|
HC LMA FASTRACH CHILD #5
|
Facility
|
OP
|
$329.00
|
|
| Hospital Charge Code |
901698643
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$65.80 |
| Max. Negotiated Rate |
$279.65 |
| Rate for Payer: Adventist Health Commercial |
$65.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$215.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$279.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$180.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$246.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$202.04
|
| Rate for Payer: Cash Price |
$180.95
|
| Rate for Payer: Cigna of CA HMO |
$210.56
|
| Rate for Payer: Cigna of CA PPO |
$243.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$279.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$279.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$279.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$131.60
|
| Rate for Payer: EPIC Health Plan Senior |
$131.60
|
| Rate for Payer: Galaxy Health WC |
$279.65
|
| Rate for Payer: Global Benefits Group Commercial |
$197.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$219.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$125.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$203.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$230.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$230.30
|
| Rate for Payer: Multiplan Commercial |
$263.20
|
| Rate for Payer: Networks By Design Commercial |
$213.85
|
| Rate for Payer: Prime Health Services Commercial |
$279.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$197.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$197.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$164.50
|
| Rate for Payer: United Healthcare All Other HMO |
$164.50
|
| Rate for Payer: United Healthcare HMO Rider |
$164.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$164.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$279.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$279.65
|
| Rate for Payer: Vantage Medical Group Senior |
$279.65
|
|
|
HC LMA FASTRACH CHILD #5
|
Facility
|
IP
|
$329.00
|
|
| Hospital Charge Code |
901698643
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$65.80 |
| Max. Negotiated Rate |
$279.65 |
| Rate for Payer: Adventist Health Commercial |
$65.80
|
| Rate for Payer: Cash Price |
$180.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$131.60
|
| Rate for Payer: EPIC Health Plan Senior |
$131.60
|
| Rate for Payer: Galaxy Health WC |
$279.65
|
| Rate for Payer: Global Benefits Group Commercial |
$197.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$219.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$125.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$203.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.96
|
| Rate for Payer: Multiplan Commercial |
$263.20
|
| Rate for Payer: Networks By Design Commercial |
$213.85
|
| Rate for Payer: Prime Health Services Commercial |
$279.65
|
|
|
HC LOCALIZATION OF TUMOR PLANAR
|
Facility
|
IP
|
$1,001.00
|
|
|
Service Code
|
CPT 78801
|
| Hospital Charge Code |
909301253
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$200.20 |
| Max. Negotiated Rate |
$850.85 |
| Rate for Payer: Adventist Health Commercial |
$200.20
|
| Rate for Payer: Cash Price |
$550.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$400.40
|
| Rate for Payer: EPIC Health Plan Senior |
$400.40
|
| Rate for Payer: Galaxy Health WC |
$850.85
|
| Rate for Payer: Global Benefits Group Commercial |
$600.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$667.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$381.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$619.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$240.24
|
| Rate for Payer: Multiplan Commercial |
$800.80
|
| Rate for Payer: Networks By Design Commercial |
$650.65
|
| Rate for Payer: Prime Health Services Commercial |
$850.85
|
|
|
HC LOCALIZATION OF TUMOR PLANAR
|
Facility
|
OP
|
$1,001.00
|
|
|
Service Code
|
CPT 78801
|
| Hospital Charge Code |
909301253
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$200.20 |
| Max. Negotiated Rate |
$1,260.70 |
| Rate for Payer: Adventist Health Commercial |
$200.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$656.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$765.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$561.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$510.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$614.71
|
| Rate for Payer: Blue Shield of California Commercial |
$612.61
|
| Rate for Payer: Blue Shield of California EPN |
$404.40
|
| Rate for Payer: Cash Price |
$550.55
|
| Rate for Payer: Cash Price |
$550.55
|
| Rate for Payer: Cigna of CA HMO |
$640.64
|
| Rate for Payer: Cigna of CA PPO |
$740.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$765.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$561.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$510.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$689.27
|
| Rate for Payer: EPIC Health Plan Senior |
$510.57
|
| Rate for Payer: Galaxy Health WC |
$850.85
|
| Rate for Payer: Global Benefits Group Commercial |
$600.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$837.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$222.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$510.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$667.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$251.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$510.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$240.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$643.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$684.16
