|
HC LOCM (OMNIPAQUE-ISOVUE) 180
|
Facility
|
IP
|
$9.40
|
|
|
Service Code
|
CPT Q9965
|
| Hospital Charge Code |
909081004
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$8.46 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Blue Shield of California Commercial |
$7.27
|
| Rate for Payer: Blue Shield of California EPN |
$4.74
|
| Rate for Payer: Cash Price |
$5.17
|
| Rate for Payer: Central Health Plan Commercial |
$7.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.76
|
| Rate for Payer: EPIC Health Plan Senior |
$3.76
|
| Rate for Payer: Galaxy Health WC |
$7.99
|
| Rate for Payer: Global Benefits Group Commercial |
$5.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.88
|
| Rate for Payer: Multiplan Commercial |
$7.05
|
| Rate for Payer: Networks By Design Commercial |
$6.11
|
| Rate for Payer: Prime Health Services Commercial |
$7.99
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 240
|
Facility
|
IP
|
$2.95
|
|
|
Service Code
|
CPT Q9966
|
| Hospital Charge Code |
909081005
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.65 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$2.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.49
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Central Health Plan Commercial |
$2.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: EPIC Health Plan Senior |
$1.18
|
| Rate for Payer: Galaxy Health WC |
$2.51
|
| Rate for Payer: Global Benefits Group Commercial |
$1.77
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$2.21
|
| Rate for Payer: Networks By Design Commercial |
$1.92
|
| Rate for Payer: Prime Health Services Commercial |
$2.51
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 240
|
Facility
|
OP
|
$2.95
|
|
|
Service Code
|
CPT Q9966
|
| Hospital Charge Code |
909081005
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$2.65 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.73
|
| Rate for Payer: Blue Shield of California Commercial |
$1.80
|
| Rate for Payer: Blue Shield of California EPN |
$1.18
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Central Health Plan Commercial |
$2.36
|
| Rate for Payer: Cigna of CA HMO |
$1.89
|
| Rate for Payer: Cigna of CA PPO |
$2.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: EPIC Health Plan Senior |
$1.18
|
| Rate for Payer: Galaxy Health WC |
$2.51
|
| Rate for Payer: Global Benefits Group Commercial |
$1.77
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.65
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.41
|
| Rate for Payer: InnovAge PACE Commercial |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.06
|
| Rate for Payer: Multiplan Commercial |
$2.21
|
| Rate for Payer: Networks By Design Commercial |
$1.92
|
| Rate for Payer: Prime Health Services Commercial |
$2.51
|
| Rate for Payer: Riverside University Health System MISP |
$1.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.77
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.48
|
| Rate for Payer: United Healthcare All Other HMO |
$1.48
|
| Rate for Payer: United Healthcare HMO Rider |
$1.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.51
|
| Rate for Payer: Vantage Medical Group Senior |
$2.51
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 300
|
Facility
|
IP
|
$3.38
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081006
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$2.61
|
| Rate for Payer: Blue Shield of California EPN |
$1.70
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: Central Health Plan Commercial |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.35
|
| Rate for Payer: EPIC Health Plan Senior |
$1.35
|
| Rate for Payer: Galaxy Health WC |
$2.87
|
| Rate for Payer: Global Benefits Group Commercial |
$2.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$2.54
|
| Rate for Payer: Networks By Design Commercial |
$2.20
|
| Rate for Payer: Prime Health Services Commercial |
$2.87
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 300
|
Facility
|
OP
|
$3.38
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081006
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.54
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.99
|
| Rate for Payer: Blue Shield of California Commercial |
$2.07
|
| Rate for Payer: Blue Shield of California EPN |
$1.35
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: Central Health Plan Commercial |
$2.70
|
| Rate for Payer: Cigna of CA HMO |
$2.16
|
| Rate for Payer: Cigna of CA PPO |
$2.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.35
|
| Rate for Payer: EPIC Health Plan Senior |
$1.35
|
| Rate for Payer: Galaxy Health WC |
$2.87
|
| Rate for Payer: Global Benefits Group Commercial |
$2.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.14
|
| Rate for Payer: InnovAge PACE Commercial |
$1.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.37
|
| Rate for Payer: Multiplan Commercial |
$2.54
|
| Rate for Payer: Networks By Design Commercial |
$2.20
|
| Rate for Payer: Prime Health Services Commercial |
$2.87
|
| Rate for Payer: Riverside University Health System MISP |
