|
HC ADD LE, CUSTOM ROSS CONGENITAL
|
Facility
|
IP
|
$2,071.00
|
|
|
Service Code
|
CPT L5681
|
| Hospital Charge Code |
915355681
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$414.20 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$414.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$931.95
|
| Rate for Payer: Cash Price |
$931.95
|
| Rate for Payer: Cigna of CA HMO |
$1,449.70
|
| Rate for Payer: Cigna of CA PPO |
$1,449.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$828.40
|
| Rate for Payer: EPIC Health Plan Senior |
$828.40
|
| Rate for Payer: Galaxy Health WC |
$1,760.35
|
| Rate for Payer: Global Benefits Group Commercial |
$1,242.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,381.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$789.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,281.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$497.04
|
| Rate for Payer: Multiplan Commercial |
$1,656.80
|
| Rate for Payer: Networks By Design Commercial |
$1,035.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,760.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$777.25
|
| Rate for Payer: United Healthcare All Other HMO |
$756.54
|
| Rate for Payer: United Healthcare HMO Rider |
$740.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$678.25
|
|
|
HC ADD LE, CUSTOM ROSS CONGENITAL
|
Facility
|
IP
|
$2,071.00
|
|
|
Service Code
|
CPT L5681
|
| Hospital Charge Code |
905355681
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$414.20 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$414.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$931.95
|
| Rate for Payer: Cash Price |
$931.95
|
| Rate for Payer: Cigna of CA HMO |
$1,449.70
|
| Rate for Payer: Cigna of CA PPO |
$1,449.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$828.40
|
| Rate for Payer: EPIC Health Plan Senior |
$828.40
|
| Rate for Payer: Galaxy Health WC |
$1,760.35
|
| Rate for Payer: Global Benefits Group Commercial |
$1,242.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,381.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$789.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,281.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$497.04
|
| Rate for Payer: Multiplan Commercial |
$1,656.80
|
| Rate for Payer: Networks By Design Commercial |
$1,035.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,760.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$777.25
|
| Rate for Payer: United Healthcare All Other HMO |
$756.54
|
| Rate for Payer: United Healthcare HMO Rider |
$740.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$678.25
|
|
|
HC ADD LE, CUSTOM ROSS CONGENITAL
|
Facility
|
OP
|
$2,071.00
|
|
|
Service Code
|
CPT L5681
|
| Hospital Charge Code |
915355681
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$497.04 |
| Max. Negotiated Rate |
$1,760.35 |
| Rate for Payer: Adventist Health Commercial |
$849.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,760.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,139.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,553.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,199.52
|
| Rate for Payer: Blue Shield of California Commercial |
$1,528.40
|
| Rate for Payer: Blue Shield of California EPN |
$1,006.51
|
| Rate for Payer: Cash Price |
$931.95
|
| Rate for Payer: Cash Price |
$931.95
|
| Rate for Payer: Cigna of CA HMO |
$1,449.70
|
| Rate for Payer: Cigna of CA PPO |
$1,449.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,760.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,760.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,760.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$828.40
|
| Rate for Payer: EPIC Health Plan Senior |
$828.40
|
| Rate for Payer: Galaxy Health WC |
$1,760.35
|
| Rate for Payer: Global Benefits Group Commercial |
$1,242.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,391.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,381.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,574.09
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,281.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$497.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,449.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,449.70
|
| Rate for Payer: Multiplan Commercial |
$1,656.80
|
| Rate for Payer: Networks By Design Commercial |
$1,035.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,760.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,242.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,242.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$777.25
|
| Rate for Payer: United Healthcare All Other HMO |
$756.54
|
| Rate for Payer: United Healthcare HMO Rider |
$740.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$678.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,760.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,760.35
|
| Rate for Payer: Vantage Medical Group Senior |
$1,760.35
|
|
|
HC ADD LE CUSTOM SILICONE INSERT
|
Facility
|
IP
|
$2,071.00
|
|
|
Service Code
|
CPT L5683
|
| Hospital Charge Code |
915355683
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$414.20 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$414.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$931.95
|
| Rate for Payer: Cash Price |
$931.95
|
| Rate for Payer: Cigna of CA HMO |
$1,449.70
|
| Rate for Payer: Cigna of CA PPO |
$1,449.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$828.40
|
| Rate for Payer: EPIC Health Plan Senior |
$828.40
|
| Rate for Payer: Galaxy Health WC |
$1,760.35
|
| Rate for Payer: Global Benefits Group Commercial |