|
| Rate for Payer: Multiplan Commercial |
$800.80
|
| Rate for Payer: Networks By Design Commercial |
$650.65
|
| Rate for Payer: Prime Health Services Commercial |
$850.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$600.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$600.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,260.70
|
| Rate for Payer: United Healthcare All Other HMO |
$1,260.70
|
| Rate for Payer: United Healthcare HMO Rider |
$1,260.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,260.70
|
| Rate for Payer: Upland Medical Group Pediatric |
$510.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$765.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$561.63
|
| Rate for Payer: Vantage Medical Group Senior |
$510.57
|
|
|
HC LOCK ELBOW FOREARM COUNTER BAL
|
Facility
|
OP
|
$5,998.00
|
|
|
Service Code
|
CPT L6693
|
| Hospital Charge Code |
905356693
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,439.52 |
| Max. Negotiated Rate |
$5,098.30 |
| Rate for Payer: Adventist Health Commercial |
$2,459.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,098.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,298.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,498.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,474.04
|
| Rate for Payer: Blue Shield of California Commercial |
$4,426.52
|
| Rate for Payer: Blue Shield of California EPN |
$2,915.03
|
| Rate for Payer: Cash Price |
$3,298.90
|
| Rate for Payer: Cash Price |
$3,298.90
|
| Rate for Payer: Cigna of CA HMO |
$4,198.60
|
| Rate for Payer: Cigna of CA PPO |
$4,198.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,098.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,098.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5,098.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,399.20
|
| Rate for Payer: EPIC Health Plan Senior |
$2,399.20
|
| Rate for Payer: Galaxy Health WC |
$5,098.30
|
| Rate for Payer: Global Benefits Group Commercial |
$3,598.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2,180.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,000.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,465.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,712.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,439.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,198.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,198.60
|
| Rate for Payer: Multiplan Commercial |
$4,798.40
|
| Rate for Payer: Networks By Design Commercial |
$2,999.00
|
| Rate for Payer: Prime Health Services Commercial |
$5,098.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,598.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,598.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,251.05
|
| Rate for Payer: United Healthcare All Other HMO |
$2,191.07
|
| Rate for Payer: United Healthcare HMO Rider |
$2,143.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,964.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,098.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,098.30
|
| Rate for Payer: Vantage Medical Group Senior |
$5,098.30
|
|
|
HC LOCK ELBOW FOREARM COUNTER BAL
|
Facility
|
OP
|
$5,998.00
|
|
|
Service Code
|
CPT L6693
|
| Hospital Charge Code |
915356693
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,439.52 |
| Max. Negotiated Rate |
$5,098.30 |
| Rate for Payer: Adventist Health Commercial |
$2,459.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,098.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,298.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,498.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,474.04
|
| Rate for Payer: Blue Shield of California Commercial |
$4,426.52
|
| Rate for Payer: Blue Shield of California EPN |
$2,915.03
|
| Rate for Payer: Cash Price |
$3,298.90
|
| Rate for Payer: Cash Price |
$3,298.90
|
| Rate for Payer: Cigna of CA HMO |
$4,198.60
|
| Rate for Payer: Cigna of CA PPO |
$4,198.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,098.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,098.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5,098.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,399.20
|
| Rate for Payer: EPIC Health Plan Senior |
$2,399.20
|
| Rate for Payer: Galaxy Health WC |
$5,098.30
|
| Rate for Payer: Global Benefits Group Commercial |
$3,598.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2,180.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,000.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,465.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,712.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,439.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,198.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,198.60
|
| Rate for Payer: Multiplan Commercial |
$4,798.40
|
| Rate for Payer: Networks By Design Commercial |
$2,999.00
|
| Rate for Payer: Prime Health Services Commercial |
$5,098.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,598.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,598.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,251.05
|
| Rate for Payer: United Healthcare All Other HMO |
$2,191.07
|
| Rate for Payer: United Healthcare HMO Rider |
$2,143.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,964.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,098.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,098.30
|
