|
HC LSO SAGITTAL RIGID PANEL CUS
|
Facility
|
IP
|
$3,047.00
|
|
|
Service Code
|
CPT L0636
|
| Hospital Charge Code |
905350636
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$609.40 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$609.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$1,371.15
|
| Rate for Payer: Cash Price |
$1,371.15
|
| Rate for Payer: Cigna of CA HMO |
$2,132.90
|
| Rate for Payer: Cigna of CA PPO |
$2,132.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,218.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1,218.80
|
| Rate for Payer: Galaxy Health WC |
$2,589.95
|
| Rate for Payer: Global Benefits Group Commercial |
$1,828.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,032.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,160.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,886.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$731.28
|
| Rate for Payer: Multiplan Commercial |
$2,437.60
|
| Rate for Payer: Networks By Design Commercial |
$1,523.50
|
| Rate for Payer: Prime Health Services Commercial |
$2,589.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,143.54
|
| Rate for Payer: United Healthcare All Other HMO |
$1,113.07
|
| Rate for Payer: United Healthcare HMO Rider |
$1,089.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$997.89
|
|
|
HC LSO SAGITTAL RIGID PANEL CUS
|
Facility
|
OP
|
$3,047.00
|
|
|
Service Code
|
CPT L0636
|
| Hospital Charge Code |
915350636
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$731.28 |
| Max. Negotiated Rate |
$2,589.95 |
| Rate for Payer: Adventist Health Commercial |
$1,249.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,589.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,675.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,285.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,764.82
|
| Rate for Payer: Blue Shield of California Commercial |
$2,248.69
|
| Rate for Payer: Blue Shield of California EPN |
$1,480.84
|
| Rate for Payer: Cash Price |
$1,371.15
|
| Rate for Payer: Cash Price |
$1,371.15
|
| Rate for Payer: Cigna of CA HMO |
$2,132.90
|
| Rate for Payer: Cigna of CA PPO |
$2,132.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,589.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,589.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,589.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,218.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1,218.80
|
| Rate for Payer: Galaxy Health WC |
$2,589.95
|
| Rate for Payer: Global Benefits Group Commercial |
$1,828.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,911.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,032.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,161.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,886.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$731.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,132.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,132.90
|
| Rate for Payer: Multiplan Commercial |
$2,437.60
|
| Rate for Payer: Networks By Design Commercial |
$1,523.50
|
| Rate for Payer: Prime Health Services Commercial |
$2,589.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,828.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,828.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,143.54
|
| Rate for Payer: United Healthcare All Other HMO |
$1,113.07
|
| Rate for Payer: United Healthcare HMO Rider |
$1,089.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$997.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,589.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,589.95
|
| Rate for Payer: Vantage Medical Group Senior |
$2,589.95
|
|
|
HC LSO SAGITTAL RIGID PANEL CUS
|
Facility
|
OP
|
$3,047.00
|
|
|
Service Code
|
CPT L0636
|
| Hospital Charge Code |
905350636
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$731.28 |
| Max. Negotiated Rate |
$2,589.95 |
| Rate for Payer: Adventist Health Commercial |
$1,249.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,589.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,675.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,285.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,764.82
|
| Rate for Payer: Blue Shield of California Commercial |
$2,248.69
|
| Rate for Payer: Blue Shield of California EPN |
$1,480.84
|
| Rate for Payer: Cash Price |
$1,371.15
|
| Rate for Payer: Cash Price |
$1,371.15
|
| Rate for Payer: Cigna of CA HMO |
$2,132.90
|
| Rate for Payer: Cigna of CA PPO |
$2,132.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,589.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,589.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,589.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,218.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1,218.80
|
| Rate for Payer: Galaxy Health WC |
$2,589.95
|
| Rate for Payer: Global Benefits Group Commercial |
$1,828.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,911.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,032.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,161.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,886.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$731.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,132.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,132.90
|
| Rate for Payer: Multiplan Commercial |
$2,437.60
|
