|
HC LYMPHANGIOGRAM EXT BILAT
|
Facility
|
IP
|
$2,579.00
|
|
|
Service Code
|
CPT 75803
|
| Hospital Charge Code |
909001373
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$515.80 |
| Max. Negotiated Rate |
$2,321.10 |
| Rate for Payer: Adventist Health Commercial |
$515.80
|
| Rate for Payer: Cash Price |
$1,160.55
|
| Rate for Payer: Central Health Plan Commercial |
$2,063.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,805.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,031.60
|
| Rate for Payer: EPIC Health Plan Senior |
$1,031.60
|
| Rate for Payer: Galaxy Health WC |
$2,192.15
|
| Rate for Payer: Global Benefits Group Commercial |
$1,547.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,321.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,637.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,521.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$515.80
|
| Rate for Payer: Multiplan Commercial |
$1,934.25
|
| Rate for Payer: Networks By Design Commercial |
$1,676.35
|
| Rate for Payer: Prime Health Services Commercial |
$2,192.15
|
|
|
HC LYMPHANGIOGRAM EXT UNILAT
|
Facility
|
IP
|
$1,719.00
|
|
|
Service Code
|
CPT 75801
|
| Hospital Charge Code |
909001375
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$343.80 |
| Max. Negotiated Rate |
$1,547.10 |
| Rate for Payer: Adventist Health Commercial |
$343.80
|
| Rate for Payer: Cash Price |
$773.55
|
| Rate for Payer: Central Health Plan Commercial |
$1,375.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,203.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$687.60
|
| Rate for Payer: EPIC Health Plan Senior |
$687.60
|
| Rate for Payer: Galaxy Health WC |
$1,461.15
|
| Rate for Payer: Global Benefits Group Commercial |
$1,031.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,547.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,091.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,014.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$343.80
|
| Rate for Payer: Multiplan Commercial |
$1,289.25
|
| Rate for Payer: Networks By Design Commercial |
$1,117.35
|
| Rate for Payer: Prime Health Services Commercial |
$1,461.15
|
|
|
HC LYMPHANGIOGRAM EXT UNILAT
|
Facility
|
OP
|
$1,719.00
|
|
|
Service Code
|
CPT 75801
|
| Hospital Charge Code |
909001375
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$223.26 |
| Max. Negotiated Rate |
$2,588.96 |
| Rate for Payer: Adventist Health Commercial |
$343.80
|
| Rate for Payer: Adventist Health Medi-Cal |
$806.82
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,588.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,210.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$887.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$806.82
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,127.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,568.04
|
| Rate for Payer: Blue Shield of California Commercial |
$1,082.97
|
| Rate for Payer: Blue Shield of California EPN |
$682.44
|
| Rate for Payer: Cash Price |
$773.55
|
| Rate for Payer: Cash Price |
$773.55
|
| Rate for Payer: Central Health Plan Commercial |
$1,375.20
|
| Rate for Payer: Cigna of CA HMO |
$1,100.16
|
| Rate for Payer: Cigna of CA PPO |
$1,272.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,210.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$887.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$806.82
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,203.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,331.25
|
| Rate for Payer: EPIC Health Plan Senior |
$887.50
|
| Rate for Payer: Galaxy Health WC |
$1,461.15
|
| Rate for Payer: Global Benefits Group Commercial |
$1,031.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,547.10
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$1,323.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$223.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$806.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,091.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$246.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,129.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$343.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,081.14
|
| Rate for Payer: Multiplan Commercial |
$1,289.25
|
| Rate for Payer: Networks By Design Commercial |
$1,117.35
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$806.82
|
| Rate for Payer: Prime Health Services Commercial |
$1,461.15
|
| Rate for Payer: Prime Health Services Medicare |
$855.23
|
| Rate for Payer: Riverside University Health System MISP |
$887.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,031.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,031.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,088.13
|
| Rate for Payer: United Healthcare All Other HMO |
$1,088.13
|
| Rate for Payer: United Healthcare HMO Rider |
$1,088.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,088.13
|
| Rate for Payer: Upland Medical Group Pediatric |
$806.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,210.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$887.50
|
| Rate for Payer: Vantage Medical Group Senior |
$806.82
|
|
|
HC LYMPHANGIOGRAM, PELV BILAT
|
Facility
|
OP
|
$2,583.00
|
|
|
Service Code
|
CPT 75807
|
| Hospital Charge Code |
909001365
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$238.19 |
| Max. Negotiated Rate |
$6,700.73 |
| Rate for Payer: Adventist Health Commercial |
$516.60
|
| Rate for Payer: Adventist Health Medi-Cal |
$4,061.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,588.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,091.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,467.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,061.05
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,263.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,755.90
|