| Rate for Payer: Vantage Medical Group Senior |
$5,098.30
|
|
|
HC LOCK ELBOW FOREARM COUNTER BAL
|
Facility
|
IP
|
$5,998.00
|
|
|
Service Code
|
CPT L6693
|
| Hospital Charge Code |
905356693
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,199.60 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$1,199.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$3,298.90
|
| Rate for Payer: Cash Price |
$3,298.90
|
| Rate for Payer: Cigna of CA HMO |
$4,198.60
|
| Rate for Payer: Cigna of CA PPO |
$4,198.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,399.20
|
| Rate for Payer: EPIC Health Plan Senior |
$2,399.20
|
| Rate for Payer: Galaxy Health WC |
$5,098.30
|
| Rate for Payer: Global Benefits Group Commercial |
$3,598.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,000.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,285.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,712.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,439.52
|
| Rate for Payer: Multiplan Commercial |
$4,798.40
|
| Rate for Payer: Networks By Design Commercial |
$2,999.00
|
| Rate for Payer: Prime Health Services Commercial |
$5,098.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,251.05
|
| Rate for Payer: United Healthcare All Other HMO |
$2,191.07
|
| Rate for Payer: United Healthcare HMO Rider |
$2,143.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,964.35
|
|
|
HC LOCK ELBOW FOREARM COUNTER BAL
|
Facility
|
IP
|
$5,998.00
|
|
|
Service Code
|
CPT L6693
|
| Hospital Charge Code |
915356693
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,199.60 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$1,199.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$3,298.90
|
| Rate for Payer: Cash Price |
$3,298.90
|
| Rate for Payer: Cigna of CA HMO |
$4,198.60
|
| Rate for Payer: Cigna of CA PPO |
$4,198.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,399.20
|
| Rate for Payer: EPIC Health Plan Senior |
$2,399.20
|
| Rate for Payer: Galaxy Health WC |
$5,098.30
|
| Rate for Payer: Global Benefits Group Commercial |
$3,598.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,000.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,285.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,712.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,439.52
|
| Rate for Payer: Multiplan Commercial |
$4,798.40
|
| Rate for Payer: Networks By Design Commercial |
$2,999.00
|
| Rate for Payer: Prime Health Services Commercial |
$5,098.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,251.05
|
| Rate for Payer: United Healthcare All Other HMO |
$2,191.07
|
| Rate for Payer: United Healthcare HMO Rider |
$2,143.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,964.35
|
|
|
HC LOCM (HEXABRIX) PER ML
|
Facility
|
IP
|
$4.30
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081002
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$3.17
|
| Rate for Payer: Blue Shield of California EPN |
$2.09
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.72
|
| Rate for Payer: EPIC Health Plan Senior |
$1.72
|
| Rate for Payer: Galaxy Health WC |
$3.65
|
| Rate for Payer: Global Benefits Group Commercial |
$2.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$3.44
|
| Rate for Payer: Networks By Design Commercial |
$2.79
|
| Rate for Payer: Prime Health Services Commercial |
$3.65
|
|
|
HC LOCM (HEXABRIX) PER ML
|
Facility
|
OP
|
$4.30
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081002
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.64
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cigna of CA HMO |
$2.75
|
| Rate for Payer: Cigna of CA PPO |
$3.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.72
|
| Rate for Payer: EPIC Health Plan Senior |
$1.72
|
| Rate for Payer: Galaxy Health WC |
$3.65
|
| Rate for Payer: Global Benefits Group Commercial |
$2.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.01
|
| Rate for Payer: Multiplan Commercial |
$3.44
|
| Rate for Payer: Networks By Design Commercial |
$2.79
|
| Rate for Payer: Prime Health Services Commercial |
$3.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.15
|
| Rate for Payer: United Healthcare All Other HMO |
$2.15
|
| Rate for Payer: United Healthcare HMO Rider |
$2.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.65
|
| Rate for Payer: Vantage Medical Group Senior |
$3.65
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 180
|
Facility
|
IP
|
$9.40
|
|
|
Service Code
|
CPT Q9965
|
| Hospital Charge Code |
909081004
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$7.99 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Blue Shield of California Commercial |
$6.94
|
| Rate for Payer: Blue Shield of California EPN |
$4.57
|
| Rate for Payer: Cash Price |
$5.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.76
|
| Rate for Payer: EPIC Health Plan Senior |
$3.76
|
| Rate for Payer: Galaxy Health WC |
$7.99
|
| Rate for Payer: Global Benefits Group Commercial |
$5.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.26
|
| Rate for Payer: Multiplan Commercial |
$7.52
|
| Rate for Payer: Networks By Design Commercial |
$6.11
|
| Rate for Payer: Prime Health Services Commercial |
$7.99
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 180
|
Facility
|
OP
|
$9.40
|
|
|
Service Code
|
CPT Q9965
|
| Hospital Charge Code |
909081004
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$7.99 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.77
|
| Rate for Payer: Cash Price |
$5.17
|
| Rate for Payer: Cash Price |
$5.17
|
| Rate for Payer: Cigna of CA HMO |
