|
HC LSO SAG-CORONAL PANEL CUSTOM
|
Facility
|
IP
|
$2,220.00
|
|
|
Service Code
|
CPT L0638
|
| Hospital Charge Code |
915350638
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$444.00 |
| Max. Negotiated Rate |
$14,109.00 |
| Rate for Payer: Adventist Health Commercial |
$444.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14,109.00
|
| Rate for Payer: Cash Price |
$999.00
|
| Rate for Payer: Cash Price |
$999.00
|
| Rate for Payer: Cigna of CA HMO |
$1,554.00
|
| Rate for Payer: Cigna of CA PPO |
$1,554.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,554.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$888.00
|
| Rate for Payer: EPIC Health Plan Senior |
$888.00
|
| Rate for Payer: Galaxy Health WC |
$1,887.00
|
| Rate for Payer: Global Benefits Group Commercial |
$1,332.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,409.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,309.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$532.80
|
| Rate for Payer: Multiplan Commercial |
$1,776.00
|
| Rate for Payer: Networks By Design Commercial |
$1,443.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,887.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$833.17
|
| Rate for Payer: United Healthcare All Other HMO |
$810.97
|
| Rate for Payer: United Healthcare HMO Rider |
$793.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$727.05
|
|
|
HC LSO SAG-CORONAL PANEL CUSTOM
|
Facility
|
IP
|
$2,220.00
|
|
|
Service Code
|
CPT L0638
|
| Hospital Charge Code |
905350638
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$444.00 |
| Max. Negotiated Rate |
$14,109.00 |
| Rate for Payer: Adventist Health Commercial |
$444.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14,109.00
|
| Rate for Payer: Cash Price |
$999.00
|
| Rate for Payer: Cash Price |
$999.00
|
| Rate for Payer: Cigna of CA HMO |
$1,554.00
|
| Rate for Payer: Cigna of CA PPO |
$1,554.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,554.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$888.00
|
| Rate for Payer: EPIC Health Plan Senior |
$888.00
|
| Rate for Payer: Galaxy Health WC |
$1,887.00
|
| Rate for Payer: Global Benefits Group Commercial |
$1,332.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,409.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,309.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$532.80
|
| Rate for Payer: Multiplan Commercial |
$1,776.00
|
| Rate for Payer: Networks By Design Commercial |
$1,443.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,887.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$833.17
|
| Rate for Payer: United Healthcare All Other HMO |
$810.97
|
| Rate for Payer: United Healthcare HMO Rider |
$793.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$727.05
|
|
|
HC LSO SAG-CORONAL PANEL PREFAB
|
Facility
|
IP
|
$2,037.00
|
|
|
Service Code
|
CPT L0637
|
| Hospital Charge Code |
905350637
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$407.40 |
| Max. Negotiated Rate |
$14,109.00 |
| Rate for Payer: Adventist Health Commercial |
$407.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14,109.00
|
| Rate for Payer: Cash Price |
$916.65
|
| Rate for Payer: Cash Price |
$916.65
|
| Rate for Payer: Cigna of CA HMO |
$1,425.90
|
| Rate for Payer: Cigna of CA PPO |
$1,425.90
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,425.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$814.80
|
| Rate for Payer: EPIC Health Plan Senior |
$814.80
|
| Rate for Payer: Galaxy Health WC |
$1,731.45
|
| Rate for Payer: Global Benefits Group Commercial |
$1,222.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,293.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,201.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$488.88
|
| Rate for Payer: Multiplan Commercial |
$1,629.60
|
| Rate for Payer: Networks By Design Commercial |
$1,324.05
|
| Rate for Payer: Prime Health Services Commercial |
$1,731.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$764.49
|
| Rate for Payer: United Healthcare All Other HMO |
$744.12
|
| Rate for Payer: United Healthcare HMO Rider |
$728.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$667.12
|
|
|
HC LSO SAG-CORONAL PANEL PREFAB
|
Facility
|
IP
|
$2,037.00
|
|
|
Service Code
|
CPT L0637
|
| Hospital Charge Code |
915350637
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$407.40 |
| Max. Negotiated Rate |
$14,109.00 |
| Rate for Payer: Adventist Health Commercial |
$407.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14,109.00
|
| Rate for Payer: Cash Price |
$916.65
|
| Rate for Payer: Cash Price |
$916.65
|
| Rate for Payer: Cigna of CA HMO |
$1,425.90
|
| Rate for Payer: Cigna of CA PPO |
$1,425.90
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,425.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$814.80
|
| Rate for Payer: EPIC Health Plan Senior |
$814.80
|
| Rate for Payer: Galaxy Health WC |
$1,731.45
|
| Rate for Payer: Global Benefits Group Commercial |
$1,222.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,293.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,201.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$488.88