| Rate for Payer: Blue Shield of California Commercial |
$1,627.29
|
| Rate for Payer: Blue Shield of California EPN |
$1,025.45
|
| Rate for Payer: Cash Price |
$1,162.35
|
| Rate for Payer: Cash Price |
$1,162.35
|
| Rate for Payer: Central Health Plan Commercial |
$2,066.40
|
| Rate for Payer: Cigna of CA HMO |
$1,653.12
|
| Rate for Payer: Cigna of CA PPO |
$1,911.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,091.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,467.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,061.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,808.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,700.73
|
| Rate for Payer: EPIC Health Plan Senior |
$4,467.15
|
| Rate for Payer: Galaxy Health WC |
$2,195.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1,549.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,324.70
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,660.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$238.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,061.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,640.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$263.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,685.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$516.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,441.81
|
| Rate for Payer: Multiplan Commercial |
$1,937.25
|
| Rate for Payer: Networks By Design Commercial |
$1,678.95
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$4,061.05
|
| Rate for Payer: Prime Health Services Commercial |
$2,195.55
|
| Rate for Payer: Prime Health Services Medicare |
$4,304.71
|
| Rate for Payer: Riverside University Health System MISP |
$4,467.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,549.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,549.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,088.13
|
| Rate for Payer: United Healthcare All Other HMO |
$1,088.13
|
| Rate for Payer: United Healthcare HMO Rider |
$1,088.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,088.13
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,061.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,091.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,467.15
|
| Rate for Payer: Vantage Medical Group Senior |
$4,061.05
|
|
|
HC LYMPHANGIOGRAM, PELV BILAT
|
Facility
|
IP
|
$2,583.00
|
|
|
Service Code
|
CPT 75807
|
| Hospital Charge Code |
909001365
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$516.60 |
| Max. Negotiated Rate |
$2,324.70 |
| Rate for Payer: Adventist Health Commercial |
$516.60
|
| Rate for Payer: Cash Price |
$1,162.35
|
| Rate for Payer: Central Health Plan Commercial |
$2,066.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,808.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,033.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1,033.20
|
| Rate for Payer: Galaxy Health WC |
$2,195.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1,549.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,324.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,640.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,523.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$516.60
|
| Rate for Payer: Multiplan Commercial |
$1,937.25
|
| Rate for Payer: Networks By Design Commercial |
$1,678.95
|
| Rate for Payer: Prime Health Services Commercial |
$2,195.55
|
|
|
HC LYMPHANGIOGRAPHY INJECTION
|
Facility
|
IP
|
$644.00
|
|
|
Service Code
|
CPT 38790
|
| Hospital Charge Code |
909000131
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$128.80 |
| Max. Negotiated Rate |
$579.60 |
| Rate for Payer: Adventist Health Commercial |
$128.80
|
| Rate for Payer: Cash Price |
$289.80
|
| Rate for Payer: Central Health Plan Commercial |
$515.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$450.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$257.60
|
| Rate for Payer: EPIC Health Plan Senior |
$257.60
|
| Rate for Payer: Galaxy Health WC |
$547.40
|
| Rate for Payer: Global Benefits Group Commercial |
$386.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$579.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$408.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$379.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$128.80
|
| Rate for Payer: Multiplan Commercial |
$483.00
|
| Rate for Payer: Networks By Design Commercial |
$418.60
|
| Rate for Payer: Prime Health Services Commercial |
$547.40
|
|
|
HC LYMPHANGIOGRAPHY INJECTION
|
Facility
|
OP
|
$644.00
|
|
|
Service Code
|
CPT 38790
|
| Hospital Charge Code |
909000131
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$128.80 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Commercial |
$128.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$547.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$354.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$483.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3,974.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,523.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,136.21
|
| Rate for Payer: Blue Shield of California EPN |
$5,113.68
|
| Rate for Payer: Cash Price |
$289.80
|
| Rate for Payer: Cash Price |
$289.80
|
| Rate for Payer: Cash Price |
$289.80
|
| Rate for Payer: Central Health Plan Commercial |
$515.20
|
| Rate for Payer: Cigna of CA HMO |
$412.16
|
| Rate for Payer: Cigna of CA PPO |
$476.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$547.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$547.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$547.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$450.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$257.60
|
| Rate for Payer: EPIC Health Plan Senior |
$257.60
|
| Rate for Payer: Galaxy Health WC |
$547.40
|
| Rate for Payer: Global Benefits Group Commercial |
