|
HC TLSO RIB GUSSET
|
Facility
|
OP
|
$221.00
|
|
|
Service Code
|
CPT L1280
|
| Hospital Charge Code |
905351280
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$72.38 |
| Max. Negotiated Rate |
$198.90 |
| Rate for Payer: Adventist Health Commercial |
$90.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$187.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$121.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$165.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$129.79
|
| Rate for Payer: Blue Shield of California Commercial |
$170.83
|
| Rate for Payer: Blue Shield of California EPN |
$111.38
|
| Rate for Payer: Cash Price |
$121.55
|
| Rate for Payer: Cash Price |
$121.55
|
| Rate for Payer: Central Health Plan Commercial |
$176.80
|
| Rate for Payer: Cigna of CA HMO |
$154.70
|
| Rate for Payer: Cigna of CA PPO |
$154.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$187.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$187.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$187.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$88.40
|
| Rate for Payer: EPIC Health Plan Senior |
$88.40
|
| Rate for Payer: Galaxy Health WC |
$187.85
|
| Rate for Payer: Global Benefits Group Commercial |
$132.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$198.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$110.77
|
| Rate for Payer: InnovAge PACE Commercial |
$110.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$147.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$122.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$136.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$154.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$154.70
|
| Rate for Payer: Multiplan Commercial |
$165.75
|
| Rate for Payer: Networks By Design Commercial |
$110.50
|
| Rate for Payer: Prime Health Services Commercial |
$187.85
|
| Rate for Payer: Riverside University Health System MISP |
$88.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$132.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$132.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$82.94
|
| Rate for Payer: United Healthcare All Other HMO |
$80.73
|
| Rate for Payer: United Healthcare HMO Rider |
$78.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$72.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$187.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$187.85
|
| Rate for Payer: Vantage Medical Group Senior |
$187.85
|
|
|
HC TLSO RIB GUSSET
|
Facility
|
IP
|
$221.00
|
|
|
Service Code
|
CPT L1280
|
| Hospital Charge Code |
915351280
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$44.20 |
| Max. Negotiated Rate |
$198.90 |
| Rate for Payer: Adventist Health Commercial |
$44.20
|
| Rate for Payer: Blue Shield of California Commercial |
$170.83
|
| Rate for Payer: Blue Shield of California EPN |
$111.38
|
| Rate for Payer: Cash Price |
$121.55
|
| Rate for Payer: Central Health Plan Commercial |
$176.80
|
| Rate for Payer: Cigna of CA HMO |
$154.70
|
| Rate for Payer: Cigna of CA PPO |
$154.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$88.40
|
| Rate for Payer: EPIC Health Plan Senior |
$88.40
|
| Rate for Payer: Galaxy Health WC |
$187.85
|
| Rate for Payer: Global Benefits Group Commercial |
$132.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$198.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$147.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$136.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.20
|
| Rate for Payer: Multiplan Commercial |
$165.75
|
| Rate for Payer: Networks By Design Commercial |
$143.65
|
| Rate for Payer: Prime Health Services Commercial |
$187.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$82.94
|
| Rate for Payer: United Healthcare All Other HMO |
$80.73
|
| Rate for Payer: United Healthcare HMO Rider |
$78.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$72.38
|
|
|
HC TLSO RIB GUSSET
|
Facility
|
OP
|
$221.00
|
|
|
Service Code
|
CPT L1280
|
| Hospital Charge Code |
915351280
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$72.38 |
| Max. Negotiated Rate |
$198.90 |
| Rate for Payer: Adventist Health Commercial |
$90.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$187.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$121.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$165.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$129.79
|
| Rate for Payer: Blue Shield of California Commercial |
$170.83
|
| Rate for Payer: Blue Shield of California EPN |
$111.38
|
| Rate for Payer: Cash Price |
$121.55
|
| Rate for Payer: Cash Price |
$121.55
|
| Rate for Payer: Central Health Plan Commercial |
$176.80
|
| Rate for Payer: Cigna of CA HMO |
$154.70
|
| Rate for Payer: Cigna of CA PPO |
$154.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$187.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$187.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$187.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$88.40
|
| Rate for Payer: EPIC Health Plan Senior |
$88.40
|
| Rate for Payer: Galaxy Health WC |
$187.85
|
| Rate for Payer: Global Benefits Group Commercial |
$132.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$198.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$110.77
|
| Rate for Payer: InnovAge PACE Commercial |
$110.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$147.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$122.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$136.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$154.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$154.70
|
| Rate for Payer: Multiplan Commercial |
$165.75
|
| Rate for Payer: Networks By Design Commercial |
$110.50
|
| Rate for Payer: Prime Health Services Commercial |
$187.85
|
| Rate for Payer: Riverside University Health System MISP |
$88.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$132.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$132.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$82.94
|
| Rate for Payer: United Healthcare All Other HMO |
$80.73
|
| Rate for Payer: United Healthcare HMO Rider |
$78.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$72.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$187.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$187.85
|
| Rate for Payer: Vantage Medical Group Senior |
$187.85
|
|
|
HC TLSO SAGITTAL CNTRL RIGID POST FRAME SFT APRON
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
CPT L0466
|
| Hospital Charge Code |
905350466
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$150.00 |