|
| Rate for Payer: Multiplan Commercial |
$1,629.60
|
| Rate for Payer: Networks By Design Commercial |
$1,324.05
|
| Rate for Payer: Prime Health Services Commercial |
$1,731.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$764.49
|
| Rate for Payer: United Healthcare All Other HMO |
$744.12
|
| Rate for Payer: United Healthcare HMO Rider |
$728.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$667.12
|
|
|
HC LSO SAG-CORONAL PANEL PREFAB
|
Facility
|
OP
|
$2,037.00
|
|
|
Service Code
|
CPT L0637
|
| Hospital Charge Code |
915350637
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$488.88 |
| Max. Negotiated Rate |
$1,731.45 |
| Rate for Payer: Adventist Health Commercial |
$835.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,731.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,120.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,527.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,233.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,566.45
|
| Rate for Payer: Blue Shield of California Commercial |
$1,032.76
|
| Rate for Payer: Cash Price |
$916.65
|
| Rate for Payer: Cash Price |
$916.65
|
| Rate for Payer: Cigna of CA HMO |
$1,425.90
|
| Rate for Payer: Cigna of CA PPO |
$1,425.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,731.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,731.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,731.45
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,425.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$814.80
|
| Rate for Payer: EPIC Health Plan Senior |
$814.80
|
| Rate for Payer: Galaxy Health WC |
$1,731.45
|
| Rate for Payer: Global Benefits Group Commercial |
$1,222.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,277.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,293.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,444.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,201.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$488.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,425.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,425.90
|
| Rate for Payer: Multiplan Commercial |
$1,629.60
|
| Rate for Payer: Networks By Design Commercial |
$1,018.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,731.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,222.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,222.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$764.49
|
| Rate for Payer: United Healthcare All Other HMO |
$744.12
|
| Rate for Payer: United Healthcare HMO Rider |
$728.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$667.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,731.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,731.45
|
| Rate for Payer: Vantage Medical Group Senior |
$1,731.45
|
|
|
HC LSO SAG-CORONAL PANEL PREFAB
|
Facility
|
OP
|
$2,037.00
|
|
|
Service Code
|
CPT L0637
|
| Hospital Charge Code |
905350637
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$488.88 |
| Max. Negotiated Rate |
$1,731.45 |
| Rate for Payer: Adventist Health Commercial |
$835.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,731.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,120.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,527.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,233.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,566.45
|
| Rate for Payer: Blue Shield of California Commercial |
$1,032.76
|
| Rate for Payer: Cash Price |
$916.65
|
| Rate for Payer: Cash Price |
$916.65
|
| Rate for Payer: Cigna of CA HMO |
$1,425.90
|
| Rate for Payer: Cigna of CA PPO |
$1,425.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,731.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,731.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,731.45
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,425.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$814.80
|
| Rate for Payer: EPIC Health Plan Senior |
$814.80
|
| Rate for Payer: Galaxy Health WC |
$1,731.45
|
| Rate for Payer: Global Benefits Group Commercial |
$1,222.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,277.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,293.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,444.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,201.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$488.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,425.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,425.90
|
| Rate for Payer: Multiplan Commercial |
$1,629.60
|
| Rate for Payer: Networks By Design Commercial |
$1,018.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,731.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,222.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,222.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$764.49
|
| Rate for Payer: United Healthcare All Other HMO |
$744.12
|
| Rate for Payer: United Healthcare HMO Rider |
$728.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$667.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,731.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,731.45
|
| Rate for Payer: Vantage Medical Group Senior |