$6.02
|
| Rate for Payer: Cigna of CA PPO |
$6.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.99
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.76
|
| Rate for Payer: EPIC Health Plan Senior |
$3.76
|
| Rate for Payer: Galaxy Health WC |
$7.99
|
| Rate for Payer: Global Benefits Group Commercial |
$5.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.58
|
| Rate for Payer: Multiplan Commercial |
$7.52
|
| Rate for Payer: Networks By Design Commercial |
$6.11
|
| Rate for Payer: Prime Health Services Commercial |
$7.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.70
|
| Rate for Payer: United Healthcare All Other HMO |
$4.70
|
| Rate for Payer: United Healthcare HMO Rider |
$4.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.99
|
| Rate for Payer: Vantage Medical Group Senior |
$7.99
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 240
|
Facility
|
IP
|
$2.95
|
|
|
Service Code
|
CPT Q9966
|
| Hospital Charge Code |
909081005
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.51 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$2.18
|
| Rate for Payer: Blue Shield of California EPN |
$1.43
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: EPIC Health Plan Senior |
$1.18
|
| Rate for Payer: Galaxy Health WC |
$2.51
|
| Rate for Payer: Global Benefits Group Commercial |
$1.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
| Rate for Payer: Networks By Design Commercial |
$1.92
|
| Rate for Payer: Prime Health Services Commercial |
$2.51
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 240
|
Facility
|
OP
|
$2.95
|
|
|
Service Code
|
CPT Q9966
|
| Hospital Charge Code |
909081005
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$2.51 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.81
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO |
$1.89
|
| Rate for Payer: Cigna of CA PPO |
$2.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: EPIC Health Plan Senior |
$1.18
|
| Rate for Payer: Galaxy Health WC |
$2.51
|
| Rate for Payer: Global Benefits Group Commercial |
$1.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.06
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
| Rate for Payer: Networks By Design Commercial |
$1.92
|
| Rate for Payer: Prime Health Services Commercial |
$2.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.77
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.48
|
| Rate for Payer: United Healthcare All Other HMO |
$1.48
|
| Rate for Payer: United Healthcare HMO Rider |
$1.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.51
|
| Rate for Payer: Vantage Medical Group Senior |
$2.51
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 300
|
Facility
|
OP
|
$3.38
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081006
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.08
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: Cigna of CA HMO |
$2.16
|
| Rate for Payer: Cigna of CA PPO |
$2.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.35
|
| Rate for Payer: EPIC Health Plan Senior |
$1.35
|
| Rate for Payer: Galaxy Health WC |
$2.87
|
| Rate for Payer: Global Benefits Group Commercial |
$2.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.37
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Networks By Design Commercial |
$2.20
|
| Rate for Payer: Prime Health Services Commercial |
$2.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.69
|
| Rate for Payer: United Healthcare All Other HMO |
$1.69
|
| Rate for Payer: United Healthcare HMO Rider |
$1.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.87
|
| Rate for Payer: Vantage Medical Group Senior |
$2.87
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 300
|
Facility
|
IP
|
$3.38
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081006
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$2.49
|
| Rate for Payer: Blue Shield of California EPN |
$1.64
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.35
|
| Rate for Payer: EPIC Health Plan Senior |
$1.35
|
| Rate for Payer: Galaxy Health WC |
$2.87
|
| Rate for Payer: Global Benefits Group Commercial |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Networks By Design Commercial |
$2.20
|
| Rate for Payer: Prime Health Services Commercial |
$2.87
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 350-370
|
Facility
|
IP
|
$4.28
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081007
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.64 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$3.16
|
| Rate for Payer: Blue Shield of California EPN |
$2.08
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.71
|
| Rate for Payer: EPIC Health Plan Senior |
$1.71
|
| Rate for Payer: Galaxy Health WC |
$3.64
|
| Rate for Payer: Global Benefits Group Commercial |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$3.42
|
| Rate for Payer: Networks By Design Commercial |
$2.78
|
| Rate for Payer: Prime Health Services Commercial |
$3.64
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 350-370
|
Facility
|
OP
|
$4.28
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081007
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$3.64 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.63
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna of CA HMO |
$2.74
|
| Rate for Payer: Cigna of CA PPO |
$3.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.71
|
| Rate for Payer: EPIC Health Plan Senior |
$1.71
|
| Rate for Payer: Galaxy Health WC |
$3.64
|
| Rate for Payer: Global Benefits Group Commercial |