| Rate for Payer: Networks By Design Commercial |
$1,523.50
|
| Rate for Payer: Prime Health Services Commercial |
$2,589.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,828.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,828.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,143.54
|
| Rate for Payer: United Healthcare All Other HMO |
$1,113.07
|
| Rate for Payer: United Healthcare HMO Rider |
$1,089.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$997.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,589.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,589.95
|
| Rate for Payer: Vantage Medical Group Senior |
$2,589.95
|
|
|
HC LSO SAG RIGID ANT/POST PANEL S1-T9 CUSTOM
|
Facility
|
IP
|
$3,047.00
|
|
|
Service Code
|
CPT L0632
|
| Hospital Charge Code |
915350632
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$609.40 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$609.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$1,371.15
|
| Rate for Payer: Cash Price |
$1,371.15
|
| Rate for Payer: Cigna of CA HMO |
$2,132.90
|
| Rate for Payer: Cigna of CA PPO |
$2,132.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,218.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1,218.80
|
| Rate for Payer: Galaxy Health WC |
$2,589.95
|
| Rate for Payer: Global Benefits Group Commercial |
$1,828.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,032.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,160.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,886.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$731.28
|
| Rate for Payer: Multiplan Commercial |
$2,437.60
|
| Rate for Payer: Networks By Design Commercial |
$1,523.50
|
| Rate for Payer: Prime Health Services Commercial |
$2,589.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,143.54
|
| Rate for Payer: United Healthcare All Other HMO |
$1,113.07
|
| Rate for Payer: United Healthcare HMO Rider |
$1,089.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$997.89
|
|
|
HC LSO SAG RIGID ANT/POST PANEL S1-T9 CUSTOM
|
Facility
|
OP
|
$3,047.00
|
|
|
Service Code
|
CPT L0632
|
| Hospital Charge Code |
915350632
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$731.28 |
| Max. Negotiated Rate |
$2,589.95 |
| Rate for Payer: Adventist Health Commercial |
$1,249.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,589.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,675.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,285.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,764.82
|
| Rate for Payer: Blue Shield of California Commercial |
$2,248.69
|
| Rate for Payer: Blue Shield of California EPN |
$1,480.84
|
| Rate for Payer: Cash Price |
$1,371.15
|
| Rate for Payer: Cigna of CA HMO |
$2,132.90
|
| Rate for Payer: Cigna of CA PPO |
$2,132.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,589.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,589.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,589.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,218.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1,218.80
|
| Rate for Payer: Galaxy Health WC |
$2,589.95
|
| Rate for Payer: Global Benefits Group Commercial |
$1,828.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,032.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,886.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$731.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,132.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,132.90
|
| Rate for Payer: Multiplan Commercial |
$2,437.60
|
| Rate for Payer: Networks By Design Commercial |
$1,523.50
|
| Rate for Payer: Prime Health Services Commercial |
$2,589.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,828.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,828.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,143.54
|
| Rate for Payer: United Healthcare All Other HMO |
$1,113.07
|
| Rate for Payer: United Healthcare HMO Rider |
$1,089.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$997.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,589.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,589.95
|
| Rate for Payer: Vantage Medical Group Senior |
$2,589.95
|
|
|
HC LSO SAG RIGID ANT/POST PANEL S1-T9 CUSTOM
|
Facility
|
IP
|
$3,047.00
|
|
|
Service Code
|
CPT L0632
|
| Hospital Charge Code |
905350632
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$609.40 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$609.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$1,371.15
|
| Rate for Payer: Cash Price |
$1,371.15
|
| Rate for Payer: Cigna of CA HMO |
$2,132.90
|
| Rate for Payer: Cigna of CA PPO |
$2,132.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,218.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1,218.80
|
| Rate for Payer: Galaxy Health WC |
$2,589.95
|
| Rate for Payer: Global Benefits Group Commercial |
$1,828.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,032.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,160.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,886.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$731.28
|
| Rate for Payer: Multiplan Commercial |
$2,437.60
|
| Rate for Payer: Networks By Design Commercial |
$1,523.50
|
| Rate for Payer: Prime Health Services Commercial |
$2,589.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,143.54
|
| Rate for Payer: United Healthcare All Other HMO |