$1,731.45
|
|
|
HC LSO SAG-CORO REGID FRAME PRE
|
Facility
|
OP
|
$1,940.00
|
|
|
Service Code
|
CPT L0631
|
| Hospital Charge Code |
915350631
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$465.60 |
| Max. Negotiated Rate |
$1,649.00 |
| Rate for Payer: Adventist Health Commercial |
$795.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,649.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,067.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,455.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,174.28
|
| Rate for Payer: Blue Shield of California Commercial |
$983.58
|
| Rate for Payer: Blue Shield of California Commercial |
$1,491.86
|
| Rate for Payer: Cash Price |
$873.00
|
| Rate for Payer: Cash Price |
$873.00
|
| Rate for Payer: Cigna of CA HMO |
$1,358.00
|
| Rate for Payer: Cigna of CA PPO |
$1,358.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,649.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,649.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,649.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,358.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$776.00
|
| Rate for Payer: EPIC Health Plan Senior |
$776.00
|
| Rate for Payer: Galaxy Health WC |
$1,649.00
|
| Rate for Payer: Global Benefits Group Commercial |
$1,164.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,084.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,231.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,226.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,144.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$465.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,358.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,358.00
|
| Rate for Payer: Multiplan Commercial |
$1,552.00
|
| Rate for Payer: Networks By Design Commercial |
$970.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,649.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,164.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,164.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$728.08
|
| Rate for Payer: United Healthcare All Other HMO |
$708.68
|
| Rate for Payer: United Healthcare HMO Rider |
$693.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$635.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,649.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,649.00
|
| Rate for Payer: Vantage Medical Group Senior |
$1,649.00
|
|
|
HC LSO SAG-CORO REGID FRAME PRE
|
Facility
|
IP
|
$1,940.00
|
|
|
Service Code
|
CPT L0631
|
| Hospital Charge Code |
915350631
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$388.00 |
| Max. Negotiated Rate |
$14,109.00 |
| Rate for Payer: Adventist Health Commercial |
$388.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14,109.00
|
| Rate for Payer: Cash Price |
$873.00
|
| Rate for Payer: Cash Price |
$873.00
|
| Rate for Payer: Cigna of CA HMO |
$1,358.00
|
| Rate for Payer: Cigna of CA PPO |
$1,358.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,358.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$776.00
|
| Rate for Payer: EPIC Health Plan Senior |
$776.00
|
| Rate for Payer: Galaxy Health WC |
$1,649.00
|
| Rate for Payer: Global Benefits Group Commercial |
$1,164.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,231.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,144.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$465.60
|
| Rate for Payer: Multiplan Commercial |
$1,552.00
|
| Rate for Payer: Networks By Design Commercial |
$1,261.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,649.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$728.08
|
| Rate for Payer: United Healthcare All Other HMO |
$708.68
|
| Rate for Payer: United Healthcare HMO Rider |
$693.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$635.35
|
|
|
HC LSO SAG-CORO REGID FRAME PRE
|
Facility
|
OP
|
$1,940.00
|
|
|
Service Code
|
CPT L0631
|
| Hospital Charge Code |
905350631
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$465.60 |
| Max. Negotiated Rate |
$1,649.00 |
| Rate for Payer: Adventist Health Commercial |
$795.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,649.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,067.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,455.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,174.28
|
| Rate for Payer: Blue Shield of California Commercial |
$983.58
|
| Rate for Payer: Blue Shield of California Commercial |
$1,491.86
|
| Rate for Payer: Cash Price |
$873.00
|
| Rate for Payer: Cash Price |
$873.00
|
| Rate for Payer: Cigna of CA HMO |
$1,358.00
|
| Rate for Payer: Cigna of CA PPO |
$1,358.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,649.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,649.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,649.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,358.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$776.00
|
| Rate for Payer: EPIC Health Plan Senior |
$776.00
|
| Rate for Payer: Galaxy Health WC |
$1,649.00
|
| Rate for Payer: Global Benefits Group Commercial |