$2.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$3.42
|
| Rate for Payer: Networks By Design Commercial |
$2.78
|
| Rate for Payer: Prime Health Services Commercial |
$3.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.14
|
| Rate for Payer: United Healthcare All Other HMO |
$2.14
|
| Rate for Payer: United Healthcare HMO Rider |
$2.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.64
|
| Rate for Payer: Vantage Medical Group Senior |
$3.64
|
|
|
HC LOCM (VISIPAQUE) 320 PER ML
|
Facility
|
OP
|
$4.27
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081008
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$3.63 |
| Rate for Payer: Adventist Health Commercial |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.62
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna of CA HMO |
$2.73
|
| Rate for Payer: Cigna of CA PPO |
$3.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.71
|
| Rate for Payer: EPIC Health Plan Senior |
$1.71
|
| Rate for Payer: Galaxy Health WC |
$3.63
|
| Rate for Payer: Global Benefits Group Commercial |
$2.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.99
|
| Rate for Payer: Multiplan Commercial |
$3.42
|
| Rate for Payer: Networks By Design Commercial |
$2.78
|
| Rate for Payer: Prime Health Services Commercial |
$3.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.13
|
| Rate for Payer: United Healthcare All Other HMO |
$2.13
|
| Rate for Payer: United Healthcare HMO Rider |
$2.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.63
|
| Rate for Payer: Vantage Medical Group Senior |
$3.63
|
|
|
HC LOCM (VISIPAQUE) 320 PER ML
|
Facility
|
IP
|
$4.27
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081008
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$3.63 |
| Rate for Payer: Adventist Health Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California Commercial |
$3.15
|
| Rate for Payer: Blue Shield of California EPN |
$2.08
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.71
|
| Rate for Payer: EPIC Health Plan Senior |
$1.71
|
| Rate for Payer: Galaxy Health WC |
$3.63
|
| Rate for Payer: Global Benefits Group Commercial |
$2.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$3.42
|
| Rate for Payer: Networks By Design Commercial |
$2.78
|
| Rate for Payer: Prime Health Services Commercial |
$3.63
|
|
|
HC LO FLEXIBL L1-BELOW L5 PRE
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
CPT L0625
|
| Hospital Charge Code |
905350625
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$28.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cigna of CA HMO |
$98.00
|
| Rate for Payer: Cigna of CA PPO |
$98.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.00
|
| Rate for Payer: EPIC Health Plan Senior |
$56.00
|
| Rate for Payer: Galaxy Health WC |
$119.00
|
| Rate for Payer: Global Benefits Group Commercial |
$84.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$93.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$53.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$86.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.60
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: Networks By Design Commercial |
$70.00
|
| Rate for Payer: Prime Health Services Commercial |
$119.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$52.54
|
| Rate for Payer: United Healthcare All Other HMO |
$51.14
|
| Rate for Payer: United Healthcare HMO Rider |
$50.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$45.85
|
|
|
HC LO FLEXIBL L1-BELOW L5 PRE
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
CPT L0625
|
| Hospital Charge Code |
915350625
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$28.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cigna of CA HMO |
$98.00
|
| Rate for Payer: Cigna of CA PPO |
$98.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.00
|
| Rate for Payer: EPIC Health Plan Senior |
$56.00
|
| Rate for Payer: Galaxy Health WC |
$119.00
|
| Rate for Payer: Global Benefits Group Commercial |
$84.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$93.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$53.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$86.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.60
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: Networks By Design Commercial |
$70.00
|
| Rate for Payer: Prime Health Services Commercial |
$119.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$52.54
|
| Rate for Payer: United Healthcare All Other HMO |
$51.14
|
| Rate for Payer: United Healthcare HMO Rider |
$50.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$45.85
|
|
|
HC LO FLEXIBL L1-BELOW L5 PRE
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
CPT L0625
|
| Hospital Charge Code |
905350625
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$119.00 |
| Rate for Payer: Adventist Health Commercial |
$57.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$119.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$77.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$105.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$81.09
|
| Rate for Payer: Blue Shield of California Commercial |
$103.32
|
| Rate for Payer: Blue Shield of California EPN |
$68.04
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cigna of CA HMO |
$98.00
|
| Rate for Payer: Cigna of CA PPO |
$98.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$119.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$119.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$119.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.00