$1.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.69
|
| Rate for Payer: United Healthcare All Other HMO |
$1.69
|
| Rate for Payer: United Healthcare HMO Rider |
$1.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.87
|
| Rate for Payer: Vantage Medical Group Senior |
$2.87
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 350-370
|
Facility
|
OP
|
$4.28
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081007
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$3.85 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.51
|
| Rate for Payer: Blue Shield of California Commercial |
$2.62
|
| Rate for Payer: Blue Shield of California EPN |
$1.71
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Central Health Plan Commercial |
$3.42
|
| Rate for Payer: Cigna of CA HMO |
$2.74
|
| Rate for Payer: Cigna of CA PPO |
$3.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.71
|
| Rate for Payer: EPIC Health Plan Senior |
$1.71
|
| Rate for Payer: Galaxy Health WC |
$3.64
|
| Rate for Payer: Global Benefits Group Commercial |
$2.57
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.14
|
| Rate for Payer: InnovAge PACE Commercial |
$2.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$3.21
|
| Rate for Payer: Networks By Design Commercial |
$2.78
|
| Rate for Payer: Prime Health Services Commercial |
$3.64
|
| Rate for Payer: Riverside University Health System MISP |
$1.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.14
|
| Rate for Payer: United Healthcare All Other HMO |
$2.14
|
| Rate for Payer: United Healthcare HMO Rider |
$2.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.64
|
| Rate for Payer: Vantage Medical Group Senior |
$3.64
|
|
|
HC LOCM (OMNIPAQUE-ISOVUE) 350-370
|
Facility
|
IP
|
$4.28
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081007
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.85 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$3.31
|
| Rate for Payer: Blue Shield of California EPN |
$2.16
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Central Health Plan Commercial |
$3.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.71
|
| Rate for Payer: EPIC Health Plan Senior |
$1.71
|
| Rate for Payer: Galaxy Health WC |
$3.64
|
| Rate for Payer: Global Benefits Group Commercial |
$2.57
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$3.21
|
| Rate for Payer: Networks By Design Commercial |
$2.78
|
| Rate for Payer: Prime Health Services Commercial |
$3.64
|
|
|
HC LOCM (VISIPAQUE) 320 PER ML
|
Facility
|
IP
|
$4.27
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081008
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Adventist Health Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California Commercial |
$3.30
|
| Rate for Payer: Blue Shield of California EPN |
$2.15
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Central Health Plan Commercial |
$3.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.71
|
| Rate for Payer: EPIC Health Plan Senior |
$1.71
|
| Rate for Payer: Galaxy Health WC |
$3.63
|
| Rate for Payer: Global Benefits Group Commercial |
$2.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: Networks By Design Commercial |
$2.78
|
| Rate for Payer: Prime Health Services Commercial |
$3.63
|
|
|
HC LOCM (VISIPAQUE) 320 PER ML
|
Facility
|
OP
|
$4.27
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
909081008
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Adventist Health Commercial |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.51
|
| Rate for Payer: Blue Shield of California Commercial |
$2.61
|
| Rate for Payer: Blue Shield of California EPN |
$1.70
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Central Health Plan Commercial |
$3.42
|
| Rate for Payer: Cigna of CA HMO |
$2.73
|
| Rate for Payer: Cigna of CA PPO |
$3.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.71
|
| Rate for Payer: EPIC Health Plan Senior |
$1.71
|
| Rate for Payer: Galaxy Health WC |
$3.63
|
| Rate for Payer: Global Benefits Group Commercial |
$2.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.14
|
| Rate for Payer: InnovAge PACE Commercial |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.99
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: Networks By Design Commercial |
$2.78
|
| Rate for Payer: Prime Health Services Commercial |
$3.63
|
| Rate for Payer: Riverside University Health System MISP |
$1.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.13
|
| Rate for Payer: United Healthcare All Other HMO |
$2.13
|
| Rate for Payer: United Healthcare HMO Rider |
$2.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.63
|
| Rate for Payer: Vantage Medical Group Senior |
$3.63
|
|
|
HC LO FLEXIBL L1-BELOW L5 PRE
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
CPT L0625
|
| Hospital Charge Code |
915350625
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Adventist Health Commercial |
$28.00
|
| Rate for Payer: Blue Shield of California Commercial |
$108.22
|
| Rate for Payer: Blue Shield of California EPN |
$70.56