$386.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$579.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$778.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$408.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$859.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$379.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$128.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$450.80
|
| Rate for Payer: Multiplan Commercial |
$483.00
|
| Rate for Payer: Networks By Design Commercial |
$418.60
|
| Rate for Payer: Prime Health Services Commercial |
$547.40
|
| Rate for Payer: Riverside University Health System MISP |
$257.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$386.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$322.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$547.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$547.40
|
| Rate for Payer: Vantage Medical Group Senior |
$547.40
|
|
|
HC LYMPHAT/ANTIMONY SCA
|
Facility
|
OP
|
$2,703.00
|
|
|
Service Code
|
CPT 78195
|
| Hospital Charge Code |
909301341
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$326.03 |
| Max. Negotiated Rate |
$2,432.70 |
| Rate for Payer: Adventist Health Commercial |
$540.60
|
| Rate for Payer: Adventist Health Medi-Cal |
$698.35
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,633.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,047.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$768.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$698.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$848.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,572.34
|
| Rate for Payer: Blue Shield of California Commercial |
$1,702.89
|
| Rate for Payer: Blue Shield of California EPN |
$1,073.09
|
| Rate for Payer: Cash Price |
$1,216.35
|
| Rate for Payer: Cash Price |
$1,216.35
|
| Rate for Payer: Central Health Plan Commercial |
$2,162.40
|
| Rate for Payer: Cigna of CA HMO |
$1,729.92
|
| Rate for Payer: Cigna of CA PPO |
$2,000.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,047.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$768.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$698.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,892.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,152.28
|
| Rate for Payer: EPIC Health Plan Senior |
$768.18
|
| Rate for Payer: Galaxy Health WC |
$2,297.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1,621.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,432.70
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$1,145.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$326.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$698.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,716.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$360.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$977.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$540.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$935.79
|
| Rate for Payer: Multiplan Commercial |
$2,027.25
|
| Rate for Payer: Networks By Design Commercial |
$1,756.95
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$698.35
|
| Rate for Payer: Prime Health Services Commercial |
$2,297.55
|
| Rate for Payer: Prime Health Services Medicare |
$740.25
|
| Rate for Payer: Riverside University Health System MISP |
$768.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,621.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,621.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$654.98
|
| Rate for Payer: United Healthcare All Other HMO |
$654.98
|
| Rate for Payer: United Healthcare HMO Rider |
$654.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$654.98
|
| Rate for Payer: Upland Medical Group Pediatric |
$698.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,047.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$768.18
|
| Rate for Payer: Vantage Medical Group Senior |
$698.35
|
|
|
HC LYMPHAT/ANTIMONY SCA
|
Facility
|
IP
|
$2,703.00
|
|
|
Service Code
|
CPT 78195
|
| Hospital Charge Code |
909301341
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$540.60 |
| Max. Negotiated Rate |
$2,432.70 |
| Rate for Payer: Adventist Health Commercial |
$540.60
|
| Rate for Payer: Cash Price |
$1,216.35
|
| Rate for Payer: Central Health Plan Commercial |
$2,162.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,892.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,081.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1,081.20
|
| Rate for Payer: Galaxy Health WC |
$2,297.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1,621.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,432.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,716.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,594.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$540.60
|
| Rate for Payer: Multiplan Commercial |
$2,027.25
|
| Rate for Payer: Networks By Design Commercial |
$1,756.95
|
| Rate for Payer: Prime Health Services Commercial |
$2,297.55
|
|
|
HC LYMPH EDEMA GAUNTLET-CUSTM MAD
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
CPT L8499
|
| Hospital Charge Code |
905380004
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$86.46 |
| Max. Negotiated Rate |
$237.60 |
| Rate for Payer: Adventist Health Commercial |
$108.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$224.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$145.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$198.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$153.57
|
| Rate for Payer: Blue Shield of California Commercial |
$211.73
|
| Rate for Payer: Blue Shield of California EPN |
$133.06
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Central Health Plan Commercial |
$211.20
|
| Rate for Payer: Cigna of CA HMO |
$184.80
|
| Rate for Payer: Cigna of CA PPO |