| Max. Negotiated Rate |
$675.00 |
| Rate for Payer: Adventist Health Commercial |
$150.00
|
| Rate for Payer: Blue Shield of California Commercial |
$579.75
|
| Rate for Payer: Blue Shield of California EPN |
$378.00
|
| Rate for Payer: Cash Price |
$412.50
|
| Rate for Payer: Central Health Plan Commercial |
$600.00
|
| Rate for Payer: Cigna of CA HMO |
$525.00
|
| Rate for Payer: Cigna of CA PPO |
$525.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$300.00
|
| Rate for Payer: EPIC Health Plan Senior |
$300.00
|
| Rate for Payer: Galaxy Health WC |
$637.50
|
| Rate for Payer: Global Benefits Group Commercial |
$450.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$675.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$500.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$285.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$464.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$150.00
|
| Rate for Payer: Multiplan Commercial |
$562.50
|
| Rate for Payer: Networks By Design Commercial |
$487.50
|
| Rate for Payer: Prime Health Services Commercial |
$637.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$281.48
|
| Rate for Payer: United Healthcare All Other HMO |
$273.98
|
| Rate for Payer: United Healthcare HMO Rider |
$268.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$245.62
|
|
|
HC TLSO SAGITTAL CNTRL RIGID POST FRAME SFT APRON
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
CPT L0466
|
| Hospital Charge Code |
905350466
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$245.62 |
| Max. Negotiated Rate |
$675.00 |
| Rate for Payer: Adventist Health Commercial |
$307.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$637.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$412.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$562.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$440.48
|
| Rate for Payer: Blue Shield of California Commercial |
$579.75
|
| Rate for Payer: Blue Shield of California EPN |
$378.00
|
| Rate for Payer: Cash Price |
$412.50
|
| Rate for Payer: Cash Price |
$412.50
|
| Rate for Payer: Central Health Plan Commercial |
$600.00
|
| Rate for Payer: Cigna of CA HMO |
$525.00
|
| Rate for Payer: Cigna of CA PPO |
$525.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$637.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$637.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$637.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$300.00
|
| Rate for Payer: EPIC Health Plan Senior |
$300.00
|
| Rate for Payer: Galaxy Health WC |
$637.50
|
| Rate for Payer: Global Benefits Group Commercial |
$450.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$675.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$515.98
|
| Rate for Payer: InnovAge PACE Commercial |
$375.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$500.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$569.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$464.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$307.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$525.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$525.00
|
| Rate for Payer: Multiplan Commercial |
$562.50
|
| Rate for Payer: Networks By Design Commercial |
$375.00
|
| Rate for Payer: Prime Health Services Commercial |
$637.50
|
| Rate for Payer: Riverside University Health System MISP |
$300.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$450.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$450.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$281.48
|
| Rate for Payer: United Healthcare All Other HMO |
$273.98
|
| Rate for Payer: United Healthcare HMO Rider |
$268.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$245.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$637.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$637.50
|
| Rate for Payer: Vantage Medical Group Senior |
$637.50
|
|
|
HC TLSO SAGITTAL CNTRL RIGID POST FRAME SFT APRON
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
CPT L0466
|
| Hospital Charge Code |
915350466
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$150.00 |
| Max. Negotiated Rate |
$675.00 |
| Rate for Payer: Adventist Health Commercial |
$150.00
|
| Rate for Payer: Blue Shield of California Commercial |
$579.75
|
| Rate for Payer: Blue Shield of California EPN |
$378.00
|
| Rate for Payer: Cash Price |
$412.50
|
| Rate for Payer: Central Health Plan Commercial |
$600.00
|
| Rate for Payer: Cigna of CA HMO |
$525.00
|
| Rate for Payer: Cigna of CA PPO |
$525.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$300.00
|
| Rate for Payer: EPIC Health Plan Senior |
$300.00
|
| Rate for Payer: Galaxy Health WC |
$637.50
|
| Rate for Payer: Global Benefits Group Commercial |
$450.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$675.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$500.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$285.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$464.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$150.00
|
| Rate for Payer: Multiplan Commercial |
$562.50
|
| Rate for Payer: Networks By Design Commercial |
$487.50
|
| Rate for Payer: Prime Health Services Commercial |
$637.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$281.48
|
| Rate for Payer: United Healthcare All Other HMO |
$273.98
|
| Rate for Payer: United Healthcare HMO Rider |
$268.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$245.62
|
|
|
HC TLSO SAGITTAL CNTRL RIGID POST FRAME SFT APRON
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
CPT L0466
|
| Hospital Charge Code |
915350466
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$245.62 |
| Max. Negotiated Rate |
$675.00 |
| Rate for Payer: Adventist Health Commercial |
$307.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$637.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$412.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$562.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$440.48
|
| Rate for Payer: Blue Shield of California Commercial |
$579.75
|
| Rate for Payer: Blue Shield of California EPN |
$378.00
|
| Rate for Payer: Cash Price |
$412.50
|
| Rate for Payer: Cash Price |
$412.50
|
| Rate for Payer: Central Health Plan Commercial |
$600.00
|
| Rate for Payer: Cigna of CA HMO |
$525.00
|
| Rate for Payer: Cigna of CA PPO |
$525.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$637.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$637.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$637.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$300.00
|
| Rate for Payer: EPIC Health Plan Senior |