$1,164.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,084.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,231.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,226.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,144.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$465.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,358.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,358.00
|
| Rate for Payer: Multiplan Commercial |
$1,552.00
|
| Rate for Payer: Networks By Design Commercial |
$970.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,649.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,164.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,164.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$728.08
|
| Rate for Payer: United Healthcare All Other HMO |
$708.68
|
| Rate for Payer: United Healthcare HMO Rider |
$693.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$635.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,649.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,649.00
|
| Rate for Payer: Vantage Medical Group Senior |
$1,649.00
|
|
|
HC LSO SAG-CORO REGID FRAME PRE
|
Facility
|
IP
|
$1,940.00
|
|
|
Service Code
|
CPT L0631
|
| Hospital Charge Code |
905350631
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$388.00 |
| Max. Negotiated Rate |
$14,109.00 |
| Rate for Payer: Adventist Health Commercial |
$388.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14,109.00
|
| Rate for Payer: Cash Price |
$873.00
|
| Rate for Payer: Cash Price |
$873.00
|
| Rate for Payer: Cigna of CA HMO |
$1,358.00
|
| Rate for Payer: Cigna of CA PPO |
$1,358.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,358.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$776.00
|
| Rate for Payer: EPIC Health Plan Senior |
$776.00
|
| Rate for Payer: Galaxy Health WC |
$1,649.00
|
| Rate for Payer: Global Benefits Group Commercial |
$1,164.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,231.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,144.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$465.60
|
| Rate for Payer: Multiplan Commercial |
$1,552.00
|
| Rate for Payer: Networks By Design Commercial |
$1,261.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,649.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$728.08
|
| Rate for Payer: United Healthcare All Other HMO |
$708.68
|
| Rate for Payer: United Healthcare HMO Rider |
$693.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$635.35
|
|
|
HC LSO SAG-COR RIGID SHELL/PANEL PREFAB
|
Facility
|
OP
|
$1,910.00
|
|
|
Service Code
|
CPT L0639
|
| Hospital Charge Code |
915340639
|
|
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 |
$1,156.12
|
| Rate for Payer: Blue Shield of California Commercial |
$968.37
|
| Rate for Payer: Blue Shield of California Commercial |
$1,468.79
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,277.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,212.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,444.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,126.90
|
| 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 SAG-COR RIGID SHELL/PANEL PREFAB
|
Facility
|
IP
|
$1,910.00
|
|
|
Service Code
|
CPT L0639
|
| Hospital Charge Code |
915340639
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$382.00 |
| Max. Negotiated Rate |
$14,109.00 |
| Rate for Payer: Adventist Health Commercial |
$382.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14,109.00
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$1,212.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,126.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$458.40
|
| Rate for Payer: Multiplan Commercial |
$1,528.00
|
| Rate for Payer: Networks By Design Commercial |
$1,241.50
|
| 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 SAGIT RIGID PANEL PREFAB
|
Facility
|
OP
|
$2,310.00
|
|
|
Service Code
|
CPT L0635
|
| Hospital Charge Code |
905350635
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$554.40 |
| Max. Negotiated Rate |
$1,963.50 |
| Rate for Payer: Adventist Health Commercial |
$947.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,963.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,270.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,732.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,398.24
|
| Rate for Payer: Blue Shield of California Commercial |
$1,776.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1,171.17
|
| Rate for Payer: Cash Price |
$1,039.50
|
| Rate for Payer: Cash Price |
$1,039.50
|
| Rate for Payer: Cigna of CA HMO |
$1,617.00
|
| Rate for Payer: Cigna of CA PPO |
$1,617.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,963.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,963.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,963.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,617.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$924.00
|
| Rate for Payer: EPIC Health Plan Senior |
$924.00
|
| Rate for Payer: Galaxy Health WC |
$1,963.50
|
| Rate for Payer: Global Benefits Group Commercial |