$1,113.07
|
| Rate for Payer: United Healthcare HMO Rider |
$1,089.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$997.89
|
|
|
HC LSO SAG RIGID ANT/POST PANEL S1-T9 CUSTOM
|
Facility
|
OP
|
$3,047.00
|
|
|
Service Code
|
CPT L0632
|
| Hospital Charge Code |
905350632
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$731.28 |
| Max. Negotiated Rate |
$2,589.95 |
| Rate for Payer: Adventist Health Commercial |
$1,249.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,589.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,675.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,285.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,764.82
|
| Rate for Payer: Blue Shield of California Commercial |
$2,248.69
|
| Rate for Payer: Blue Shield of California EPN |
$1,480.84
|
| Rate for Payer: Cash Price |
$1,371.15
|
| Rate for Payer: Cigna of CA HMO |
$2,132.90
|
| Rate for Payer: Cigna of CA PPO |
$2,132.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,589.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,589.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,589.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,218.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1,218.80
|
| Rate for Payer: Galaxy Health WC |
$2,589.95
|
| Rate for Payer: Global Benefits Group Commercial |
$1,828.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,032.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,886.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$731.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,132.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,132.90
|
| Rate for Payer: Multiplan Commercial |
$2,437.60
|
| Rate for Payer: Networks By Design Commercial |
$1,523.50
|
| Rate for Payer: Prime Health Services Commercial |
$2,589.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,828.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,828.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,143.54
|
| Rate for Payer: United Healthcare All Other HMO |
$1,113.07
|
| Rate for Payer: United Healthcare HMO Rider |
$1,089.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$997.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,589.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,589.95
|
| Rate for Payer: Vantage Medical Group Senior |
$2,589.95
|
|
|
HC LSO S/C SHELL/PANEL CUSTOM
|
Facility
|
OP
|
$1,644.00
|
|
|
Service Code
|
CPT L0640
|
| Hospital Charge Code |
915350640
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$394.56 |
| Max. Negotiated Rate |
$1,397.40 |
| Rate for Payer: Adventist Health Commercial |
$674.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,397.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$904.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,233.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$952.20
|
| Rate for Payer: Blue Shield of California Commercial |
$1,213.27
|
| Rate for Payer: Blue Shield of California EPN |
$798.98
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cigna of CA HMO |
$1,150.80
|
| Rate for Payer: Cigna of CA PPO |
$1,150.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,397.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,397.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,397.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$657.60
|
| Rate for Payer: EPIC Health Plan Senior |
$657.60
|
| Rate for Payer: Galaxy Health WC |
$1,397.40
|
| Rate for Payer: Global Benefits Group Commercial |
$986.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,105.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,096.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,249.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,017.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$394.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,150.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,150.80
|
| Rate for Payer: Multiplan Commercial |
$1,315.20
|
| Rate for Payer: Networks By Design Commercial |
$822.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,397.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$986.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$986.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$616.99
|
| Rate for Payer: United Healthcare All Other HMO |
$600.55
|
| Rate for Payer: United Healthcare HMO Rider |
$587.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$538.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,397.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,397.40
|
| Rate for Payer: Vantage Medical Group Senior |
$1,397.40
|
|
|
HC LSO S/C SHELL/PANEL CUSTOM
|
Facility
|
OP
|
$1,644.00
|
|
|
Service Code
|
CPT L0640
|
| Hospital Charge Code |
905350640
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$394.56 |
| Max. Negotiated Rate |
$1,397.40 |
| Rate for Payer: Adventist Health Commercial |
$674.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,397.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$904.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,233.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$952.20
|
| Rate for Payer: Blue Shield of California Commercial |
$1,213.27
|
| Rate for Payer: Blue Shield of California EPN |
$798.98
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cigna of CA HMO |
$1,150.80
|
| Rate for Payer: Cigna of CA PPO |