$300.00
|
| Rate for Payer: Galaxy Health WC |
$637.50
|
| Rate for Payer: Global Benefits Group Commercial |
$450.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$675.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$515.98
|
| Rate for Payer: InnovAge PACE Commercial |
$375.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$500.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$569.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$464.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$307.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$525.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$525.00
|
| Rate for Payer: Multiplan Commercial |
$562.50
|
| Rate for Payer: Networks By Design Commercial |
$375.00
|
| Rate for Payer: Prime Health Services Commercial |
$637.50
|
| Rate for Payer: Riverside University Health System MISP |
$300.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$450.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$450.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$281.48
|
| Rate for Payer: United Healthcare All Other HMO |
$273.98
|
| Rate for Payer: United Healthcare HMO Rider |
$268.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$245.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$637.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$637.50
|
| Rate for Payer: Vantage Medical Group Senior |
$637.50
|
|
|
HC TLSO SAGITTAL CORONAL CONTROL ONE PIECE
|
Facility
|
OP
|
$2,249.00
|
|
|
Service Code
|
CPT L0490
|
| Hospital Charge Code |
905350490
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$305.85 |
| Max. Negotiated Rate |
$2,024.10 |
| Rate for Payer: Adventist Health Commercial |
$922.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,911.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,236.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,686.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,320.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1,738.48
|
| Rate for Payer: Blue Shield of California EPN |
$1,133.50
|
| Rate for Payer: Cash Price |
$1,236.95
|
| Rate for Payer: Cash Price |
$1,236.95
|
| Rate for Payer: Central Health Plan Commercial |
$1,799.20
|
| Rate for Payer: Cigna of CA HMO |
$1,574.30
|
| Rate for Payer: Cigna of CA PPO |
$1,574.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,911.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,911.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,911.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$899.60
|
| Rate for Payer: EPIC Health Plan Senior |
$899.60
|
| Rate for Payer: Galaxy Health WC |
$1,911.65
|
| Rate for Payer: Global Benefits Group Commercial |
$1,349.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,024.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$305.85
|
| Rate for Payer: InnovAge PACE Commercial |
$1,124.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,500.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$337.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,392.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$922.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,574.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,574.30
|
| Rate for Payer: Multiplan Commercial |
$1,686.75
|
| Rate for Payer: Networks By Design Commercial |
$1,124.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,911.65
|
| Rate for Payer: Riverside University Health System MISP |
$899.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,349.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,349.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$844.05
|
| Rate for Payer: United Healthcare All Other HMO |
$821.56
|
| Rate for Payer: United Healthcare HMO Rider |
$803.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$736.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,911.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,911.65
|
| Rate for Payer: Vantage Medical Group Senior |
$1,911.65
|
|
|
HC TLSO SAGITTAL CORONAL CONTROL ONE PIECE
|
Facility
|
OP
|
$2,249.00
|
|
|
Service Code
|
CPT L0490
|
| Hospital Charge Code |
915350490
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$305.85 |
| Max. Negotiated Rate |
$2,024.10 |
| Rate for Payer: Adventist Health Commercial |
$922.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,911.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,236.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,686.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,320.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1,738.48
|
| Rate for Payer: Blue Shield of California EPN |
$1,133.50
|
| Rate for Payer: Cash Price |
$1,236.95
|
| Rate for Payer: Cash Price |
$1,236.95
|
| Rate for Payer: Central Health Plan Commercial |
$1,799.20
|
| Rate for Payer: Cigna of CA HMO |
$1,574.30
|
| Rate for Payer: Cigna of CA PPO |
$1,574.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,911.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,911.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,911.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$899.60
|
| Rate for Payer: EPIC Health Plan Senior |
$899.60
|
| Rate for Payer: Galaxy Health WC |
$1,911.65
|
| Rate for Payer: Global Benefits Group Commercial |
$1,349.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,024.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$305.85
|
| Rate for Payer: InnovAge PACE Commercial |
$1,124.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,500.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$337.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,392.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$922.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,574.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,574.30
|
| Rate for Payer: Multiplan Commercial |
$1,686.75
|
| Rate for Payer: Networks By Design Commercial |
$1,124.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,911.65
|
| Rate for Payer: Riverside University Health System MISP |
$899.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,349.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,349.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$844.05
|
| Rate for Payer: United Healthcare All Other HMO |
$821.56
|
| Rate for Payer: United Healthcare HMO Rider |
$803.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$736.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,911.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,911.65
|
| Rate for Payer: Vantage Medical Group Senior |
$1,911.65
|
|
|