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Central Health Plan Commercial |
$112.00
|
| Rate for Payer: Cigna of CA HMO |
$98.00
|
| Rate for Payer: Cigna of CA PPO |
$98.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.00
|
| Rate for Payer: EPIC Health Plan Senior |
$56.00
|
| Rate for Payer: Galaxy Health WC |
$119.00
|
| Rate for Payer: Global Benefits Group Commercial |
$84.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$126.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$93.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$53.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$86.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$105.00
|
| Rate for Payer: Networks By Design Commercial |
$91.00
|
| Rate for Payer: Prime Health Services Commercial |
$119.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$52.54
|
| Rate for Payer: United Healthcare All Other HMO |
$51.14
|
| Rate for Payer: United Healthcare HMO Rider |
$50.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$45.85
|
|
|
HC LO FLEXIBL L1-BELOW L5 PRE
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
CPT L0625
|
| Hospital Charge Code |
905350625
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$45.85 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Adventist Health Commercial |
$57.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$119.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$77.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$105.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$82.22
|
| Rate for Payer: Blue Shield of California Commercial |
$108.22
|
| Rate for Payer: Blue Shield of California EPN |
$70.56
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Central Health Plan Commercial |
$112.00
|
| Rate for Payer: Cigna of CA HMO |
$98.00
|
| Rate for Payer: Cigna of CA PPO |
$98.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$119.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$119.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$119.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.00
|
| Rate for Payer: EPIC Health Plan Senior |
$56.00
|
| Rate for Payer: Galaxy Health WC |
$119.00
|
| Rate for Payer: Global Benefits Group Commercial |
$84.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$126.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$59.55
|
| Rate for Payer: InnovAge PACE Commercial |
$70.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$93.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$65.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$86.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$98.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$98.00
|
| Rate for Payer: Multiplan Commercial |
$105.00
|
| Rate for Payer: Networks By Design Commercial |
$70.00
|
| Rate for Payer: Prime Health Services Commercial |
$119.00
|
| Rate for Payer: Riverside University Health System MISP |
$56.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$84.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$84.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$52.54
|
| Rate for Payer: United Healthcare All Other HMO |
$51.14
|
| Rate for Payer: United Healthcare HMO Rider |
$50.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$45.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$119.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$119.00
|
| Rate for Payer: Vantage Medical Group Senior |
$119.00
|
|
|
HC LO FLEXIBL L1-BELOW L5 PRE
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
CPT L0625
|
| Hospital Charge Code |
915350625
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$45.85 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Adventist Health Commercial |
$57.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$119.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$77.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$105.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$82.22
|
| Rate for Payer: Blue Shield of California Commercial |
$108.22
|
| Rate for Payer: Blue Shield of California EPN |
$70.56
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Central Health Plan Commercial |
$112.00
|
| Rate for Payer: Cigna of CA HMO |
$98.00
|
| Rate for Payer: Cigna of CA PPO |
$98.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$119.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$119.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$119.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.00
|
| Rate for Payer: EPIC Health Plan Senior |
$56.00
|
| Rate for Payer: Galaxy Health WC |
$119.00
|
| Rate for Payer: Global Benefits Group Commercial |
$84.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$126.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$59.55
|
| Rate for Payer: InnovAge PACE Commercial |
$70.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$93.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$65.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$86.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$98.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$98.00