$1,242.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,381.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$789.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,281.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$497.04
|
| Rate for Payer: Multiplan Commercial |
$1,656.80
|
| Rate for Payer: Networks By Design Commercial |
$1,035.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,760.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$777.25
|
| Rate for Payer: United Healthcare All Other HMO |
$756.54
|
| Rate for Payer: United Healthcare HMO Rider |
$740.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$678.25
|
|
|
HC ADD LE CUSTOM SILICONE INSERT
|
Facility
|
OP
|
$2,071.00
|
|
|
Service Code
|
CPT L5683
|
| Hospital Charge Code |
915355683
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$497.04 |
| Max. Negotiated Rate |
$1,760.35 |
| Rate for Payer: Adventist Health Commercial |
$849.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,760.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,139.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,553.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,199.52
|
| Rate for Payer: Blue Shield of California Commercial |
$1,528.40
|
| Rate for Payer: Blue Shield of California EPN |
$1,006.51
|
| Rate for Payer: Cash Price |
$931.95
|
| Rate for Payer: Cash Price |
$931.95
|
| Rate for Payer: Cigna of CA HMO |
$1,449.70
|
| Rate for Payer: Cigna of CA PPO |
$1,449.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,760.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,760.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,760.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$828.40
|
| Rate for Payer: EPIC Health Plan Senior |
$828.40
|
| Rate for Payer: Galaxy Health WC |
$1,760.35
|
| Rate for Payer: Global Benefits Group Commercial |
$1,242.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,391.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,381.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,574.09
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,281.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$497.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,449.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,449.70
|
| Rate for Payer: Multiplan Commercial |
$1,656.80
|
| Rate for Payer: Networks By Design Commercial |
$1,035.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,760.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,242.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,242.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$777.25
|
| Rate for Payer: United Healthcare All Other HMO |
$756.54
|
| Rate for Payer: United Healthcare HMO Rider |
$740.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$678.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,760.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,760.35
|
| Rate for Payer: Vantage Medical Group Senior |
$1,760.35
|
|
|
HC ADD LE CUSTOM SILICONE INSERT
|
Facility
|
OP
|
$2,071.00
|
|
|
Service Code
|
CPT L5683
|
| Hospital Charge Code |
905355683
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$497.04 |
| Max. Negotiated Rate |
$1,760.35 |
| Rate for Payer: Adventist Health Commercial |
$849.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,760.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,139.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,553.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,199.52
|
| Rate for Payer: Blue Shield of California Commercial |
$1,528.40
|
| Rate for Payer: Blue Shield of California EPN |
$1,006.51
|
| Rate for Payer: Cash Price |
$931.95
|
| Rate for Payer: Cash Price |
$931.95
|
| Rate for Payer: Cigna of CA HMO |
$1,449.70
|
| Rate for Payer: Cigna of CA PPO |
$1,449.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,760.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,760.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,760.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$828.40
|
| Rate for Payer: EPIC Health Plan Senior |
$828.40
|
| Rate for Payer: Galaxy Health WC |
$1,760.35
|
| Rate for Payer: Global Benefits Group Commercial |
$1,242.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,391.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,381.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,574.09
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,281.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$497.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,449.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,449.70
|
| Rate for Payer: Multiplan Commercial |
$1,656.80
|
| Rate for Payer: Networks By Design Commercial |
$1,035.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,760.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,242.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,242.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$777.25
|
| Rate for Payer: United Healthcare All Other HMO |
$756.54
|
| Rate for Payer: United Healthcare HMO Rider |
$740.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$678.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,760.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,760.35
|
| Rate for Payer: Vantage Medical Group Senior |
$1,760.35
|
|
|
HC ADD LE CUSTOM SILICONE INSERT
|
Facility
|
IP
|
$2,071.00
|
|
|
Service Code
|
CPT L5683
|
| Hospital Charge Code |
905355683
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$414.20 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$414.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$931.95