$184.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$224.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$224.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$224.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$184.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$105.60
|
| Rate for Payer: EPIC Health Plan Senior |
$105.60
|
| Rate for Payer: Galaxy Health WC |
$224.40
|
| Rate for Payer: Global Benefits Group Commercial |
$158.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$237.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$167.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$95.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$155.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$184.80
|
| Rate for Payer: Multiplan Commercial |
$198.00
|
| Rate for Payer: Networks By Design Commercial |
$132.00
|
| Rate for Payer: Prime Health Services Commercial |
$224.40
|
| Rate for Payer: Riverside University Health System MISP |
$105.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$158.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$158.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$99.08
|
| Rate for Payer: United Healthcare All Other HMO |
$96.44
|
| Rate for Payer: United Healthcare HMO Rider |
$94.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$86.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$224.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$224.40
|
| Rate for Payer: Vantage Medical Group Senior |
$224.40
|
|
|
HC LYMPH EDEMA GAUNTLET-CUSTM MAD
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
CPT L8499
|
| Hospital Charge Code |
915380004
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$86.46 |
| Max. Negotiated Rate |
$237.60 |
| Rate for Payer: Galaxy Health WC |
$224.40
|
| Rate for Payer: Adventist Health Commercial |
$108.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$224.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$145.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$198.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$153.57
|
| Rate for Payer: Blue Shield of California Commercial |
$211.73
|
| Rate for Payer: Blue Shield of California EPN |
$133.06
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Central Health Plan Commercial |
$211.20
|
| Rate for Payer: Cigna of CA HMO |
$184.80
|
| Rate for Payer: Cigna of CA PPO |
$184.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$224.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$224.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$224.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$184.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$105.60
|
| Rate for Payer: EPIC Health Plan Senior |
$105.60
|
| Rate for Payer: Global Benefits Group Commercial |
$158.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$237.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$167.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$95.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$155.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$184.80
|
| Rate for Payer: Multiplan Commercial |
$198.00
|
| Rate for Payer: Networks By Design Commercial |
$132.00
|
| Rate for Payer: Prime Health Services Commercial |
$224.40
|
| Rate for Payer: Riverside University Health System MISP |
$105.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$158.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$158.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$99.08
|
| Rate for Payer: United Healthcare All Other HMO |
$96.44
|
| Rate for Payer: United Healthcare HMO Rider |
$94.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$86.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$224.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$224.40
|
| Rate for Payer: Vantage Medical Group Senior |
$224.40
|
|
|
HC LYMPH EDEMA GAUNTLET-CUSTM MAD
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
CPT L8499
|
| Hospital Charge Code |
905380004
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$52.80 |
| Max. Negotiated Rate |
$237.60 |
| Rate for Payer: Adventist Health Commercial |
$52.80
|
| Rate for Payer: Blue Shield of California Commercial |
$211.73
|
| Rate for Payer: Blue Shield of California EPN |
$133.06
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Central Health Plan Commercial |
$211.20
|
| Rate for Payer: Cigna of CA HMO |
$184.80
|
| Rate for Payer: Cigna of CA PPO |
$184.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$184.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$105.60
|
| Rate for Payer: EPIC Health Plan Senior |
$105.60
|
| Rate for Payer: Galaxy Health WC |
$224.40
|
| Rate for Payer: Global Benefits Group Commercial |
$158.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$237.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$167.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$155.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.80
|
| Rate for Payer: Multiplan Commercial |
$198.00
|
| Rate for Payer: Networks By Design Commercial |
$171.60
|
| Rate for Payer: Prime Health Services Commercial |
$224.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$99.08
|
| Rate for Payer: United Healthcare All Other HMO |
$96.44
|
| Rate for Payer: United Healthcare HMO Rider |
$94.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$86.46
|
|
|
HC LYMPH EDEMA GAUNTLET-CUSTM MAD
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
CPT L8499
|
| Hospital Charge Code |
915380004
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$52.80 |
| Max. Negotiated Rate |
$237.60 |
| Rate for Payer: Adventist Health Commercial |
$52.80
|
| Rate for Payer: Blue Shield of California Commercial |
$211.73
|
| Rate for Payer: Blue Shield of California EPN |
$133.06
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Central Health Plan Commercial |
$211.20
|
| Rate for Payer: Cigna of CA HMO |
$184.80
|
| Rate for Payer: Cigna of CA PPO |