HC TLSO SAGITTAL CORONAL CONTROL ONE PIECE
|
Facility
|
IP
|
$2,249.00
|
|
|
Service Code
|
CPT L0490
|
| Hospital Charge Code |
915350490
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$449.80 |
| Max. Negotiated Rate |
$2,024.10 |
| Rate for Payer: Adventist Health Commercial |
$449.80
|
| Rate for Payer: Blue Shield of California Commercial |
$1,738.48
|
| Rate for Payer: Blue Shield of California EPN |
$1,133.50
|
| Rate for Payer: Cash Price |
$1,236.95
|
| Rate for Payer: Central Health Plan Commercial |
$1,799.20
|
| Rate for Payer: Cigna of CA HMO |
$1,574.30
|
| Rate for Payer: Cigna of CA PPO |
$1,574.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$899.60
|
| Rate for Payer: EPIC Health Plan Senior |
$899.60
|
| Rate for Payer: Galaxy Health WC |
$1,911.65
|
| Rate for Payer: Global Benefits Group Commercial |
$1,349.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,024.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,500.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$856.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,392.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$449.80
|
| Rate for Payer: Multiplan Commercial |
$1,686.75
|
| Rate for Payer: Networks By Design Commercial |
$1,461.85
|
| Rate for Payer: Prime Health Services Commercial |
$1,911.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$844.05
|
| Rate for Payer: United Healthcare All Other HMO |
$821.56
|
| Rate for Payer: United Healthcare HMO Rider |
$803.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$736.55
|
|
|
HC TLSO SAGITTAL CORONAL CONTROL ONE PIECE
|
Facility
|
IP
|
$2,249.00
|
|
|
Service Code
|
CPT L0490
|
| Hospital Charge Code |
905350490
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$449.80 |
| Max. Negotiated Rate |
$2,024.10 |
| Rate for Payer: Adventist Health Commercial |
$449.80
|
| Rate for Payer: Blue Shield of California Commercial |
$1,738.48
|
| Rate for Payer: Blue Shield of California EPN |
$1,133.50
|
| Rate for Payer: Cash Price |
$1,236.95
|
| Rate for Payer: Central Health Plan Commercial |
$1,799.20
|
| Rate for Payer: Cigna of CA HMO |
$1,574.30
|
| Rate for Payer: Cigna of CA PPO |
$1,574.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$899.60
|
| Rate for Payer: EPIC Health Plan Senior |
$899.60
|
| Rate for Payer: Galaxy Health WC |
$1,911.65
|
| Rate for Payer: Global Benefits Group Commercial |
$1,349.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,024.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,500.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$856.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,392.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$449.80
|
| Rate for Payer: Multiplan Commercial |
$1,686.75
|
| Rate for Payer: Networks By Design Commercial |
$1,461.85
|
| Rate for Payer: Prime Health Services Commercial |
$1,911.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$844.05
|
| Rate for Payer: United Healthcare All Other HMO |
$821.56
|
| Rate for Payer: United Healthcare HMO Rider |
$803.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$736.55
|
|
|
HC TLSO SAGITTAL-CORONAL RIGID POST FRAME SFT APRON
|
Facility
|
IP
|
$909.00
|
|
|
Service Code
|
CPT L0468
|
| Hospital Charge Code |
905350468
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$181.80 |
| Max. Negotiated Rate |
$818.10 |
| Rate for Payer: Adventist Health Commercial |
$181.80
|
| Rate for Payer: Blue Shield of California Commercial |
$702.66
|
| Rate for Payer: Blue Shield of California EPN |
$458.14
|
| Rate for Payer: Cash Price |
$499.95
|
| Rate for Payer: Central Health Plan Commercial |
$727.20
|
| Rate for Payer: Cigna of CA HMO |
$636.30
|
| Rate for Payer: Cigna of CA PPO |
$636.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$363.60
|
| Rate for Payer: EPIC Health Plan Senior |
$363.60
|
| Rate for Payer: Galaxy Health WC |
$772.65
|
| Rate for Payer: Global Benefits Group Commercial |
$545.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$818.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$606.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$346.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$562.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$181.80
|
| Rate for Payer: Multiplan Commercial |
$681.75
|
| Rate for Payer: Networks By Design Commercial |
$590.85
|
| Rate for Payer: Prime Health Services Commercial |
$772.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$341.15
|
| Rate for Payer: United Healthcare All Other HMO |
$332.06
|
| Rate for Payer: United Healthcare HMO Rider |
$324.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$297.70
|
|
|
HC TLSO SAGITTAL-CORONAL RIGID POST FRAME SFT APRON
|
Facility
|
OP
|
$909.00
|
|
|
Service Code
|
CPT L0468
|
| Hospital Charge Code |
905350468
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$297.70 |
| Max. Negotiated Rate |
$818.10 |
| Rate for Payer: Adventist Health Commercial |
$372.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$772.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$499.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$681.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$533.86
|
| Rate for Payer: Blue Shield of California Commercial |
$702.66
|
| Rate for Payer: Blue Shield of California EPN |
$458.14
|
| Rate for Payer: Cash Price |
$499.95
|
| Rate for Payer: Cash Price |
$499.95
|
| Rate for Payer: Central Health Plan Commercial |
$727.20
|
| Rate for Payer: Cigna of CA HMO |
$636.30
|
| Rate for Payer: Cigna of CA PPO |
$636.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$772.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$772.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$772.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$363.60
|
| Rate for Payer: EPIC Health Plan Senior |
$363.60
|
| Rate for Payer: Galaxy Health WC |
$772.65
|
| Rate for Payer: Global Benefits Group Commercial |
$545.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$818.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$625.39
|
| Rate for Payer: InnovAge PACE Commercial |
$454.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$606.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$690.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$562.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$372.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$636.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$636.30
|
| Rate for Payer: Multiplan Commercial |
$681.75
|
| Rate for Payer: Networks By Design Commercial |
$454.50
|
| Rate for Payer: Prime Health Services Commercial |