$1,150.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,397.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,397.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,397.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$657.60
|
| Rate for Payer: EPIC Health Plan Senior |
$657.60
|
| Rate for Payer: Galaxy Health WC |
$1,397.40
|
| Rate for Payer: Global Benefits Group Commercial |
$986.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,105.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,096.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,249.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,017.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$394.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,150.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,150.80
|
| Rate for Payer: Multiplan Commercial |
$1,315.20
|
| Rate for Payer: Networks By Design Commercial |
$822.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,397.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$986.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$986.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$616.99
|
| Rate for Payer: United Healthcare All Other HMO |
$600.55
|
| Rate for Payer: United Healthcare HMO Rider |
$587.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$538.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,397.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,397.40
|
| Rate for Payer: Vantage Medical Group Senior |
$1,397.40
|
|
|
HC LSO S/C SHELL/PANEL CUSTOM
|
Facility
|
IP
|
$1,644.00
|
|
|
Service Code
|
CPT L0640
|
| Hospital Charge Code |
905350640
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$328.80 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$328.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cigna of CA HMO |
$1,150.80
|
| Rate for Payer: Cigna of CA PPO |
$1,150.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$657.60
|
| Rate for Payer: EPIC Health Plan Senior |
$657.60
|
| Rate for Payer: Galaxy Health WC |
$1,397.40
|
| Rate for Payer: Global Benefits Group Commercial |
$986.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,096.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$626.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,017.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$394.56
|
| Rate for Payer: Multiplan Commercial |
$1,315.20
|
| Rate for Payer: Networks By Design Commercial |
$822.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,397.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$616.99
|
| Rate for Payer: United Healthcare All Other HMO |
$600.55
|
| Rate for Payer: United Healthcare HMO Rider |
$587.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$538.41
|
|
|
HC LSO S/C SHELL/PANEL CUSTOM
|
Facility
|
IP
|
$1,644.00
|
|
|
Service Code
|
CPT L0640
|
| Hospital Charge Code |
915350640
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$328.80 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$328.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cigna of CA HMO |
$1,150.80
|
| Rate for Payer: Cigna of CA PPO |
$1,150.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$657.60
|
| Rate for Payer: EPIC Health Plan Senior |
$657.60
|
| Rate for Payer: Galaxy Health WC |
$1,397.40
|
| Rate for Payer: Global Benefits Group Commercial |
$986.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,096.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$626.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,017.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$394.56
|
| Rate for Payer: Multiplan Commercial |
$1,315.20
|
| Rate for Payer: Networks By Design Commercial |
$822.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,397.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$616.99
|
| Rate for Payer: United Healthcare All Other HMO |
$600.55
|
| Rate for Payer: United Healthcare HMO Rider |
$587.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$538.41
|
|
|
HC LSO S/C SHELL/PANEL PREFAB
|
Facility
|
IP
|
$1,910.00
|
|
|
Service Code
|
CPT L0639
|
| Hospital Charge Code |
905350639
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$382.00 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Networks By Design Commercial |
$955.00
|
| Rate for Payer: Adventist Health Commercial |
$382.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$859.50
|
| Rate for Payer: Cash Price |
$859.50
|
| Rate for Payer: Cigna of CA HMO |
$1,337.00
|
| Rate for Payer: Cigna of CA PPO |
$1,337.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$764.00
|
| Rate for Payer: EPIC Health Plan Senior |
$764.00
|
| Rate for Payer: Galaxy Health WC |
$1,623.50
|
| Rate for Payer: Global Benefits Group Commercial |
$1,146.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,273.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$727.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,182.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$458.40
|
| Rate for Payer: Multiplan Commercial |
$1,528.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,623.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$716.82
|
| Rate for Payer: United Healthcare All Other HMO |
$697.72
|
| Rate for Payer: United Healthcare HMO Rider |
$682.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$625.52
|
|
|
HC LSO S/C SHELL/PANEL PREFAB
|
Facility
|
OP
|
$1,910.00
|
|
|
Service Code
|
CPT L0639