$184.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$184.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$105.60
|
| Rate for Payer: EPIC Health Plan Senior |
$105.60
|
| Rate for Payer: Galaxy Health WC |
$224.40
|
| Rate for Payer: Global Benefits Group Commercial |
$158.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$237.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$167.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$155.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.80
|
| Rate for Payer: Multiplan Commercial |
$198.00
|
| Rate for Payer: Networks By Design Commercial |
$171.60
|
| Rate for Payer: Prime Health Services Commercial |
$224.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$99.08
|
| Rate for Payer: United Healthcare All Other HMO |
$96.44
|
| Rate for Payer: United Healthcare HMO Rider |
$94.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$86.46
|
|
|
HC LYMPH EDEMA GAUNTLET-CUSTOM FT
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
CPT L8499
|
| Hospital Charge Code |
915380003
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$52.40 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Adventist Health Commercial |
$65.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$136.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$88.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$120.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$93.07
|
| Rate for Payer: Blue Shield of California Commercial |
$128.32
|
| Rate for Payer: Blue Shield of California EPN |
$80.64
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Central Health Plan Commercial |
$128.00
|
| Rate for Payer: Cigna of CA HMO |
$112.00
|
| Rate for Payer: Cigna of CA PPO |
$112.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$136.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$136.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$136.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$112.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.00
|
| Rate for Payer: EPIC Health Plan Senior |
$64.00
|
| Rate for Payer: Galaxy Health WC |
$136.00
|
| Rate for Payer: Global Benefits Group Commercial |
$96.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$144.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$101.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$58.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$94.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$112.00
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: Networks By Design Commercial |
$80.00
|
| Rate for Payer: Prime Health Services Commercial |
$136.00
|
| Rate for Payer: Riverside University Health System MISP |
$64.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$96.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$96.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.05
|
| Rate for Payer: United Healthcare All Other HMO |
$58.45
|
| Rate for Payer: United Healthcare HMO Rider |
$57.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$136.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$136.00
|
| Rate for Payer: Vantage Medical Group Senior |
$136.00
|
|
|
HC LYMPH EDEMA GAUNTLET-CUSTOM FT
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
CPT L8499
|
| Hospital Charge Code |
915380003
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$32.00 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Adventist Health Commercial |
$32.00
|
| Rate for Payer: Blue Shield of California Commercial |
$128.32
|
| Rate for Payer: Blue Shield of California EPN |
$80.64
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Central Health Plan Commercial |
$128.00
|
| Rate for Payer: Cigna of CA HMO |
$112.00
|
| Rate for Payer: Cigna of CA PPO |
$112.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$112.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.00
|
| Rate for Payer: EPIC Health Plan Senior |
$64.00
|
| Rate for Payer: Galaxy Health WC |
$136.00
|
| Rate for Payer: Global Benefits Group Commercial |
$96.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$144.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$101.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$94.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.00
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: Networks By Design Commercial |
$104.00
|
| Rate for Payer: Prime Health Services Commercial |
$136.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.05
|
| Rate for Payer: United Healthcare All Other HMO |
$58.45
|
| Rate for Payer: United Healthcare HMO Rider |
$57.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.40
|
|
|
HC LYMPH EDEMA GAUNTLET-CUSTOM FT
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
CPT L8499
|
| Hospital Charge Code |
905380003
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$52.40 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Adventist Health Commercial |
$65.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$136.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$88.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$120.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$93.07
|
| Rate for Payer: Blue Shield of California Commercial |
$128.32
|
| Rate for Payer: Blue Shield of California EPN |
$80.64
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Central Health Plan Commercial |
$128.00
|
| Rate for Payer: Cigna of CA HMO |
$112.00
|
| Rate for Payer: Cigna of CA PPO |
$112.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$136.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$136.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$136.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$112.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.00
|
| Rate for Payer: EPIC Health Plan Senior |
$64.00
|
| Rate for Payer: Galaxy Health WC |
$136.00
|