|
| Rate for Payer: EPIC Health Plan Senior |
$56.00
|
| Rate for Payer: Galaxy Health WC |
$119.00
|
| Rate for Payer: Global Benefits Group Commercial |
$84.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$58.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$93.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$65.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$86.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$98.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$98.00
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: Networks By Design Commercial |
$70.00
|
| Rate for Payer: Prime Health Services Commercial |
$119.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$84.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$84.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$52.54
|
| Rate for Payer: United Healthcare All Other HMO |
$51.14
|
| Rate for Payer: United Healthcare HMO Rider |
$50.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$45.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$119.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$119.00
|
| Rate for Payer: Vantage Medical Group Senior |
$119.00
|
|
|
HC LO FLEXIBL L1-BELOW L5 PRE
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
CPT L0625
|
| Hospital Charge Code |
915350625
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$119.00 |
| Rate for Payer: Adventist Health Commercial |
$57.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$119.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$77.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$105.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$81.09
|
| Rate for Payer: Blue Shield of California Commercial |
$103.32
|
| Rate for Payer: Blue Shield of California EPN |
$68.04
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cigna of CA HMO |
$98.00
|
| Rate for Payer: Cigna of CA PPO |
$98.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$119.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$119.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$119.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.00
|
| Rate for Payer: EPIC Health Plan Senior |
$56.00
|
| Rate for Payer: Galaxy Health WC |
$119.00
|
| Rate for Payer: Global Benefits Group Commercial |
$84.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$58.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$93.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$65.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$86.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$98.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$98.00
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: Networks By Design Commercial |
$70.00
|
| Rate for Payer: Prime Health Services Commercial |
$119.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$84.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$84.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$52.54
|
| Rate for Payer: United Healthcare All Other HMO |
$51.14
|
| Rate for Payer: United Healthcare HMO Rider |
$50.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$45.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$119.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$119.00
|
| Rate for Payer: Vantage Medical Group Senior |
$119.00
|
|
|
HC LONG TONGUE STIRRUP ADDITION LE
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
CPT L2265
|
| Hospital Charge Code |
905352265
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$297.50 |
| Rate for Payer: Adventist Health Commercial |
$143.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$297.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$192.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$262.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$202.72
|
| Rate for Payer: Blue Shield of California Commercial |
$258.30
|
| Rate for Payer: Blue Shield of California EPN |
$170.10
|
| Rate for Payer: Cash Price |
$192.50
|
| Rate for Payer: Cash Price |
$192.50
|
| Rate for Payer: Cigna of CA HMO |
$245.00
|
| Rate for Payer: Cigna of CA PPO |
$245.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$297.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$297.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$297.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$140.00
|
| Rate for Payer: EPIC Health Plan Senior |
$140.00
|
| Rate for Payer: Galaxy Health WC |
$297.50
|
| Rate for Payer: Global Benefits Group Commercial |
$210.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$88.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$233.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$100.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$216.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$245.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$245.00
|
| Rate for Payer: Multiplan Commercial |
$280.00
|
| Rate for Payer: Networks By Design Commercial |
$175.00
|
| Rate for Payer: Prime Health Services Commercial |
$297.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$210.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$210.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$131.35
|
| Rate for Payer: United Healthcare All Other HMO |
$127.86
|
| Rate for Payer: United Healthcare HMO Rider |
$125.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$114.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$297.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$297.50
|
| Rate for Payer: Vantage Medical Group Senior |
$297.50
|
|