|
| Hospital Charge Code |
905350639
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$458.40 |
| Max. Negotiated Rate |
$1,623.50 |
| Rate for Payer: Adventist Health Commercial |
$783.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,623.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,050.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,432.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,106.27
|
| Rate for Payer: Blue Shield of California Commercial |
$1,409.58
|
| Rate for Payer: Blue Shield of California EPN |
$928.26
|
| Rate for Payer: Cash Price |
$859.50
|
| Rate for Payer: Cash Price |
$859.50
|
| Rate for Payer: Cigna of CA HMO |
$1,337.00
|
| Rate for Payer: Cigna of CA PPO |
$1,337.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,623.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,623.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,623.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$764.00
|
| Rate for Payer: EPIC Health Plan Senior |
$764.00
|
| Rate for Payer: Galaxy Health WC |
$1,623.50
|
| Rate for Payer: Global Benefits Group Commercial |
$1,146.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,277.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,273.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,444.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,182.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$458.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,337.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,337.00
|
| Rate for Payer: Multiplan Commercial |
$1,528.00
|
| Rate for Payer: Networks By Design Commercial |
$955.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,623.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,146.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,146.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$716.82
|
| Rate for Payer: United Healthcare All Other HMO |
$697.72
|
| Rate for Payer: United Healthcare HMO Rider |
$682.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$625.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,623.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,623.50
|
| Rate for Payer: Vantage Medical Group Senior |
$1,623.50
|
|
|
HC LTD TAGGED WBC SCAN LIMITED
|
Facility
|
IP
|
$3,163.00
|
|
|
Service Code
|
CPT 78805
|
| Hospital Charge Code |
909301442
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$632.60 |
| Max. Negotiated Rate |
$2,688.55 |
| Rate for Payer: Adventist Health Commercial |
$632.60
|
| Rate for Payer: Cash Price |
$1,423.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,265.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1,265.20
|
| Rate for Payer: Galaxy Health WC |
$2,688.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1,897.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,109.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,205.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,957.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$759.12
|
| Rate for Payer: Multiplan Commercial |
$2,530.40
|
| Rate for Payer: Networks By Design Commercial |
$2,055.95
|
| Rate for Payer: Prime Health Services Commercial |
$2,688.55
|
|
|
HC LTD TAGGED WBC SCAN LIMITED
|
Facility
|
OP
|
$3,163.00
|
|
|
Service Code
|
CPT 78805
|
| Hospital Charge Code |
909301442
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$632.60 |
| Max. Negotiated Rate |
$2,688.55 |
| Rate for Payer: Adventist Health Commercial |
$632.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,074.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,688.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,739.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,372.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,942.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1,935.76
|
| Rate for Payer: Blue Shield of California EPN |
$1,277.85
|
| Rate for Payer: Cash Price |
$1,423.35
|
| Rate for Payer: Cigna of CA HMO |
$2,024.32
|
| Rate for Payer: Cigna of CA PPO |
$2,340.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,688.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,688.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,688.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,265.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1,265.20
|
| Rate for Payer: Galaxy Health WC |
$2,688.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1,897.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,109.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,205.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,957.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$759.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,214.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,214.10
|
| Rate for Payer: Multiplan Commercial |
$2,530.40
|
| Rate for Payer: Networks By Design Commercial |
$2,055.95
|
| Rate for Payer: Prime Health Services Commercial |
$2,688.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,897.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,897.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,581.50
|
| Rate for Payer: United Healthcare All Other HMO |
$1,581.50
|
| Rate for Payer: United Healthcare HMO Rider |
$1,581.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,581.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,688.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,688.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2,688.55