|
| Rate for Payer: Cash Price |
$931.95
|
| Rate for Payer: Cigna of CA HMO |
$1,449.70
|
| Rate for Payer: Cigna of CA PPO |
$1,449.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$828.40
|
| Rate for Payer: EPIC Health Plan Senior |
$828.40
|
| Rate for Payer: Galaxy Health WC |
$1,760.35
|
| Rate for Payer: Global Benefits Group Commercial |
$1,242.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,381.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$789.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,281.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$497.04
|
| Rate for Payer: Multiplan Commercial |
$1,656.80
|
| Rate for Payer: Networks By Design Commercial |
$1,035.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,760.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$777.25
|
| Rate for Payer: United Healthcare All Other HMO |
$756.54
|
| Rate for Payer: United Healthcare HMO Rider |
$740.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$678.25
|
|
|
HC ADD. LE FOOT LAMIN/PREPREG COMPOSIT
|
Facility
|
OP
|
$523.00
|
|
|
Service Code
|
CPT L3031
|
| Hospital Charge Code |
905353031
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$125.52 |
| Max. Negotiated Rate |
$444.55 |
| Rate for Payer: Adventist Health Commercial |
$214.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$444.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$287.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$392.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$302.92
|
| Rate for Payer: Blue Shield of California Commercial |
$385.97
|
| Rate for Payer: Blue Shield of California EPN |
$254.18
|
| Rate for Payer: Cash Price |
$235.35
|
| Rate for Payer: Cigna of CA HMO |
$366.10
|
| Rate for Payer: Cigna of CA PPO |
$366.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$444.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$444.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$444.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$209.20
|
| Rate for Payer: EPIC Health Plan Senior |
$209.20
|
| Rate for Payer: Galaxy Health WC |
$444.55
|
| Rate for Payer: Global Benefits Group Commercial |
$313.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$348.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$199.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$323.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$366.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$366.10
|
| Rate for Payer: Multiplan Commercial |
$418.40
|
| Rate for Payer: Networks By Design Commercial |
$261.50
|
| Rate for Payer: Prime Health Services Commercial |
$444.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$313.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$313.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$196.28
|
| Rate for Payer: United Healthcare All Other HMO |
$191.05
|
| Rate for Payer: United Healthcare HMO Rider |
$186.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$171.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$444.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$444.55
|
| Rate for Payer: Vantage Medical Group Senior |
$444.55
|
|
|
HC ADD. LE FOOT LAMIN/PREPREG COMPOSIT
|
Facility
|
IP
|
$523.00
|
|
|
Service Code
|
CPT L3031
|
| Hospital Charge Code |
905353031
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$104.60 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$104.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$235.35
|
| Rate for Payer: Cash Price |
$235.35
|
| Rate for Payer: Cigna of CA HMO |
$366.10
|
| Rate for Payer: Cigna of CA PPO |
$366.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$209.20
|
| Rate for Payer: EPIC Health Plan Senior |
$209.20
|
| Rate for Payer: Galaxy Health WC |
$444.55
|
| Rate for Payer: Global Benefits Group Commercial |
$313.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$348.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$199.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$323.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.52
|
| Rate for Payer: Multiplan Commercial |
$418.40
|
| Rate for Payer: Networks By Design Commercial |
$261.50
|
| Rate for Payer: Prime Health Services Commercial |
$444.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$196.28
|
| Rate for Payer: United Healthcare All Other HMO |
$191.05
|
| Rate for Payer: United Healthcare HMO Rider |
$186.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$171.28
|
|
|
HC ADD. LE FOOT LAMIN/PREPREG COMPOSIT
|
Facility
|
OP
|
$523.00
|
|
|
Service Code
|
CPT L3031
|
| Hospital Charge Code |
915353031
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$125.52 |
| Max. Negotiated Rate |
$444.55 |
| Rate for Payer: Adventist Health Commercial |
$214.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$444.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$287.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$392.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$302.92
|
| Rate for Payer: Blue Shield of California Commercial |
$385.97
|
| Rate for Payer: Blue Shield of California EPN |
$254.18
|
| Rate for Payer: Cash Price |
$235.35
|
| Rate for Payer: Cigna of CA HMO |
$366.10
|
| Rate for Payer: Cigna of CA PPO |
$366.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$444.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$444.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$444.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$209.20
|
| Rate for Payer: EPIC Health Plan Senior |
$209.20
|
