|
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 |
$904.20
|
| Rate for Payer: Cash Price |
$904.20
|
| 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
|
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 |
$904.20
|
| Rate for Payer: Cash Price |
$904.20
|
| 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 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 |
$1,050.50
|
| Rate for Payer: Cash Price |
$1,050.50
|
| 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 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 |
$1,050.50
|
| Rate for Payer: Cash Price |
$1,050.50
|
| 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 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 |
$1,739.65
|
| 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 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 |
$1,739.65
|
| 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 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 |
$376.75
|
| Rate for Payer: Cash Price |
$376.75
|
| Rate for Payer: Cash Price |
$376.75
|
| 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 |
$376.75
|
| 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 |
$330.00
|
| 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 |
$330.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cash Price |
$330.00
|
| 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
|
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 |
$787.60
|
| Rate for Payer: Cash Price |
$787.60
|
| Rate for Payer: Cash Price |
$787.60
|
| 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 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 |
$787.60
|
| 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 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 |
$1,438.25
|
| Rate for Payer: Cash Price |
$1,438.25
|
| Rate for Payer: Cash Price |
$1,438.25
|
| 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/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 |
$1,438.25
|
| 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/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 |
$1,617.00
|
| Rate for Payer: Cash Price |
$1,617.00
|
| Rate for Payer: Cash Price |
$1,617.00
|
| 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
|
|
|
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 |
$1,617.00
|
| 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 SPINE AP AND LATERAL
|
Facility
|
OP
|
$853.00
|
|
|
Service Code
|
CPT 72100
|
| Hospital Charge Code |
909001315
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$50.89 |
| Max. Negotiated Rate |
$725.05 |
| Rate for Payer: Galaxy Health WC |
$725.05
|
| Rate for Payer: Adventist Health Commercial |
$170.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$559.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$135.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$189.38
|
| Rate for Payer: Blue Shield of California Commercial |
$522.04
|
| Rate for Payer: Blue Shield of California EPN |
$344.61
|
| Rate for Payer: Cash Price |
$469.15
|
| Rate for Payer: Cash Price |
$469.15
|
| Rate for Payer: Cigna of CA HMO |
$545.92
|
| Rate for Payer: Cigna of CA PPO |
$631.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$202.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$148.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$135.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$182.41
|
| Rate for Payer: EPIC Health Plan Senior |
$135.12
|
| Rate for Payer: Global Benefits Group Commercial |
$511.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$221.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$50.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$135.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$568.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$57.55
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$135.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$204.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$170.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$181.06
|
| Rate for Payer: Multiplan Commercial |
$682.40
|
| Rate for Payer: Networks By Design Commercial |
$554.45
|
| Rate for Payer: Prime Health Services Commercial |
$725.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$511.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$511.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$114.69
|
| Rate for Payer: United Healthcare All Other HMO |
$114.69
|
| Rate for Payer: United Healthcare HMO Rider |
$114.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$114.69
|
| Rate for Payer: Upland Medical Group Pediatric |
$135.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Vantage Medical Group Senior |
$135.12
|
|
|
HC LUMBAR SPINE AP AND LATERAL
|
Facility
|
IP
|
$853.00
|
|
|
Service Code
|
CPT 72100
|
| Hospital Charge Code |
909001315
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$170.60 |
| Max. Negotiated Rate |
$725.05 |
| Rate for Payer: Adventist Health Commercial |
$170.60
|
| Rate for Payer: Cash Price |
$469.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$341.20
|
| Rate for Payer: EPIC Health Plan Senior |
$341.20
|
| Rate for Payer: Galaxy Health WC |
$725.05
|
| Rate for Payer: Global Benefits Group Commercial |
$511.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$568.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$324.99
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$528.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$204.72
|
| Rate for Payer: Multiplan Commercial |
$682.40
|
| Rate for Payer: Networks By Design Commercial |
$554.45
|
| Rate for Payer: Prime Health Services Commercial |
$725.05
|
|
|
HC LUMBAR SPINE LIMITED
|
Facility
|
OP
|
$169.00
|
|
|
Service Code
|
CPT 72100
|
| Hospital Charge Code |
909001136
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$33.80 |