|
|
|
HC LUMBAR DISCOGRAPHY, 1 LEVEL
|
Facility
|
OP
|
$685.00
|
|
|
Service Code
|
CPT 62290
|
| Hospital Charge Code |
909000183
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$137.00 |
| Max. Negotiated Rate |
$6,906.11 |
| Rate for Payer: Adventist Health Commercial |
$137.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3,429.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$582.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$376.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$513.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,427.00
|
| Rate for Payer: Blue Shield of California Commercial |
$6,906.11
|
| Rate for Payer: Blue Shield of California EPN |
$4,560.14
|
| Rate for Payer: Cash Price |
$308.25
|
| Rate for Payer: Cash Price |
$308.25
|
| Rate for Payer: Cash Price |
$308.25
|
| Rate for Payer: Cigna of CA HMO |
$438.40
|
| Rate for Payer: Cigna of CA PPO |
$506.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$582.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$582.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$582.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$274.00
|
| Rate for Payer: EPIC Health Plan Senior |
$274.00
|
| Rate for Payer: Galaxy Health WC |
$582.25
|
| Rate for Payer: Global Benefits Group Commercial |
$411.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$214.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$456.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$242.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$424.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$164.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$479.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$479.50
|
| Rate for Payer: Multiplan Commercial |
$548.00
|
| Rate for Payer: Networks By Design Commercial |
$445.25
|
| Rate for Payer: Prime Health Services Commercial |
$582.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$411.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,932.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$582.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$582.25
|
| Rate for Payer: Vantage Medical Group Senior |
$582.25
|
|
|
HC LUMBAR DISCOGRAPHY, 1 LEVEL
|
Facility
|
IP
|
$685.00
|
|
|
Service Code
|
CPT 62290
|
| Hospital Charge Code |
909000183
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$137.00 |
| Max. Negotiated Rate |
$582.25 |
| Rate for Payer: Adventist Health Commercial |
$137.00
|
| Rate for Payer: Cash Price |
$308.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$274.00
|
| Rate for Payer: EPIC Health Plan Senior |
$274.00
|
| Rate for Payer: Galaxy Health WC |
$582.25
|
| Rate for Payer: Global Benefits Group Commercial |
$411.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$456.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$260.99
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$424.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$164.40
|
| Rate for Payer: Multiplan Commercial |
$548.00
|
| Rate for Payer: Networks By Design Commercial |
$445.25
|
| Rate for Payer: Prime Health Services Commercial |
$582.25
|
|
|
HC LUMBAR PUNCTURE FOR MYELOGR
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
CPT 62284
|
| Hospital Charge Code |
909000181
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$120.00 |
| Max. Negotiated Rate |
$510.00 |
| Rate for Payer: Adventist Health Commercial |
$120.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$240.00
|
| Rate for Payer: EPIC Health Plan Senior |
$240.00
|
| Rate for Payer: Galaxy Health WC |
$510.00
|
| Rate for Payer: Global Benefits Group Commercial |
$360.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$400.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$228.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$371.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$144.00
|
| Rate for Payer: Multiplan Commercial |
$480.00
|
| Rate for Payer: Networks By Design Commercial |
$390.00
|
| Rate for Payer: Prime Health Services Commercial |
$510.00
|
|
|
HC LUMBAR PUNCTURE FOR MYELOGR
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
CPT 62284
|
| Hospital Charge Code |
909000181
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$120.00 |
| Max. Negotiated Rate |
$6,906.11 |
| Rate for Payer: Adventist Health Commercial |
$120.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3,429.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$510.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$330.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$450.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,427.00
|
| Rate for Payer: Blue Shield of California Commercial |
$6,906.11
|
| Rate for Payer: Blue Shield of California EPN |
$4,560.14
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna of CA HMO |
$384.00
|
| Rate for Payer: Cigna of CA PPO |
$444.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$510.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$510.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$510.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$240.00
|
| Rate for Payer: EPIC Health Plan Senior |
$240.00
|
| Rate for Payer: Galaxy Health WC |
$510.00
|
| Rate for Payer: Global Benefits Group Commercial |