| Rate for Payer: Galaxy Health WC |
$444.55
|
| Rate for Payer: Global Benefits Group Commercial |
$313.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$348.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$199.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$323.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$366.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$366.10
|
| Rate for Payer: Multiplan Commercial |
$418.40
|
| Rate for Payer: Networks By Design Commercial |
$261.50
|
| Rate for Payer: Prime Health Services Commercial |
$444.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$313.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$313.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$196.28
|
| Rate for Payer: United Healthcare All Other HMO |
$191.05
|
| Rate for Payer: United Healthcare HMO Rider |
$186.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$171.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$444.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$444.55
|
| Rate for Payer: Vantage Medical Group Senior |
$444.55
|
|
|
HC ADD. LE FOOT LAMIN/PREPREG COMPOSIT
|
Facility
|
IP
|
$523.00
|
|
|
Service Code
|
CPT L3031
|
| Hospital Charge Code |
915353031
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$104.60 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Cigna of CA PPO |
$366.10
|
| Rate for Payer: Adventist Health Commercial |
$104.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$235.35
|
| Rate for Payer: Cash Price |
$235.35
|
| Rate for Payer: Cigna of CA HMO |
$366.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$209.20
|
| Rate for Payer: EPIC Health Plan Senior |
$209.20
|
| Rate for Payer: Galaxy Health WC |
$444.55
|
| Rate for Payer: Global Benefits Group Commercial |
$313.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$348.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$199.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$323.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.52
|
| Rate for Payer: Multiplan Commercial |
$418.40
|
| Rate for Payer: Networks By Design Commercial |
$261.50
|
| Rate for Payer: Prime Health Services Commercial |
$444.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$196.28
|
| Rate for Payer: United Healthcare All Other HMO |
$191.05
|
| Rate for Payer: United Healthcare HMO Rider |
$186.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$171.28
|
|
|
HC ADD/LE PROS VACUUM PUMP VLM MG
|
Facility
|
IP
|
$6,750.00
|
|
|
Service Code
|
CPT L5781
|
| Hospital Charge Code |
905355781
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,350.00 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$1,350.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$3,037.50
|
| Rate for Payer: Cash Price |
$3,037.50
|
| Rate for Payer: Cigna of CA HMO |
$4,725.00
|
| Rate for Payer: Cigna of CA PPO |
$4,725.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,700.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2,700.00
|
| Rate for Payer: Galaxy Health WC |
$5,737.50
|
| Rate for Payer: Global Benefits Group Commercial |
$4,050.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,502.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,571.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,178.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,620.00
|
| Rate for Payer: Multiplan Commercial |
$5,400.00
|
| Rate for Payer: Networks By Design Commercial |
$3,375.00
|
| Rate for Payer: Prime Health Services Commercial |
$5,737.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,533.28
|
| Rate for Payer: United Healthcare All Other HMO |
$2,465.78
|
| Rate for Payer: United Healthcare HMO Rider |
$2,412.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,210.62
|
|
|
HC ADD/LE PROS VACUUM PUMP VLM MG
|
Facility
|
OP
|
$6,750.00
|
|
|
Service Code
|
CPT L5781
|
| Hospital Charge Code |
905355781
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,620.00 |
| Max. Negotiated Rate |
$5,737.50 |
| Rate for Payer: Adventist Health Commercial |
$2,767.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,737.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,712.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,062.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,909.60
|
| Rate for Payer: Blue Shield of California Commercial |
$4,981.50
|
| Rate for Payer: Blue Shield of California EPN |
$3,280.50
|
| Rate for Payer: Cash Price |
$3,037.50
|
| Rate for Payer: Cash Price |
$3,037.50
|
| Rate for Payer: Cigna of CA HMO |
$4,725.00
|
| Rate for Payer: Cigna of CA PPO |
$4,725.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,737.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,737.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5,737.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,700.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2,700.00
|
| Rate for Payer: Galaxy Health WC |
$5,737.50
|
| Rate for Payer: Global Benefits Group Commercial |
$4,050.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4,233.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,502.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,788.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,178.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,620.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,725.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,725.00
|
| Rate for Payer: Multiplan Commercial |
$5,400.00
|
| Rate for Payer: Networks By Design Commercial |
$3,375.00
|
| Rate for Payer: Prime Health Services Commercial |