$1,386.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,291.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,466.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,460.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,362.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$554.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,617.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,617.00
|
| Rate for Payer: Multiplan Commercial |
$1,848.00
|
| Rate for Payer: Networks By Design Commercial |
$1,155.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,963.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,386.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,386.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$866.94
|
| Rate for Payer: United Healthcare All Other HMO |
$843.84
|
| Rate for Payer: United Healthcare HMO Rider |
$825.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$756.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,963.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,963.50
|
| Rate for Payer: Vantage Medical Group Senior |
$1,963.50
|
|
|
HC LSO SAGIT RIGID PANEL PREFAB
|
Facility
|
IP
|
$2,310.00
|
|
|
Service Code
|
CPT L0635
|
| Hospital Charge Code |
915350635
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$462.00 |
| Max. Negotiated Rate |
$14,109.00 |
| Rate for Payer: Adventist Health Commercial |
$462.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14,109.00
|
| Rate for Payer: Cash Price |
$1,039.50
|
| Rate for Payer: Cash Price |
$1,039.50
|
| Rate for Payer: Cigna of CA HMO |
$1,617.00
|
| Rate for Payer: Cigna of CA PPO |
$1,617.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,617.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$924.00
|
| Rate for Payer: EPIC Health Plan Senior |
$924.00
|
| Rate for Payer: Galaxy Health WC |
$1,963.50
|
| Rate for Payer: Global Benefits Group Commercial |
$1,386.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,466.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,362.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$554.40
|
| Rate for Payer: Multiplan Commercial |
$1,848.00
|
| Rate for Payer: Networks By Design Commercial |
$1,501.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,963.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$866.94
|
| Rate for Payer: United Healthcare All Other HMO |
$843.84
|
| Rate for Payer: United Healthcare HMO Rider |
$825.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$756.52
|
|
|
HC LSO SAGIT RIGID PANEL PREFAB
|
Facility
|
OP
|
$2,310.00
|
|
|
Service Code
|
CPT L0635
|
| Hospital Charge Code |
915350635
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$554.40 |
| Max. Negotiated Rate |
$1,963.50 |
| Rate for Payer: Adventist Health Commercial |
$947.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,963.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,270.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,732.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,398.24
|
| Rate for Payer: Blue Shield of California Commercial |
$1,776.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1,171.17
|
| Rate for Payer: Cash Price |
$1,039.50
|
| Rate for Payer: Cash Price |
$1,039.50
|
| Rate for Payer: Cigna of CA HMO |
$1,617.00
|
| Rate for Payer: Cigna of CA PPO |
$1,617.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,963.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,963.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,963.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,617.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$924.00
|
| Rate for Payer: EPIC Health Plan Senior |
$924.00
|
| Rate for Payer: Galaxy Health WC |
$1,963.50
|
| Rate for Payer: Global Benefits Group Commercial |
$1,386.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,291.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,466.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,460.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,362.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$554.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,617.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,617.00
|
| Rate for Payer: Multiplan Commercial |
$1,848.00
|
| Rate for Payer: Networks By Design Commercial |
$1,155.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,963.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,386.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,386.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$866.94
|
| Rate for Payer: United Healthcare All Other HMO |
$843.84
|
| Rate for Payer: United Healthcare HMO Rider |
$825.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$756.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,963.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,963.50
|
| Rate for Payer: Vantage Medical Group Senior |
$1,963.50
|
|
|
HC LSO SAGIT RIGID PANEL PREFAB
|
Facility
|
IP
|
$2,310.00
|
|
|
Service Code
|
CPT L0635
|
| Hospital Charge Code |
905350635
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$462.00 |
| Max. Negotiated Rate |
$14,109.00 |
| Rate for Payer: Adventist Health Commercial |
$462.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14,109.00
|
| Rate for Payer: Cash Price |
$1,039.50