$360.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$148.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$400.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$168.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$371.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$144.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$420.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$420.00
|
| Rate for Payer: Multiplan Commercial |
$480.00
|
| Rate for Payer: Networks By Design Commercial |
$390.00
|
| Rate for Payer: Prime Health Services Commercial |
$510.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$360.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,932.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$510.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$510.00
|
| Rate for Payer: Vantage Medical Group Senior |
$510.00
|
|
|
HC LUMBAR/SACRAL FACET INJ 3RD EA
|
Facility
|
IP
|
$1,432.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
909020044
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$286.40 |
| Max. Negotiated Rate |
$1,217.20 |
| Rate for Payer: Adventist Health Commercial |
$286.40
|
| Rate for Payer: Cash Price |
$644.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$572.80
|
| Rate for Payer: EPIC Health Plan Senior |
$572.80
|
| Rate for Payer: Galaxy Health WC |
$1,217.20
|
| Rate for Payer: Global Benefits Group Commercial |
$859.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$955.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$545.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$886.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$343.68
|
| Rate for Payer: Multiplan Commercial |
$1,145.60
|
| Rate for Payer: Networks By Design Commercial |
$930.80
|
| Rate for Payer: Prime Health Services Commercial |
$1,217.20
|
|
|
HC LUMBAR/SACRAL FACET INJ 3RD EA
|
Facility
|
OP
|
$1,432.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
909020044
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$124.47 |
| Max. Negotiated Rate |
$11,230.65 |
| Rate for Payer: Adventist Health Commercial |
$286.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3,429.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,217.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$787.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,074.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,398.00
|
| Rate for Payer: Blue Shield of California Commercial |
$11,230.65
|
| Rate for Payer: Blue Shield of California EPN |
$1,845.77
|
| Rate for Payer: Cash Price |
$644.40
|
| Rate for Payer: Cash Price |
$644.40
|
| Rate for Payer: Cash Price |
$644.40
|
| Rate for Payer: Cigna of CA HMO |
$916.48
|
| Rate for Payer: Cigna of CA PPO |
$1,059.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,217.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,217.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,217.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$572.80
|
| Rate for Payer: EPIC Health Plan Senior |
$572.80
|
| Rate for Payer: Galaxy Health WC |
$1,217.20
|
| Rate for Payer: Global Benefits Group Commercial |
$859.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$124.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$955.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$140.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$886.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$343.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,002.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,002.40
|
| Rate for Payer: Multiplan Commercial |
$1,145.60
|
| Rate for Payer: Networks By Design Commercial |
$930.80
|
| Rate for Payer: Prime Health Services Commercial |
$1,217.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$859.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,932.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,217.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,217.20
|
| Rate for Payer: Vantage Medical Group Senior |
$1,217.20
|
|
|
HC LUMBAR/SACRAL FACET INJECT/ADD
|
Facility
|
IP
|
$2,615.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
909000186
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$523.00 |
| Max. Negotiated Rate |
$2,222.75 |
| Rate for Payer: Adventist Health Commercial |
$523.00
|
| Rate for Payer: Cash Price |
$1,176.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,046.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,046.00
|
| Rate for Payer: Galaxy Health WC |
$2,222.75
|
| Rate for Payer: Global Benefits Group Commercial |
$1,569.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,744.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$996.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,618.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$627.60
|
| Rate for Payer: Multiplan Commercial |
$2,092.00
|
| Rate for Payer: Networks By Design Commercial |
$1,699.75
|
| Rate for Payer: Prime Health Services Commercial |
$2,222.75
|
|
|
HC LUMBAR/SACRAL FACET INJECT/ADD
|
Facility
|
OP
|
$2,615.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
909000186
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$122.59 |
| Max. Negotiated Rate |
$11,230.65 |
| Rate for Payer: Adventist Health Commercial |
$523.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3,429.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,222.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,438.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,961.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,398.00