$5,737.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4,050.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4,050.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,533.28
|
| Rate for Payer: United Healthcare All Other HMO |
$2,465.78
|
| Rate for Payer: United Healthcare HMO Rider |
$2,412.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,210.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,737.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,737.50
|
| Rate for Payer: Vantage Medical Group Senior |
$5,737.50
|
|
|
HC ADD/LE PROS VACUUM PUMP VLM MG
|
Facility
|
OP
|
$6,750.00
|
|
|
Service Code
|
CPT L5781
|
| Hospital Charge Code |
915355781
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,620.00 |
| Max. Negotiated Rate |
$5,737.50 |
| Rate for Payer: Adventist Health Commercial |
$2,767.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,737.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,712.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,062.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,909.60
|
| Rate for Payer: Blue Shield of California Commercial |
$4,981.50
|
| Rate for Payer: Blue Shield of California EPN |
$3,280.50
|
| Rate for Payer: Cash Price |
$3,037.50
|
| Rate for Payer: Cash Price |
$3,037.50
|
| Rate for Payer: Cigna of CA HMO |
$4,725.00
|
| Rate for Payer: Cigna of CA PPO |
$4,725.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,737.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,737.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5,737.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,700.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2,700.00
|
| Rate for Payer: Galaxy Health WC |
$5,737.50
|
| Rate for Payer: Global Benefits Group Commercial |
$4,050.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4,233.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,502.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,788.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,178.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,620.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,725.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,725.00
|
| Rate for Payer: Multiplan Commercial |
$5,400.00
|
| Rate for Payer: Networks By Design Commercial |
$3,375.00
|
| Rate for Payer: Prime Health Services Commercial |
$5,737.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4,050.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4,050.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,533.28
|
| Rate for Payer: United Healthcare All Other HMO |
$2,465.78
|
| Rate for Payer: United Healthcare HMO Rider |
$2,412.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,210.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,737.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,737.50
|
| Rate for Payer: Vantage Medical Group Senior |
$5,737.50
|
|
|
HC ADD/LE PROS VACUUM PUMP VLM MG
|
Facility
|
IP
|
$6,750.00
|
|
|
Service Code
|
CPT L5781
|
| Hospital Charge Code |
915355781
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,350.00 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$1,350.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$3,037.50
|
| Rate for Payer: Cash Price |
$3,037.50
|
| Rate for Payer: Cigna of CA HMO |
$4,725.00
|
| Rate for Payer: Cigna of CA PPO |
$4,725.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,700.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2,700.00
|
| Rate for Payer: Galaxy Health WC |
$5,737.50
|
| Rate for Payer: Global Benefits Group Commercial |
$4,050.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,502.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,571.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,178.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,620.00
|
| Rate for Payer: Multiplan Commercial |
$5,400.00
|
| Rate for Payer: Networks By Design Commercial |
$3,375.00
|
| Rate for Payer: Prime Health Services Commercial |
$5,737.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,533.28
|
| Rate for Payer: United Healthcare All Other HMO |
$2,465.78
|
| Rate for Payer: United Healthcare HMO Rider |
$2,412.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,210.62
|
|
|
HC ADD LE SILICONE INSERT NO LOCK
|
Facility
|
IP
|
$1,122.00
|
|
|
Service Code
|
CPT L5679
|
| Hospital Charge Code |
905355679
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$224.40 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$224.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$504.90
|
| Rate for Payer: Cash Price |
$504.90
|
| Rate for Payer: Cigna of CA HMO |
$785.40
|
| Rate for Payer: Cigna of CA PPO |
$785.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$448.80
|
| Rate for Payer: EPIC Health Plan Senior |
$448.80
|
| Rate for Payer: Galaxy Health WC |
$953.70
|
| Rate for Payer: Global Benefits Group Commercial |
$673.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$748.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$427.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$694.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$269.28
|
| Rate for Payer: Multiplan Commercial |
$897.60
|
| Rate for Payer: Networks By Design Commercial |
$561.00
|
| Rate for Payer: Prime Health Services Commercial |
$953.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$421.09
|
| Rate for Payer: United Healthcare All Other HMO |
$409.87
|
| Rate for Payer: United Healthcare HMO Rider |
$401.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$367.45
|
|
|
HC ADD LE SILICONE INSERT NO LOCK
|
Facility
|
OP
|
$1,122.00
|
|
|
Service Code