| Rate for Payer: Global Benefits Group Commercial |
$96.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$144.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$101.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$58.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$94.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$112.00
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: Networks By Design Commercial |
$80.00
|
| Rate for Payer: Prime Health Services Commercial |
$136.00
|
| Rate for Payer: Riverside University Health System MISP |
$64.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$96.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$96.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.05
|
| Rate for Payer: United Healthcare All Other HMO |
$58.45
|
| Rate for Payer: United Healthcare HMO Rider |
$57.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$136.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$136.00
|
| Rate for Payer: Vantage Medical Group Senior |
$136.00
|
|
|
HC LYMPH EDEMA GAUNTLET-CUSTOM FT
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
CPT L8499
|
| Hospital Charge Code |
905380003
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$32.00 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Adventist Health Commercial |
$32.00
|
| Rate for Payer: Blue Shield of California Commercial |
$128.32
|
| Rate for Payer: Blue Shield of California EPN |
$80.64
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Central Health Plan Commercial |
$128.00
|
| Rate for Payer: Cigna of CA HMO |
$112.00
|
| Rate for Payer: Cigna of CA PPO |
$112.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$112.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.00
|
| Rate for Payer: EPIC Health Plan Senior |
$64.00
|
| Rate for Payer: Galaxy Health WC |
$136.00
|
| Rate for Payer: Global Benefits Group Commercial |
$96.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$144.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$101.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$94.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.00
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: Networks By Design Commercial |
$104.00
|
| Rate for Payer: Prime Health Services Commercial |
$136.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.05
|
| Rate for Payer: United Healthcare All Other HMO |
$58.45
|
| Rate for Payer: United Healthcare HMO Rider |
$57.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.40
|
|
|
HC LYMPH EDEMA GLOVE-CUSTOM FIT
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
CPT L8499
|
| Hospital Charge Code |
905380005
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$32.00 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Adventist Health Commercial |
$32.00
|
| Rate for Payer: Blue Shield of California Commercial |
$128.32
|
| Rate for Payer: Blue Shield of California EPN |
$80.64
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Central Health Plan Commercial |
$128.00
|
| Rate for Payer: Cigna of CA HMO |
$112.00
|
| Rate for Payer: Cigna of CA PPO |
$112.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$112.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.00
|
| Rate for Payer: EPIC Health Plan Senior |
$64.00
|
| Rate for Payer: Galaxy Health WC |
$136.00
|
| Rate for Payer: Global Benefits Group Commercial |
$96.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$144.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$101.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$94.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.00
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: Networks By Design Commercial |
$104.00
|
| Rate for Payer: Prime Health Services Commercial |
$136.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.05
|
| Rate for Payer: United Healthcare All Other HMO |
$58.45
|
| Rate for Payer: United Healthcare HMO Rider |
$57.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.40
|
|
|
HC LYMPH EDEMA GLOVE-CUSTOM FIT
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
CPT L8499
|
| Hospital Charge Code |
905380005
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$52.40 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Adventist Health Commercial |
$65.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$136.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$88.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$120.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$93.07
|
| Rate for Payer: Blue Shield of California Commercial |
$128.32
|
| Rate for Payer: Blue Shield of California EPN |
$80.64
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Central Health Plan Commercial |
$128.00
|
| Rate for Payer: Cigna of CA HMO |
$112.00
|
| Rate for Payer: Cigna of CA PPO |
$112.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$136.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$136.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$136.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$112.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.00
|
| Rate for Payer: EPIC Health Plan Senior |
$64.00
|
| Rate for Payer: Galaxy Health WC |
$136.00
|
| Rate for Payer: Global Benefits Group Commercial |
$96.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$144.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$101.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$58.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$94.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$112.00
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: Networks By Design Commercial |
$80.00
|
| Rate for Payer: Prime Health Services Commercial |
$136.00
|
| Rate for Payer: Riverside University Health System MISP |
$64.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$96.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$96.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.05