|
| Rate for Payer: Multiplan Commercial |
$105.00
|
| Rate for Payer: Networks By Design Commercial |
$70.00
|
| Rate for Payer: Prime Health Services Commercial |
$119.00
|
| Rate for Payer: Riverside University Health System MISP |
$56.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$84.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$84.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$52.54
|
| Rate for Payer: United Healthcare All Other HMO |
$51.14
|
| Rate for Payer: United Healthcare HMO Rider |
$50.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$45.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$119.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$119.00
|
| Rate for Payer: Vantage Medical Group Senior |
$119.00
|
|
|
HC LO FLEXIBL L1-BELOW L5 PRE
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
CPT L0625
|
| Hospital Charge Code |
905350625
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Adventist Health Commercial |
$28.00
|
| Rate for Payer: Blue Shield of California Commercial |
$108.22
|
| Rate for Payer: Blue Shield of California EPN |
$70.56
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Central Health Plan Commercial |
$112.00
|
| Rate for Payer: Cigna of CA HMO |
$98.00
|
| Rate for Payer: Cigna of CA PPO |
$98.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.00
|
| Rate for Payer: EPIC Health Plan Senior |
$56.00
|
| Rate for Payer: Galaxy Health WC |
$119.00
|
| Rate for Payer: Global Benefits Group Commercial |
$84.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$126.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$93.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$53.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$86.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$105.00
|
| Rate for Payer: Networks By Design Commercial |
$91.00
|
| Rate for Payer: Prime Health Services Commercial |
$119.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$52.54
|
| Rate for Payer: United Healthcare All Other HMO |
$51.14
|
| Rate for Payer: United Healthcare HMO Rider |
$50.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$45.85
|
|
|
HC LONG TONGUE STIRRUP ADDITION LE
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
CPT L2265
|
| Hospital Charge Code |
905352265
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$315.00 |
| Rate for Payer: Adventist Health Commercial |
$70.00
|
| Rate for Payer: Blue Shield of California Commercial |
$270.55
|
| Rate for Payer: Blue Shield of California EPN |
$176.40
|
| Rate for Payer: Cash Price |
$192.50
|
| Rate for Payer: Central Health Plan Commercial |
$280.00
|
| Rate for Payer: Cigna of CA HMO |
$245.00
|
| Rate for Payer: Cigna of CA PPO |
$245.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$140.00
|
| Rate for Payer: EPIC Health Plan Senior |
$140.00
|
| Rate for Payer: Galaxy Health WC |
$297.50
|
| Rate for Payer: Global Benefits Group Commercial |
$210.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$315.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$233.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$133.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$216.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.00
|
| Rate for Payer: Multiplan Commercial |
$262.50
|
| Rate for Payer: Networks By Design Commercial |
$227.50
|
| Rate for Payer: Prime Health Services Commercial |
$297.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$131.35
|
| Rate for Payer: United Healthcare All Other HMO |
$127.86
|
| Rate for Payer: United Healthcare HMO Rider |
$125.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$114.62
|
|
|
HC LONG TONGUE STIRRUP ADDITION LE
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
CPT L2265
|
| Hospital Charge Code |
915352265
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$315.00 |
| Rate for Payer: Adventist Health Commercial |
$70.00
|
| Rate for Payer: Blue Shield of California Commercial |
$270.55
|
| Rate for Payer: Blue Shield of California EPN |
$176.40
|
| Rate for Payer: Cash Price |
$192.50
|
| Rate for Payer: Central Health Plan Commercial |
$280.00
|
| Rate for Payer: Cigna of CA HMO |
$245.00
|
| Rate for Payer: Cigna of CA PPO |
$245.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$140.00
|
| Rate for Payer: EPIC Health Plan Senior |
$140.00
|
| Rate for Payer: Galaxy Health WC |
$297.50
|
| Rate for Payer: Global Benefits Group Commercial |
$210.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$315.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$233.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$133.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$216.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.00
|
| Rate for Payer: Multiplan Commercial |
$262.50
|
| Rate for Payer: Networks By Design Commercial |
$227.50
|
| Rate for Payer: Prime Health Services Commercial |
$297.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$131.35
|
| Rate for Payer: United Healthcare All Other HMO |
$127.86
|