|
CPT L5679
|
| Hospital Charge Code |
915355679
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$269.28 |
| Max. Negotiated Rate |
$953.70 |
| Rate for Payer: Adventist Health Commercial |
$460.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$953.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$617.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$841.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$649.86
|
| Rate for Payer: Blue Shield of California Commercial |
$828.04
|
| Rate for Payer: Blue Shield of California EPN |
$545.29
|
| Rate for Payer: Cash Price |
$504.90
|
| Rate for Payer: Cash Price |
$504.90
|
| Rate for Payer: Cigna of CA HMO |
$785.40
|
| Rate for Payer: Cigna of CA PPO |
$785.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$953.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$953.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$953.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$448.80
|
| Rate for Payer: EPIC Health Plan Senior |
$448.80
|
| Rate for Payer: Galaxy Health WC |
$953.70
|
| Rate for Payer: Global Benefits Group Commercial |
$673.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$703.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$748.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$795.99
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$694.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$269.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$785.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$785.40
|
| Rate for Payer: Multiplan Commercial |
$897.60
|
| Rate for Payer: Networks By Design Commercial |
$561.00
|
| Rate for Payer: Prime Health Services Commercial |
$953.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$673.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$673.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$421.09
|
| Rate for Payer: United Healthcare All Other HMO |
$409.87
|
| Rate for Payer: United Healthcare HMO Rider |
$401.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$367.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$953.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$953.70
|
| Rate for Payer: Vantage Medical Group Senior |
$953.70
|
|
|
HC ADD LE SILICONE INSERT NO LOCK
|
Facility
|
OP
|
$1,122.00
|
|
|
Service Code
|
CPT L5679
|
| Hospital Charge Code |
905355679
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$269.28 |
| Max. Negotiated Rate |
$953.70 |
| Rate for Payer: Adventist Health Commercial |
$460.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$953.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$617.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$841.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$649.86
|
| Rate for Payer: Blue Shield of California Commercial |
$828.04
|
| Rate for Payer: Blue Shield of California EPN |
$545.29
|
| Rate for Payer: Cash Price |
$504.90
|
| Rate for Payer: Cash Price |
$504.90
|
| Rate for Payer: Cigna of CA HMO |
$785.40
|
| Rate for Payer: Cigna of CA PPO |
$785.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$953.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$953.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$953.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$448.80
|
| Rate for Payer: EPIC Health Plan Senior |
$448.80
|
| Rate for Payer: Galaxy Health WC |
$953.70
|
| Rate for Payer: Global Benefits Group Commercial |
$673.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$703.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$748.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$795.99
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$694.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$269.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$785.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$785.40
|
| Rate for Payer: Multiplan Commercial |
$897.60
|
| Rate for Payer: Networks By Design Commercial |
$561.00
|
| Rate for Payer: Prime Health Services Commercial |
$953.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$673.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$673.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$421.09
|
| Rate for Payer: United Healthcare All Other HMO |
$409.87
|
| Rate for Payer: United Healthcare HMO Rider |
$401.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$367.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$953.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$953.70
|
| Rate for Payer: Vantage Medical Group Senior |
$953.70
|
|
|
HC ADD LE SILICONE INSERT NO LOCK
|
Facility
|
IP
|
$1,122.00
|
|
|
Service Code
|
CPT L5679
|
| Hospital Charge Code |
915355679
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$224.40 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$224.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$504.90
|
| Rate for Payer: Cash Price |
$504.90
|
| Rate for Payer: Cigna of CA HMO |
$785.40
|
| Rate for Payer: Cigna of CA PPO |
$785.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$448.80
|
| Rate for Payer: EPIC Health Plan Senior |
$448.80
|
| Rate for Payer: Galaxy Health WC |
$953.70
|
| Rate for Payer: Global Benefits Group Commercial |
$673.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$748.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$427.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$694.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$269.28
|
| Rate for Payer: Multiplan Commercial |
$897.60
|
| Rate for Payer: Networks By Design Commercial |
$561.00
|
| Rate for Payer: Prime Health Services Commercial |