$772.65
|
| Rate for Payer: Riverside University Health System MISP |
$363.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$545.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$545.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$341.15
|
| Rate for Payer: United Healthcare All Other HMO |
$332.06
|
| Rate for Payer: United Healthcare HMO Rider |
$324.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$297.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$772.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$772.65
|
| Rate for Payer: Vantage Medical Group Senior |
$772.65
|
|
|
HC TLSO SAGITTAL-CORONAL RIGID POST FRAME SFT APRON
|
Facility
|
IP
|
$909.00
|
|
|
Service Code
|
CPT L0468
|
| Hospital Charge Code |
915350468
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$181.80 |
| Max. Negotiated Rate |
$818.10 |
| Rate for Payer: Adventist Health Commercial |
$181.80
|
| Rate for Payer: Blue Shield of California Commercial |
$702.66
|
| Rate for Payer: Blue Shield of California EPN |
$458.14
|
| Rate for Payer: Cash Price |
$499.95
|
| Rate for Payer: Central Health Plan Commercial |
$727.20
|
| Rate for Payer: Cigna of CA HMO |
$636.30
|
| Rate for Payer: Cigna of CA PPO |
$636.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$363.60
|
| Rate for Payer: EPIC Health Plan Senior |
$363.60
|
| Rate for Payer: Galaxy Health WC |
$772.65
|
| Rate for Payer: Global Benefits Group Commercial |
$545.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$818.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$606.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$346.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$562.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$181.80
|
| Rate for Payer: Multiplan Commercial |
$681.75
|
| Rate for Payer: Networks By Design Commercial |
$590.85
|
| Rate for Payer: Prime Health Services Commercial |
$772.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$341.15
|
| Rate for Payer: United Healthcare All Other HMO |
$332.06
|
| Rate for Payer: United Healthcare HMO Rider |
$324.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$297.70
|
|
|
HC TLSO SAGITTAL-CORONAL RIGID POST FRAME SFT APRON
|
Facility
|
OP
|
$909.00
|
|
|
Service Code
|
CPT L0468
|
| Hospital Charge Code |
915350468
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$297.70 |
| Max. Negotiated Rate |
$818.10 |
| Rate for Payer: Adventist Health Commercial |
$372.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$772.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$499.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$681.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$533.86
|
| Rate for Payer: Blue Shield of California Commercial |
$702.66
|
| Rate for Payer: Blue Shield of California EPN |
$458.14
|
| Rate for Payer: Cash Price |
$499.95
|
| Rate for Payer: Cash Price |
$499.95
|
| Rate for Payer: Central Health Plan Commercial |
$727.20
|
| Rate for Payer: Cigna of CA HMO |
$636.30
|
| Rate for Payer: Cigna of CA PPO |
$636.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$772.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$772.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$772.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$363.60
|
| Rate for Payer: EPIC Health Plan Senior |
$363.60
|
| Rate for Payer: Galaxy Health WC |
$772.65
|
| Rate for Payer: Global Benefits Group Commercial |
$545.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$818.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$625.39
|
| Rate for Payer: InnovAge PACE Commercial |
$454.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$606.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$690.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$562.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$372.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$636.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$636.30
|
| Rate for Payer: Multiplan Commercial |
$681.75
|
| Rate for Payer: Networks By Design Commercial |
$454.50
|
| Rate for Payer: Prime Health Services Commercial |
$772.65
|
| Rate for Payer: Riverside University Health System MISP |
$363.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$545.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$545.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$341.15
|
| Rate for Payer: United Healthcare All Other HMO |
$332.06
|
| Rate for Payer: United Healthcare HMO Rider |
$324.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$297.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$772.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$772.65
|
| Rate for Payer: Vantage Medical Group Senior |
$772.65
|
|
|
HC TLSO SCOLIOSIS PROCEDURE
|
Facility
|
IP
|
$4,062.00
|
|
|
Service Code
|
CPT L1300
|
| Hospital Charge Code |
915351300
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$812.40 |
| Max. Negotiated Rate |
$3,655.80 |
| Rate for Payer: Adventist Health Commercial |
$812.40
|
| Rate for Payer: Blue Shield of California Commercial |
$3,139.93
|
| Rate for Payer: Blue Shield of California EPN |
$2,047.25
|
| Rate for Payer: Cash Price |
$2,234.10
|
| Rate for Payer: Central Health Plan Commercial |
$3,249.60
|
| Rate for Payer: Cigna of CA HMO |
$2,843.40
|
| Rate for Payer: Cigna of CA PPO |
$2,843.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,624.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1,624.80
|
| Rate for Payer: Galaxy Health WC |
$3,452.70
|
| Rate for Payer: Global Benefits Group Commercial |
$2,437.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,655.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,709.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,547.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,514.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$812.40
|
| Rate for Payer: Multiplan Commercial |
$3,046.50
|
| Rate for Payer: Networks By Design Commercial |
$2,640.30
|
| Rate for Payer: Prime Health Services Commercial |
$3,452.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,524.47
|
| Rate for Payer: United Healthcare All Other HMO |
$1,483.85
|
| Rate for Payer: United Healthcare HMO Rider |
$1,451.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,330.31
|
|
|
HC TLSO SCOLIOSIS PROCEDURE
|
Facility
|
IP
|
$4,062.00
|
|
|
Service Code
|
CPT L1300
|
| Hospital Charge Code |
905351300
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$812.40 |
| Max. Negotiated Rate |
$3,655.80 |
| Rate for Payer: Adventist Health Commercial |
$812.40
|
| Rate for Payer: Blue Shield of California Commercial |