| Rate for Payer: United Healthcare HMO Rider |
$125.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$114.62
|
|
|
HC LONG TONGUE STIRRUP ADDITION LE
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
CPT L2265
|
| Hospital Charge Code |
915352265
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$90.54 |
| Max. Negotiated Rate |
$315.00 |
| Rate for Payer: Adventist Health Commercial |
$143.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$297.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$192.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$262.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$205.56
|
| Rate for Payer: Blue Shield of California Commercial |
$270.55
|
| Rate for Payer: Blue Shield of California EPN |
$176.40
|
| Rate for Payer: Cash Price |
$192.50
|
| Rate for Payer: Cash Price |
$192.50
|
| Rate for Payer: Central Health Plan Commercial |
$280.00
|
| Rate for Payer: Cigna of CA HMO |
$245.00
|
| Rate for Payer: Cigna of CA PPO |
$245.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$297.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$297.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$297.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$140.00
|
| Rate for Payer: EPIC Health Plan Senior |
$140.00
|
| Rate for Payer: Galaxy Health WC |
$297.50
|
| Rate for Payer: Global Benefits Group Commercial |
$210.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$315.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$90.54
|
| Rate for Payer: InnovAge PACE Commercial |
$175.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$233.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$100.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$216.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$143.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$245.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$245.00
|
| Rate for Payer: Multiplan Commercial |
$262.50
|
| Rate for Payer: Networks By Design Commercial |
$175.00
|
| Rate for Payer: Prime Health Services Commercial |
$297.50
|
| Rate for Payer: Riverside University Health System MISP |
$140.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$210.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$210.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$131.35
|
| Rate for Payer: United Healthcare All Other HMO |
$127.86
|
| Rate for Payer: United Healthcare HMO Rider |
$125.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$114.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$297.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$297.50
|
| Rate for Payer: Vantage Medical Group Senior |
$297.50
|
|
|
HC LONG TONGUE STIRRUP ADDITION LE
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
CPT L2265
|
| Hospital Charge Code |
905352265
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$90.54 |
| Max. Negotiated Rate |
$315.00 |
| Rate for Payer: Adventist Health Commercial |
$143.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$297.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$192.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$262.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$205.56
|
| Rate for Payer: Blue Shield of California Commercial |
$270.55
|
| Rate for Payer: Blue Shield of California EPN |
$176.40
|
| Rate for Payer: Cash Price |
$192.50
|
| Rate for Payer: Cash Price |
$192.50
|
| Rate for Payer: Central Health Plan Commercial |
$280.00
|
| Rate for Payer: Cigna of CA HMO |
$245.00
|
| Rate for Payer: Cigna of CA PPO |
$245.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$297.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$297.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$297.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$140.00
|
| Rate for Payer: EPIC Health Plan Senior |
$140.00
|
| Rate for Payer: Galaxy Health WC |
$297.50
|
| Rate for Payer: Global Benefits Group Commercial |
$210.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$315.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$90.54
|
| Rate for Payer: InnovAge PACE Commercial |
$175.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$233.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$100.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$216.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$143.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$245.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$245.00
|
| Rate for Payer: Multiplan Commercial |
$262.50
|
| Rate for Payer: Networks By Design Commercial |
$175.00
|
| Rate for Payer: Prime Health Services Commercial |
$297.50
|
| Rate for Payer: Riverside University Health System MISP |
$140.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$210.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$210.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$131.35
|
| Rate for Payer: United Healthcare All Other HMO |
$127.86
|
| Rate for Payer: United Healthcare HMO Rider |