| Max. Negotiated Rate |
$221.60 |
| Rate for Payer: Adventist Health Commercial |
$33.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$110.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$135.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$189.38
|
| Rate for Payer: Blue Shield of California Commercial |
$103.43
|
| Rate for Payer: Blue Shield of California EPN |
$68.28
|
| Rate for Payer: Cash Price |
$92.95
|
| Rate for Payer: Cash Price |
$92.95
|
| Rate for Payer: Cigna of CA HMO |
$108.16
|
| Rate for Payer: Cigna of CA PPO |
$125.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$202.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$148.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$135.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$182.41
|
| Rate for Payer: EPIC Health Plan Senior |
$135.12
|
| Rate for Payer: Galaxy Health WC |
$143.65
|
| Rate for Payer: Global Benefits Group Commercial |
$101.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$221.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$50.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$135.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$112.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$57.55
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$135.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$170.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$181.06
|
| Rate for Payer: Multiplan Commercial |
$135.20
|
| Rate for Payer: Networks By Design Commercial |
$109.85
|
| Rate for Payer: Prime Health Services Commercial |
$143.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$101.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$101.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$114.69
|
| Rate for Payer: United Healthcare All Other HMO |
$114.69
|
| Rate for Payer: United Healthcare HMO Rider |
$114.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$114.69
|
| Rate for Payer: Upland Medical Group Pediatric |
$135.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Vantage Medical Group Senior |
$135.12
|
|
|
HC LUMBAR SPINE LIMITED
|
Facility
|
IP
|
$169.00
|
|
|
Service Code
|
CPT 72100
|
| Hospital Charge Code |
909001136
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$33.80 |
| Max. Negotiated Rate |
$143.65 |
| Rate for Payer: Adventist Health Commercial |
$33.80
|
| Rate for Payer: Cash Price |
$92.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.60
|
| Rate for Payer: EPIC Health Plan Senior |
$67.60
|
| Rate for Payer: Galaxy Health WC |
$143.65
|
| Rate for Payer: Global Benefits Group Commercial |
$101.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$112.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$64.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$104.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.56
|
| Rate for Payer: Multiplan Commercial |
$135.20
|
| Rate for Payer: Networks By Design Commercial |
$109.85
|
| Rate for Payer: Prime Health Services Commercial |
$143.65
|
|
|
HC LUM/SAC ABL EA ADD LEVEL
|
Facility
|
OP
|
$2,203.00
|
|
|
Service Code
|
CPT 64636
|
| Hospital Charge Code |
909000263
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$86.32 |
| Max. Negotiated Rate |
$6,906.11 |
| Rate for Payer: Adventist Health Commercial |
$440.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3,429.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,872.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,211.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,652.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,398.00
|
| 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 |
$1,211.65
|
| Rate for Payer: Cash Price |
$1,211.65
|
| Rate for Payer: Cash Price |
$1,211.65
|
| Rate for Payer: Cigna of CA HMO |
$1,409.92
|
| Rate for Payer: Cigna of CA PPO |
$1,630.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,872.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,872.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,872.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$881.20
|
| Rate for Payer: EPIC Health Plan Senior |
$881.20
|
| Rate for Payer: Galaxy Health WC |
$1,872.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1,321.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$86.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,469.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,363.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$528.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,542.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,542.10
|
| Rate for Payer: Multiplan Commercial |
$1,762.40
|
| Rate for Payer: Networks By Design Commercial |
$1,431.95
|
| Rate for Payer: Prime Health Services Commercial |
$1,872.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,321.80
|
| 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 |
$1,872.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,872.55
|
| Rate for Payer: Vantage Medical Group Senior |
$1,872.55
|
|
|
HC LUM/SAC ABL EA ADD LEVEL
|
Facility
|
IP
|
$2,203.00
|
|
|
Service Code
|
CPT 64636
|
| Hospital Charge Code |
909000263
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$440.60 |
| Max. Negotiated Rate |
$1,872.55 |
| Rate for Payer: Adventist Health Commercial |
$440.60
|
| Rate for Payer: Cash Price |
$1,211.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$881.20
|
| Rate for Payer: EPIC Health Plan Senior |
$881.20
|
| Rate for Payer: Galaxy Health WC |
$1,872.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1,321.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,469.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$839.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,363.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$528.72
|
| Rate for Payer: Multiplan Commercial |
$1,762.40
|