$3,139.93
|
| Rate for Payer: Blue Shield of California EPN |
$2,047.25
|
| Rate for Payer: Cash Price |
$2,234.10
|
| Rate for Payer: Central Health Plan Commercial |
$3,249.60
|
| Rate for Payer: Cigna of CA HMO |
$2,843.40
|
| Rate for Payer: Cigna of CA PPO |
$2,843.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,624.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1,624.80
|
| Rate for Payer: Galaxy Health WC |
$3,452.70
|
| Rate for Payer: Global Benefits Group Commercial |
$2,437.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,655.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,709.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,547.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,514.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$812.40
|
| Rate for Payer: Multiplan Commercial |
$3,046.50
|
| Rate for Payer: Networks By Design Commercial |
$2,640.30
|
| Rate for Payer: Prime Health Services Commercial |
$3,452.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,524.47
|
| Rate for Payer: United Healthcare All Other HMO |
$1,483.85
|
| Rate for Payer: United Healthcare HMO Rider |
$1,451.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,330.31
|
|
|
HC TLSO SCOLIOSIS PROCEDURE
|
Facility
|
OP
|
$4,062.00
|
|
|
Service Code
|
CPT L1300
|
| Hospital Charge Code |
905351300
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,330.31 |
| Max. Negotiated Rate |
$3,655.80 |
| Rate for Payer: Adventist Health Commercial |
$1,665.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,452.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,234.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,046.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,385.61
|
| Rate for Payer: Blue Shield of California Commercial |
$3,139.93
|
| Rate for Payer: Blue Shield of California EPN |
$2,047.25
|
| Rate for Payer: Cash Price |
$2,234.10
|
| Rate for Payer: Cash Price |
$2,234.10
|
| Rate for Payer: Central Health Plan Commercial |
$3,249.60
|
| Rate for Payer: Cigna of CA HMO |
$2,843.40
|
| Rate for Payer: Cigna of CA PPO |
$2,843.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,452.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,452.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,452.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,624.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1,624.80
|
| Rate for Payer: Galaxy Health WC |
$3,452.70
|
| Rate for Payer: Global Benefits Group Commercial |
$2,437.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,655.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1,765.37
|
| Rate for Payer: InnovAge PACE Commercial |
$2,031.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,709.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,950.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,514.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,665.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,843.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,843.40
|
| Rate for Payer: Multiplan Commercial |
$3,046.50
|
| Rate for Payer: Networks By Design Commercial |
$2,031.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,452.70
|
| Rate for Payer: Riverside University Health System MISP |
$1,624.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,437.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,437.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,524.47
|
| Rate for Payer: United Healthcare All Other HMO |
$1,483.85
|
| Rate for Payer: United Healthcare HMO Rider |
$1,451.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,330.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,452.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,452.70
|
| Rate for Payer: Vantage Medical Group Senior |
$3,452.70
|
|
|
HC TLSO SCOLIOSIS PROCEDURE
|
Facility
|
OP
|
$4,062.00
|
|
|
Service Code
|
CPT L1300
|
| Hospital Charge Code |
915351300
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,330.31 |
| Max. Negotiated Rate |
$3,655.80 |
| Rate for Payer: Adventist Health Commercial |
$1,665.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,452.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,234.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,046.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,385.61
|
| Rate for Payer: Blue Shield of California Commercial |
$3,139.93
|
| Rate for Payer: Blue Shield of California EPN |
$2,047.25
|
| Rate for Payer: Cash Price |
$2,234.10
|
| Rate for Payer: Cash Price |
$2,234.10
|
| Rate for Payer: Central Health Plan Commercial |
$3,249.60
|
| Rate for Payer: Cigna of CA HMO |
$2,843.40
|
| Rate for Payer: Cigna of CA PPO |
$2,843.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,452.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,452.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,452.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,624.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1,624.80
|
| Rate for Payer: Galaxy Health WC |
$3,452.70
|
| Rate for Payer: Global Benefits Group Commercial |
$2,437.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,655.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1,765.37
|
| Rate for Payer: InnovAge PACE Commercial |
$2,031.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,709.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,950.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,514.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,665.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,843.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,843.40
|
| Rate for Payer: Multiplan Commercial |
$3,046.50
|
| Rate for Payer: Networks By Design Commercial |
$2,031.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,452.70
|
| Rate for Payer: Riverside University Health System MISP |
$1,624.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,437.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,437.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,524.47
|
| Rate for Payer: United Healthcare All Other HMO |
$1,483.85
|
| Rate for Payer: United Healthcare HMO Rider |
$1,451.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,330.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,452.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,452.70
|
| Rate for Payer: Vantage Medical Group Senior |
$3,452.70
|
|
|
HC TLSO SCOLI POST OPERATIVE
|
Facility
|
OP
|
$1,580.00
|
|
|
Service Code
|
CPT L1310
|
| Hospital Charge Code |
905351310
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$517.45 |
| Max. Negotiated Rate |