$953.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$421.09
|
| Rate for Payer: United Healthcare All Other HMO |
$409.87
|
| Rate for Payer: United Healthcare HMO Rider |
$401.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$367.45
|
|
|
HC ADD LE SILICONE INSERT W/LOCK
|
Facility
|
IP
|
$1,534.00
|
|
|
Service Code
|
CPT L5673
|
| Hospital Charge Code |
915355673
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$306.80 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$306.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$690.30
|
| Rate for Payer: Cash Price |
$690.30
|
| Rate for Payer: Cigna of CA HMO |
$1,073.80
|
| Rate for Payer: Cigna of CA PPO |
$1,073.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$613.60
|
| Rate for Payer: EPIC Health Plan Senior |
$613.60
|
| Rate for Payer: Galaxy Health WC |
$1,303.90
|
| Rate for Payer: Global Benefits Group Commercial |
$920.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,023.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$584.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$949.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$368.16
|
| Rate for Payer: Multiplan Commercial |
$1,227.20
|
| Rate for Payer: Networks By Design Commercial |
$767.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,303.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$575.71
|
| Rate for Payer: United Healthcare All Other HMO |
$560.37
|
| Rate for Payer: United Healthcare HMO Rider |
$548.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$502.38
|
|
|
HC ADD LE SILICONE INSERT W/LOCK
|
Facility
|
IP
|
$1,346.00
|
|
|
Service Code
|
CPT L5673
|
| Hospital Charge Code |
905355673
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$269.20 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$269.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$605.70
|
| Rate for Payer: Cash Price |
$605.70
|
| Rate for Payer: Cigna of CA HMO |
$942.20
|
| Rate for Payer: Cigna of CA PPO |
$942.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$538.40
|
| Rate for Payer: EPIC Health Plan Senior |
$538.40
|
| Rate for Payer: Galaxy Health WC |
$1,144.10
|
| Rate for Payer: Global Benefits Group Commercial |
$807.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$897.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$512.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$833.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$323.04
|
| Rate for Payer: Multiplan Commercial |
$1,076.80
|
| Rate for Payer: Networks By Design Commercial |
$673.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,144.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$505.15
|
| Rate for Payer: United Healthcare All Other HMO |
$491.69
|
| Rate for Payer: United Healthcare HMO Rider |
$481.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$440.81
|
|
|
HC ADD LE SILICONE INSERT W/LOCK
|
Facility
|
OP
|
$1,346.00
|
|
|
Service Code
|
CPT L5673
|
| Hospital Charge Code |
905355673
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$323.04 |
| Max. Negotiated Rate |
$1,144.10 |
| Rate for Payer: Adventist Health Commercial |
$551.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,144.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$740.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,009.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$779.60
|
| Rate for Payer: Blue Shield of California Commercial |
$993.35
|
| Rate for Payer: Blue Shield of California EPN |
$654.16
|
| Rate for Payer: Cash Price |
$605.70
|
| Rate for Payer: Cash Price |
$605.70
|
| Rate for Payer: Cigna of CA HMO |
$942.20
|
| Rate for Payer: Cigna of CA PPO |
$942.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,144.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,144.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,144.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$538.40
|
| Rate for Payer: EPIC Health Plan Senior |
$538.40
|
| Rate for Payer: Galaxy Health WC |
$1,144.10
|
| Rate for Payer: Global Benefits Group Commercial |
$807.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$844.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$897.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$955.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$833.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$323.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$942.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$942.20
|
| Rate for Payer: Multiplan Commercial |
$1,076.80
|
| Rate for Payer: Networks By Design Commercial |
$673.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,144.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$807.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$807.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$505.15
|
| Rate for Payer: United Healthcare All Other HMO |
$491.69
|
| Rate for Payer: United Healthcare HMO Rider |
$481.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$440.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,144.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,144.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1,144.10
|
|
|
HC ADD LE SILICONE INSERT W/LOCK
|
Facility
|
OP
|
$1,534.00
|
|
|
Service Code
|
CPT L5673
|
| Hospital Charge Code |
915355673
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$368.16 |
| Max. Negotiated Rate |
$1,303.90 |
| Rate for Payer: Adventist Health Commercial |
$628.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,303.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$843.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,150.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$888.49