|
| Rate for Payer: United Healthcare All Other HMO |
$58.45
|
| Rate for Payer: United Healthcare HMO Rider |
$57.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$136.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$136.00
|
| Rate for Payer: Vantage Medical Group Senior |
$136.00
|
|
|
HC LYMPH EDEMA GLOVE-CUSTOM FIT
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
CPT L8499
|
| Hospital Charge Code |
915380005
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$52.40 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: United Healthcare HMO Rider |
$57.18
|
| Rate for Payer: Adventist Health Commercial |
$65.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$136.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$88.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$120.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$93.07
|
| Rate for Payer: Blue Shield of California Commercial |
$128.32
|
| Rate for Payer: Blue Shield of California EPN |
$80.64
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Central Health Plan Commercial |
$128.00
|
| Rate for Payer: Cigna of CA HMO |
$112.00
|
| Rate for Payer: Cigna of CA PPO |
$112.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$136.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$136.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$136.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$112.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.00
|
| Rate for Payer: EPIC Health Plan Senior |
$64.00
|
| Rate for Payer: Galaxy Health WC |
$136.00
|
| Rate for Payer: Global Benefits Group Commercial |
$96.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$144.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$101.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$58.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$94.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$112.00
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: Networks By Design Commercial |
$80.00
|
| Rate for Payer: Prime Health Services Commercial |
$136.00
|
| Rate for Payer: Riverside University Health System MISP |
$64.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$96.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$96.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.05
|
| Rate for Payer: United Healthcare All Other HMO |
$58.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$136.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$136.00
|
| Rate for Payer: Vantage Medical Group Senior |
$136.00
|
|
|
HC LYMPH EDEMA GLOVE-CUSTOM FIT
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
CPT L8499
|
| Hospital Charge Code |
915380005
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$32.00 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Adventist Health Commercial |
$32.00
|
| Rate for Payer: Blue Shield of California Commercial |
$128.32
|
| Rate for Payer: Blue Shield of California EPN |
$80.64
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Central Health Plan Commercial |
$128.00
|
| Rate for Payer: Cigna of CA HMO |
$112.00
|
| Rate for Payer: Cigna of CA PPO |
$112.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$112.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.00
|
| Rate for Payer: EPIC Health Plan Senior |
$64.00
|
| Rate for Payer: Galaxy Health WC |
$136.00
|
| Rate for Payer: Global Benefits Group Commercial |
$96.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$144.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$101.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$94.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.00
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: Networks By Design Commercial |
$104.00
|
| Rate for Payer: Prime Health Services Commercial |
$136.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.05
|
| Rate for Payer: United Healthcare All Other HMO |
$58.45
|
| Rate for Payer: United Healthcare HMO Rider |
$57.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.40
|
|
|
HC LYMPH EDEMA GLOVE-CUSTOM MADE
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
CPT L8499
|
| Hospital Charge Code |
905380006
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$86.46 |
| Max. Negotiated Rate |
$237.60 |
| Rate for Payer: Adventist Health Commercial |
$108.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$224.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$145.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$198.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$153.57
|
| Rate for Payer: Blue Shield of California Commercial |
$211.73
|
| Rate for Payer: Blue Shield of California EPN |
$133.06
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Central Health Plan Commercial |
$211.20
|
| Rate for Payer: Cigna of CA HMO |
$184.80
|
| Rate for Payer: Cigna of CA PPO |
$184.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$224.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$224.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$224.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$184.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$105.60
|
| Rate for Payer: EPIC Health Plan Senior |
$105.60
|
| Rate for Payer: Galaxy Health WC |
$224.40
|
| Rate for Payer: Global Benefits Group Commercial |
$158.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$237.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$167.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$95.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$155.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$184.80
|
| Rate for Payer: Multiplan Commercial |
$198.00
|
| Rate for Payer: Networks By Design Commercial |
$132.00
|
| Rate for Payer: Prime Health Services Commercial |
$224.40
|
| Rate for Payer: Riverside University Health System MISP |