|
| Rate for Payer: Blue Shield of California Commercial |
$11,230.65
|
| Rate for Payer: Blue Shield of California EPN |
$1,845.77
|
| Rate for Payer: Cash Price |
$1,176.75
|
| Rate for Payer: Cash Price |
$1,176.75
|
| Rate for Payer: Cash Price |
$1,176.75
|
| Rate for Payer: Cigna of CA HMO |
$1,673.60
|
| Rate for Payer: Cigna of CA PPO |
$1,935.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,222.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,222.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,222.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,046.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,046.00
|
| Rate for Payer: Galaxy Health WC |
$2,222.75
|
| Rate for Payer: Global Benefits Group Commercial |
$1,569.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$122.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,744.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$138.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,618.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$627.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,830.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,830.50
|
| Rate for Payer: Multiplan Commercial |
$2,092.00
|
| Rate for Payer: Networks By Design Commercial |
$1,699.75
|
| Rate for Payer: Prime Health Services Commercial |
$2,222.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,569.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,932.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,222.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,222.75
|
| Rate for Payer: Vantage Medical Group Senior |
$2,222.75
|
|
|
HC LUMBAR/SACRAL FACET INJECT/INT
|
Facility
|
IP
|
$2,940.00
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
909000185
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$588.00 |
| Max. Negotiated Rate |
$2,499.00 |
| Rate for Payer: Adventist Health Commercial |
$588.00
|
| Rate for Payer: Cash Price |
$1,323.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,176.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,176.00
|
| Rate for Payer: Galaxy Health WC |
$2,499.00
|
| Rate for Payer: Global Benefits Group Commercial |
$1,764.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,960.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,120.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,819.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$705.60
|
| Rate for Payer: Multiplan Commercial |
$2,352.00
|
| Rate for Payer: Networks By Design Commercial |
$1,911.00
|
| Rate for Payer: Prime Health Services Commercial |
$2,499.00
|
|
|
HC LUMBAR/SACRAL FACET INJECT/INT
|
Facility
|
OP
|
$2,940.00
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
909000185
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$242.68 |
| Max. Negotiated Rate |
$11,230.65 |
| Rate for Payer: Adventist Health Commercial |
$588.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3,429.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,696.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,244.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,131.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,398.00
|
| Rate for Payer: Blue Shield of California Commercial |
$11,230.65
|
| Rate for Payer: Blue Shield of California EPN |
$1,845.77
|
| Rate for Payer: Cash Price |
$1,323.00
|
| Rate for Payer: Cash Price |
$1,323.00
|
| Rate for Payer: Cash Price |
$1,323.00
|
| Rate for Payer: Cigna of CA HMO |
$1,881.60
|
| Rate for Payer: Cigna of CA PPO |
$2,175.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,696.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,244.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,131.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,527.12
|
| Rate for Payer: EPIC Health Plan Senior |
$1,131.20
|
| Rate for Payer: Galaxy Health WC |
$2,499.00
|
| Rate for Payer: Global Benefits Group Commercial |
$1,764.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,855.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$242.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,131.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,960.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$274.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,131.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$705.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,425.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,515.81
|
| Rate for Payer: Multiplan Commercial |
$2,352.00
|
| Rate for Payer: Multiplan WC |
$1,802.37
|
| Rate for Payer: Networks By Design Commercial |
$1,911.00
|
| Rate for Payer: Prime Health Services Commercial |
$2,499.00
|
| Rate for Payer: Prime Health Services WC |
$1,783.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,764.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,341.00
|
| Rate for Payer: United Healthcare All Other HMO |
$4,460.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,591.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,374.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$1,131.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,696.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,244.32
|
| Rate for Payer: Vantage Medical Group Senior |
$1,131.20
|
|