| Rate for Payer: Networks By Design Commercial |
$1,431.95
|
| Rate for Payer: Prime Health Services Commercial |
$1,872.55
|
|
|
HC LUM SPINE BEND ONLY/4 VIEWS
|
Facility
|
IP
|
$1,012.00
|
|
|
Service Code
|
CPT 72120
|
| Hospital Charge Code |
909001318
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$202.40 |
| Max. Negotiated Rate |
$860.20 |
| Rate for Payer: Adventist Health Commercial |
$202.40
|
| Rate for Payer: Cash Price |
$556.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$404.80
|
| Rate for Payer: EPIC Health Plan Senior |
$404.80
|
| Rate for Payer: Galaxy Health WC |
$860.20
|
| Rate for Payer: Global Benefits Group Commercial |
$607.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$675.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$385.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$626.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$242.88
|
| Rate for Payer: Multiplan Commercial |
$809.60
|
| Rate for Payer: Networks By Design Commercial |
$657.80
|
| Rate for Payer: Prime Health Services Commercial |
$860.20
|
|
|
HC LUM SPINE BEND ONLY/4 VIEWS
|
Facility
|
OP
|
$1,012.00
|
|
|
Service Code
|
CPT 72120
|
| Hospital Charge Code |
909001318
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$58.14 |
| Max. Negotiated Rate |
$860.20 |
| Rate for Payer: Adventist Health Commercial |
$202.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$663.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$135.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$252.22
|
| Rate for Payer: Blue Shield of California Commercial |
$619.34
|
| Rate for Payer: Blue Shield of California EPN |
$408.85
|
| Rate for Payer: Cash Price |
$556.60
|
| Rate for Payer: Cash Price |
$556.60
|
| Rate for Payer: Cigna of CA HMO |
$647.68
|
| Rate for Payer: Cigna of CA PPO |
$748.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$202.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$148.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$135.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$182.41
|
| Rate for Payer: EPIC Health Plan Senior |
$135.12
|
| Rate for Payer: Galaxy Health WC |
$860.20
|
| Rate for Payer: Global Benefits Group Commercial |
$607.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$221.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$58.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$135.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$675.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$65.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$135.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$242.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$170.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$181.06
|
| Rate for Payer: Multiplan Commercial |
$809.60
|
| Rate for Payer: Networks By Design Commercial |
$657.80
|
| Rate for Payer: Prime Health Services Commercial |
$860.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$607.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$607.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$114.69
|
| Rate for Payer: United Healthcare All Other HMO |
$114.69
|
| Rate for Payer: United Healthcare HMO Rider |
$114.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$114.69
|
| Rate for Payer: Upland Medical Group Pediatric |
$135.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Vantage Medical Group Senior |
$135.12
|
|
|
HC LUM SPINE COMP W/BENDING VIEWS
|
Facility
|
OP
|
$1,564.00
|
|
|
Service Code
|
CPT 72114
|
| Hospital Charge Code |
909001316
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$88.89 |
| Max. Negotiated Rate |
$1,329.40 |
| Rate for Payer: Adventist Health Commercial |
$312.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,025.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$135.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$334.41
|
| Rate for Payer: Blue Shield of California Commercial |
$957.17
|
| Rate for Payer: Blue Shield of California EPN |
$631.86
|
| Rate for Payer: Cash Price |
$860.20
|
| Rate for Payer: Cash Price |
$860.20
|
| Rate for Payer: Cigna of CA HMO |
$1,000.96
|
| Rate for Payer: Cigna of CA PPO |
$1,157.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$202.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$148.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$135.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$182.41
|
| Rate for Payer: EPIC Health Plan Senior |
$135.12
|
| Rate for Payer: Galaxy Health WC |
$1,329.40
|
| Rate for Payer: Global Benefits Group Commercial |
$938.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$221.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$88.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$135.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,043.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$100.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$135.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$375.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$170.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$181.06
|
| Rate for Payer: Multiplan Commercial |
$1,251.20
|
| Rate for Payer: Networks By Design Commercial |
$1,016.60
|
| Rate for Payer: Prime Health Services Commercial |
$1,329.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$938.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$938.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$193.23
|
| Rate for Payer: United Healthcare All Other HMO |
$193.23
|
| Rate for Payer: United Healthcare HMO Rider |
$193.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$193.23
|
| Rate for Payer: Upland Medical Group Pediatric |
$135.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$202.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$148.63
|
| Rate for Payer: Vantage Medical Group Senior |
$135.12
|
|