$1,541.74 |
| Rate for Payer: Adventist Health Commercial |
$647.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,343.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$869.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,185.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$927.93
|
| Rate for Payer: Blue Shield of California Commercial |
$1,221.34
|
| Rate for Payer: Blue Shield of California EPN |
$796.32
|
| Rate for Payer: Cash Price |
$869.00
|
| Rate for Payer: Cash Price |
$869.00
|
| Rate for Payer: Central Health Plan Commercial |
$1,264.00
|
| Rate for Payer: Cigna of CA HMO |
$1,106.00
|
| Rate for Payer: Cigna of CA PPO |
$1,106.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,343.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,343.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,343.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$632.00
|
| Rate for Payer: EPIC Health Plan Senior |
$632.00
|
| Rate for Payer: Galaxy Health WC |
$1,343.00
|
| Rate for Payer: Global Benefits Group Commercial |
$948.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,422.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1,395.68
|
| Rate for Payer: InnovAge PACE Commercial |
$790.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,053.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,541.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$978.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$647.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,106.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,106.00
|
| Rate for Payer: Multiplan Commercial |
$1,185.00
|
| Rate for Payer: Networks By Design Commercial |
$790.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,343.00
|
| Rate for Payer: Riverside University Health System MISP |
$632.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$948.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$948.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$592.97
|
| Rate for Payer: United Healthcare All Other HMO |
$577.17
|
| Rate for Payer: United Healthcare HMO Rider |
$564.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$517.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,343.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,343.00
|
| Rate for Payer: Vantage Medical Group Senior |
$1,343.00
|
|
|
HC TLSO SCOLI POST OPERATIVE
|
Facility
|
IP
|
$1,580.00
|
|
|
Service Code
|
CPT L1310
|
| Hospital Charge Code |
905351310
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$316.00 |
| Max. Negotiated Rate |
$1,422.00 |
| Rate for Payer: Adventist Health Commercial |
$316.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,221.34
|
| Rate for Payer: Blue Shield of California EPN |
$796.32
|
| Rate for Payer: Cash Price |
$869.00
|
| Rate for Payer: Central Health Plan Commercial |
$1,264.00
|
| Rate for Payer: Cigna of CA HMO |
$1,106.00
|
| Rate for Payer: Cigna of CA PPO |
$1,106.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$632.00
|
| Rate for Payer: EPIC Health Plan Senior |
$632.00
|
| Rate for Payer: Galaxy Health WC |
$1,343.00
|
| Rate for Payer: Global Benefits Group Commercial |
$948.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,422.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,053.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$601.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$978.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$316.00
|
| Rate for Payer: Multiplan Commercial |
$1,185.00
|
| Rate for Payer: Networks By Design Commercial |
$1,027.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,343.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$592.97
|
| Rate for Payer: United Healthcare All Other HMO |
$577.17
|
| Rate for Payer: United Healthcare HMO Rider |
$564.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$517.45
|
|
|
HC TLSO SCOLI POST OPERATIVE
|
Facility
|
OP
|
$3,500.00
|
|
|
Service Code
|
CPT L1310
|
| Hospital Charge Code |
915351310
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,146.25 |
| Max. Negotiated Rate |
$3,150.00 |
| Rate for Payer: Adventist Health Commercial |
$1,435.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,975.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,925.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,625.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,055.55
|
| Rate for Payer: Blue Shield of California Commercial |
$2,705.50
|
| Rate for Payer: Blue Shield of California EPN |
$1,764.00
|
| Rate for Payer: Cash Price |
$1,925.00
|
| Rate for Payer: Cash Price |
$1,925.00
|
| Rate for Payer: Central Health Plan Commercial |
$2,800.00
|
| Rate for Payer: Cigna of CA HMO |
$2,450.00
|
| Rate for Payer: Cigna of CA PPO |
$2,450.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,975.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,975.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,975.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,400.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,400.00
|
| Rate for Payer: Galaxy Health WC |
$2,975.00
|
| Rate for Payer: Global Benefits Group Commercial |
$2,100.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,150.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1,395.68
|
| Rate for Payer: InnovAge PACE Commercial |
$1,750.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,334.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,541.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,166.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,435.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,450.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,450.00
|
| Rate for Payer: Multiplan Commercial |
$2,625.00
|
| Rate for Payer: Networks By Design Commercial |
$1,750.00
|
| Rate for Payer: Prime Health Services Commercial |
$2,975.00
|
| Rate for Payer: Riverside University Health System MISP |
$1,400.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,100.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,100.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,313.55
|
| Rate for Payer: United Healthcare All Other HMO |
$1,278.55
|
| Rate for Payer: United Healthcare HMO Rider |
$1,250.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,146.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,975.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,975.00
|
| Rate for Payer: Vantage Medical Group Senior |
$2,975.00
|
|
|
HC TLSO SCOLI POST OPERATIVE
|
Facility
|
IP
|
$3,500.00
|
|
|
Service Code
|
CPT L1310
|
| Hospital Charge Code |
915351310
