3X3
|
Facility
|
IP
|
$263.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101464
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$197.25 |
| Rate for Payer: Adventist Health Commercial |
$52.60
|
| Rate for Payer: Cash Price |
$144.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$120.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$142.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$121.77
|
| Rate for Payer: Heritage Provider Network Senior |
$121.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.75
|
| Rate for Payer: Multiplan Commercial |
$197.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$95.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$87.08
|
|
|
HC SKIN SUBSTITUTE PRIMATRIX 3X3
|
Facility
|
OP
|
$263.00
|
|
|
Service Code
|
CPT Q4110
|
| Hospital Charge Code |
900101464
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$223.55 |
| Rate for Payer: Adventist Health Commercial |
$52.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$140.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$180.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$223.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$144.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$197.25
|
| Rate for Payer: Blue Shield of California Commercial |
$160.43
|
| Rate for Payer: Blue Shield of California EPN |
$128.34
|
| Rate for Payer: Cash Price |
$144.65
|
| Rate for Payer: Cash Price |
$144.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$120.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$223.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$223.55
|
| Rate for Payer: Dignity Health Senior |
$223.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$168.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$121.77
|
| Rate for Payer: Heritage Provider Network Senior |
$121.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$65.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$125.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$184.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$184.10
|
| Rate for Payer: Multiplan Commercial |
$197.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$105.20
|
| Rate for Payer: TriValley Medical Group Senior |
$105.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$95.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$87.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$223.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$223.55
|
| Rate for Payer: Vantage Medical Group Senior |
$223.55
|
|