|
| Rate for Payer: Blue Shield of California Commercial |
$1,132.09
|
| Rate for Payer: Blue Shield of California EPN |
$745.52
|
| Rate for Payer: Cash Price |
$690.30
|
| Rate for Payer: Cash Price |
$690.30
|
| Rate for Payer: Cigna of CA HMO |
$1,073.80
|
| Rate for Payer: Cigna of CA PPO |
$1,073.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,303.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,303.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,303.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$613.60
|
| Rate for Payer: EPIC Health Plan Senior |
$613.60
|
| Rate for Payer: Galaxy Health WC |
$1,303.90
|
| Rate for Payer: Global Benefits Group Commercial |
$920.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$844.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,023.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$955.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$949.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$368.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,073.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,073.80
|
| Rate for Payer: Multiplan Commercial |
$1,227.20
|
| Rate for Payer: Networks By Design Commercial |
$767.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,303.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$920.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$920.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$575.71
|
| Rate for Payer: United Healthcare All Other HMO |
$560.37
|
| Rate for Payer: United Healthcare HMO Rider |
$548.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$502.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,303.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,303.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1,303.90
|
|
|
HC ADDN ENDO KNEE/SHIN HYDRAULIC
|
Facility
|
IP
|
$6,265.00
|
|
|
Service Code
|
CPT L5814
|
| Hospital Charge Code |
905355814
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,253.00 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$1,253.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$2,819.25
|
| Rate for Payer: Cash Price |
$2,819.25
|
| Rate for Payer: Cigna of CA HMO |
$4,385.50
|
| Rate for Payer: Cigna of CA PPO |
$4,385.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,506.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2,506.00
|
| Rate for Payer: Galaxy Health WC |
$5,325.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3,759.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,178.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,386.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,878.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,503.60
|
| Rate for Payer: Multiplan Commercial |
$5,012.00
|
| Rate for Payer: Networks By Design Commercial |
$3,132.50
|
| Rate for Payer: Prime Health Services Commercial |
$5,325.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,351.25
|
| Rate for Payer: United Healthcare All Other HMO |
$2,288.60
|
| Rate for Payer: United Healthcare HMO Rider |
$2,239.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,051.79
|
|
|
HC ADDN ENDO KNEE/SHIN HYDRAULIC
|
Facility
|
OP
|
$6,265.00
|
|
|
Service Code
|
CPT L5814
|
| Hospital Charge Code |
915355814
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,503.60 |
| Max. Negotiated Rate |
$5,325.25 |
| Rate for Payer: Adventist Health Commercial |
$2,568.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,325.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,445.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,698.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,628.69
|
| Rate for Payer: Blue Shield of California Commercial |
$4,623.57
|
| Rate for Payer: Blue Shield of California EPN |
$3,044.79
|
| Rate for Payer: Cash Price |
$2,819.25
|
| Rate for Payer: Cash Price |
$2,819.25
|
| Rate for Payer: Cigna of CA HMO |
$4,385.50
|
| Rate for Payer: Cigna of CA PPO |
$4,385.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,325.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,325.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5,325.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,506.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2,506.00
|
| Rate for Payer: Galaxy Health WC |
$5,325.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3,759.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2,726.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,178.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,083.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,878.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,503.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,385.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,385.50
|
| Rate for Payer: Multiplan Commercial |
$5,012.00
|
| Rate for Payer: Networks By Design Commercial |
$3,132.50
|
| Rate for Payer: Prime Health Services Commercial |
$5,325.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,759.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,759.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,351.25
|
| Rate for Payer: United Healthcare All Other HMO |
$2,288.60
|
| Rate for Payer: United Healthcare HMO Rider |
$2,239.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,051.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,325.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,325.25
|
| Rate for Payer: Vantage Medical Group Senior |
$5,325.25
|
|