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$700.00 |
| Max. Negotiated Rate |
$3,150.00 |
| Rate for Payer: Adventist Health Commercial |
$700.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,705.50
|
| Rate for Payer: Blue Shield of California EPN |
$1,764.00
|
| Rate for Payer: Cash Price |
$1,925.00
|
| Rate for Payer: Central Health Plan Commercial |
$2,800.00
|
| Rate for Payer: Cigna of CA HMO |
$2,450.00
|
| Rate for Payer: Cigna of CA PPO |
$2,450.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,400.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,400.00
|
| Rate for Payer: Galaxy Health WC |
$2,975.00
|
| Rate for Payer: Global Benefits Group Commercial |
$2,100.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,150.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,334.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,333.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,166.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$700.00
|
| Rate for Payer: Multiplan Commercial |
$2,625.00
|
| Rate for Payer: Networks By Design Commercial |
$2,275.00
|
| Rate for Payer: Prime Health Services Commercial |
$2,975.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,313.55
|
| Rate for Payer: United Healthcare All Other HMO |
$1,278.55
|
| Rate for Payer: United Healthcare HMO Rider |
$1,250.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,146.25
|
|
|
HC TLSO TRIPLANAR CNTRL 2 PIECE
|
Facility
|
OP
|
$3,126.00
|
|
|
Service Code
|
CPT L0484
|
| Hospital Charge Code |
905350484
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,023.76 |
| Max. Negotiated Rate |
$2,813.40 |
| Rate for Payer: Adventist Health Commercial |
$1,281.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,657.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,719.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,344.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,835.90
|
| Rate for Payer: Blue Shield of California Commercial |
$2,416.40
|
| Rate for Payer: Blue Shield of California EPN |
$1,575.50
|
| Rate for Payer: Cash Price |
$1,719.30
|
| Rate for Payer: Cash Price |
$1,719.30
|
| Rate for Payer: Central Health Plan Commercial |
$2,500.80
|
| Rate for Payer: Cigna of CA HMO |
$2,188.20
|
| Rate for Payer: Cigna of CA PPO |
$2,188.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,657.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,657.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,657.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,250.40
|
| Rate for Payer: EPIC Health Plan Senior |
$1,250.40
|
| Rate for Payer: Galaxy Health WC |
$2,657.10
|
| Rate for Payer: Global Benefits Group Commercial |
$1,875.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,813.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$2,150.50
|
| Rate for Payer: InnovAge PACE Commercial |
$1,563.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,085.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,375.55
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,934.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,281.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,188.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,188.20
|
| Rate for Payer: Multiplan Commercial |
$2,344.50
|
| Rate for Payer: Networks By Design Commercial |
$1,563.00
|
| Rate for Payer: Prime Health Services Commercial |
$2,657.10
|
| Rate for Payer: Riverside University Health System MISP |
$1,250.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,875.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,875.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,173.19
|
| Rate for Payer: United Healthcare All Other HMO |
$1,141.93
|
| Rate for Payer: United Healthcare HMO Rider |
$1,117.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,023.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,657.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,657.10
|
| Rate for Payer: Vantage Medical Group Senior |
$2,657.10
|
|
|
HC TLSO TRIPLANAR CNTRL 2 PIECE
|
Facility
|
OP
|
$3,126.00
|
|
|
Service Code
|
CPT L0484
|
| Hospital Charge Code |
915350484
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,023.76 |
| Max. Negotiated Rate |
$2,813.40 |
| Rate for Payer: Adventist Health Commercial |
$1,281.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,657.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,719.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,344.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,835.90
|
| Rate for Payer: Blue Shield of California Commercial |
$2,416.40
|
| Rate for Payer: Blue Shield of California EPN |
$1,575.50
|
| Rate for Payer: Cash Price |
$1,719.30
|
| Rate for Payer: Cash Price |
$1,719.30
|
| Rate for Payer: Central Health Plan Commercial |
$2,500.80
|
| Rate for Payer: Cigna of CA HMO |
$2,188.20
|
| Rate for Payer: Cigna of CA PPO |
$2,188.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,657.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,657.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,657.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,250.40
|
| Rate for Payer: EPIC Health Plan Senior |
$1,250.40
|
| Rate for Payer: Galaxy Health WC |
$2,657.10
|
| Rate for Payer: Global Benefits Group Commercial |
$1,875.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,813.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$2,150.50
|
| Rate for Payer: InnovAge PACE Commercial |
$1,563.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,085.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,375.55
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,934.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,281.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,188.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,188.20
|
| Rate for Payer: Multiplan Commercial |
$2,344.50
|
| Rate for Payer: Networks By Design Commercial |
$1,563.00
|
| Rate for Payer: Prime Health Services Commercial |
$2,657.10
|
| Rate for Payer: Riverside University Health System MISP |
$1,250.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,875.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,875.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,173.19
|
| Rate for Payer: United Healthcare All Other HMO |
$1,141.93
|
| Rate for Payer: United Healthcare HMO Rider |
$1,117.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,023.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,657.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,657.10
|
| Rate for Payer: Vantage Medical Group Senior |
$2,657.10
|
|