|
| Rate for Payer: Cash Price |
$1,039.50
|
| Rate for Payer: Cigna of CA HMO |
$1,617.00
|
| Rate for Payer: Cigna of CA PPO |
$1,617.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,617.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$924.00
|
| Rate for Payer: EPIC Health Plan Senior |
$924.00
|
| Rate for Payer: Galaxy Health WC |
$1,963.50
|
| Rate for Payer: Global Benefits Group Commercial |
$1,386.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,466.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,362.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$554.40
|
| Rate for Payer: Multiplan Commercial |
$1,848.00
|
| Rate for Payer: Networks By Design Commercial |
$1,501.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,963.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$866.94
|
| Rate for Payer: United Healthcare All Other HMO |
$843.84
|
| Rate for Payer: United Healthcare HMO Rider |
$825.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$756.52
|
|
|
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 |
$1,844.35
|
| Rate for Payer: Blue Shield of California Commercial |
$2,343.14
|
| Rate for Payer: Blue Shield of California Commercial |
$1,544.83
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,911.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,934.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,161.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,797.73
|
| 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 |
$1,844.35
|
| Rate for Payer: Blue Shield of California Commercial |
$2,343.14
|
| Rate for Payer: Blue Shield of California Commercial |
$1,544.83
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,911.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,934.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,161.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,797.73
|
| 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
|
IP
|
$3,047.00
|
|
|
Service Code
|
CPT L0636
|
| Hospital Charge Code |
905350636
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$609.40 |
| Max. Negotiated Rate |
$14,109.00 |
| Rate for Payer: Adventist Health Commercial |
$609.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14,109.00
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$1,934.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,797.73
|
| 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 |
$1,980.55
|
| 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
|
IP
|
$3,047.00
|
|
|
Service Code
|
CPT L0636
|
| Hospital Charge Code |
915350636
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$609.40 |
| Max. Negotiated Rate |
$14,109.00 |
| Rate for Payer: Adventist Health Commercial |
$609.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14,109.00
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$1,934.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,797.73
|
| 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 |
$1,980.55
|
| 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
|
IP
|
$3,047.00
|
|
|
Service Code
|
CPT L0632
|
| Hospital Charge Code |
915350632
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$609.40 |
| Max. Negotiated Rate |
$14,109.00 |
| Rate for Payer: Adventist Health Commercial |
$609.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14,109.00
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$1,934.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,797.73
|
| 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 |
$1,980.55
|
| 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 |
$1,844.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1,544.83
|
| Rate for Payer: Blue Shield of California Commercial |
$2,343.14
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$1,934.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,797.73
|
| 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 |
$14,109.00 |
| Rate for Payer: Adventist Health Commercial |
$609.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14,109.00
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$1,934.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,797.73
|
| 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 |
$1,980.55
|
| 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 |
$1,844.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1,544.83
|
| Rate for Payer: Blue Shield of California Commercial |
$2,343.14
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$1,934.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,797.73
|
| 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
|
IP
|
$1,644.00
|
|
|
Service Code
|
CPT L0640
|
| Hospital Charge Code |
915350640
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$328.80 |
| Max. Negotiated Rate |
$14,109.00 |
| Rate for Payer: Adventist Health Commercial |
$328.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14,109.00
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$1,043.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$969.96
|
| 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 |
$1,068.60
|
| 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
|
|