$105.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$158.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$158.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$99.08
|
| Rate for Payer: United Healthcare All Other HMO |
$96.44
|
| Rate for Payer: United Healthcare HMO Rider |
$94.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$86.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$224.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$224.40
|
| Rate for Payer: Vantage Medical Group Senior |
$224.40
|
|
|
HC LYMPH EDEMA GLOVE-CUSTOM MADE
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
CPT L8499
|
| Hospital Charge Code |
915380006
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$86.46 |
| Max. Negotiated Rate |
$237.60 |
| Rate for Payer: Adventist Health Commercial |
$108.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$224.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$145.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$198.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$153.57
|
| Rate for Payer: Blue Shield of California Commercial |
$211.73
|
| Rate for Payer: Blue Shield of California EPN |
$133.06
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Central Health Plan Commercial |
$211.20
|
| Rate for Payer: Cigna of CA HMO |
$184.80
|
| Rate for Payer: Cigna of CA PPO |
$184.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$224.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$224.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$224.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$184.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$105.60
|
| Rate for Payer: EPIC Health Plan Senior |
$105.60
|
| Rate for Payer: Galaxy Health WC |
$224.40
|
| Rate for Payer: Global Benefits Group Commercial |
$158.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$237.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$167.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$95.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$155.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$184.80
|
| Rate for Payer: Multiplan Commercial |
$198.00
|
| Rate for Payer: Networks By Design Commercial |
$132.00
|
| Rate for Payer: Prime Health Services Commercial |
$224.40
|
| Rate for Payer: Riverside University Health System MISP |
$105.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$158.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$158.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$99.08
|
| Rate for Payer: United Healthcare All Other HMO |
$96.44
|
| Rate for Payer: United Healthcare HMO Rider |
$94.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$86.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$224.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$224.40
|
| Rate for Payer: Vantage Medical Group Senior |
$224.40
|
|
|
HC LYMPH EDEMA GLOVE-CUSTOM MADE
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
CPT L8499
|
| Hospital Charge Code |
905380006
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$52.80 |
| Max. Negotiated Rate |
$237.60 |
| Rate for Payer: Adventist Health Commercial |
$52.80
|
| Rate for Payer: Blue Shield of California Commercial |
$211.73
|
| Rate for Payer: Blue Shield of California EPN |
$133.06
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Central Health Plan Commercial |
$211.20
|
| Rate for Payer: Cigna of CA HMO |
$184.80
|
| Rate for Payer: Cigna of CA PPO |
$184.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$184.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$105.60
|
| Rate for Payer: EPIC Health Plan Senior |
$105.60
|
| Rate for Payer: Galaxy Health WC |
$224.40
|
| Rate for Payer: Global Benefits Group Commercial |
$158.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$237.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$167.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$155.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.80
|
| Rate for Payer: Multiplan Commercial |
$198.00
|
| Rate for Payer: Networks By Design Commercial |
$171.60
|
| Rate for Payer: Prime Health Services Commercial |
$224.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$99.08
|
| Rate for Payer: United Healthcare All Other HMO |
$96.44
|
| Rate for Payer: United Healthcare HMO Rider |
$94.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$86.46
|
|
|
HC LYMPH EDEMA GLOVE-CUSTOM MADE
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
CPT L8499
|
| Hospital Charge Code |
915380006
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$52.80 |
| Max. Negotiated Rate |
$237.60 |
| Rate for Payer: Adventist Health Commercial |
$52.80
|
| Rate for Payer: Blue Shield of California Commercial |
$211.73
|
| Rate for Payer: Blue Shield of California EPN |
$133.06
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Central Health Plan Commercial |
$211.20
|
| Rate for Payer: Cigna of CA HMO |
$184.80
|
| Rate for Payer: Cigna of CA PPO |
$184.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$184.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$105.60
|
| Rate for Payer: EPIC Health Plan Senior |
$105.60
|
| Rate for Payer: Galaxy Health WC |
$224.40
|
| Rate for Payer: Global Benefits Group Commercial |
$158.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$237.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$167.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$155.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.80
|
| Rate for Payer: Multiplan Commercial |
$198.00
|
| Rate for Payer: Networks By Design Commercial |
$171.60
|
| Rate for Payer: Prime Health Services Commercial |
$224.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$99.08
|
| Rate for Payer: United Healthcare All Other HMO |
$96.44
|
| Rate for Payer: United Healthcare HMO Rider |
$94.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$86.46
|
|