$125.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$114.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$297.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$297.50
|
| Rate for Payer: Vantage Medical Group Senior |
$297.50
|
|
|
HC LOOPOGRAM (ILEAL CONDUIT)
|
Facility
|
OP
|
$445.00
|
|
|
Service Code
|
CPT 50690
|
| Hospital Charge Code |
909000207
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$89.00 |
| Max. Negotiated Rate |
$7,837.47 |
| Rate for Payer: Adventist Health Commercial |
$89.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$378.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$244.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$333.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$215.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$261.35
|
| Rate for Payer: Blue Shield of California Commercial |
$7,837.47
|
| Rate for Payer: Blue Shield of California EPN |
$5,113.68
|
| Rate for Payer: Cash Price |
$244.75
|
| Rate for Payer: Cash Price |
$244.75
|
| Rate for Payer: Cash Price |
$244.75
|
| Rate for Payer: Central Health Plan Commercial |
$356.00
|
| Rate for Payer: Cigna of CA HMO |
$284.80
|
| Rate for Payer: Cigna of CA PPO |
$329.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$378.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$378.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.00
|
| Rate for Payer: EPIC Health Plan Senior |
$178.00
|
| Rate for Payer: Galaxy Health WC |
$378.25
|
| Rate for Payer: Global Benefits Group Commercial |
$267.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$400.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$462.34
|
| Rate for Payer: InnovAge PACE Commercial |
$222.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$296.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$510.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$275.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$311.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$311.50
|
| Rate for Payer: Multiplan Commercial |
$333.75
|
| Rate for Payer: Networks By Design Commercial |
$289.25
|
| Rate for Payer: Prime Health Services Commercial |
$378.25
|
| Rate for Payer: Riverside University Health System MISP |
$178.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$267.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,932.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$378.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$378.25
|
| Rate for Payer: Vantage Medical Group Senior |
$378.25
|
|
|
HC LOOPOGRAM (ILEAL CONDUIT)
|
Facility
|
IP
|
$445.00
|
|
|
Service Code
|
CPT 50690
|
| Hospital Charge Code |
909000207
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$89.00 |
| Max. Negotiated Rate |
$400.50 |
| Rate for Payer: Adventist Health Commercial |
$89.00
|
| Rate for Payer: Cash Price |
$244.75
|
| Rate for Payer: Central Health Plan Commercial |
$356.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.00
|
| Rate for Payer: EPIC Health Plan Senior |
$178.00
|
| Rate for Payer: Galaxy Health WC |
$378.25
|
| Rate for Payer: Global Benefits Group Commercial |
$267.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$400.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$296.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$169.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$275.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.00
|
| Rate for Payer: Multiplan Commercial |
$333.75
|
| Rate for Payer: Networks By Design Commercial |
$289.25
|
| Rate for Payer: Prime Health Services Commercial |
$378.25
|
|
|
HC LO SAGITT RIGID PANEL PREFAB
|
Facility
|
IP
|
$710.00
|
|
|
Service Code
|
CPT L0627
|
| Hospital Charge Code |
905350627
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$142.00 |
| Max. Negotiated Rate |
$639.00 |
| Rate for Payer: Adventist Health Commercial |
$142.00
|
| Rate for Payer: Blue Shield of California Commercial |
$548.83
|
| Rate for Payer: Blue Shield of California EPN |
$357.84
|
| Rate for Payer: Cash Price |
$390.50
|
| Rate for Payer: Central Health Plan Commercial |
$568.00
|
| Rate for Payer: Cigna of CA HMO |
$497.00
|
| Rate for Payer: Cigna of CA PPO |
$497.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$284.00
|
| Rate for Payer: EPIC Health Plan Senior |
$284.00
|
| Rate for Payer: Galaxy Health WC |
$603.50
|
| Rate for Payer: Global Benefits Group Commercial |
$426.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$639.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$473.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$270.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$439.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$142.00
|
| Rate for Payer: Multiplan Commercial |
$532.50
|
| Rate for Payer: Networks By Design Commercial |
$461.50
|
| Rate for Payer: Prime Health Services Commercial |
$603.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$266.46
|
| Rate for Payer: United Healthcare All Other HMO |
$259.36
|
| Rate for Payer: United Healthcare HMO Rider |
$253.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$232.53
|
|
|
HC LO SAGITT RIGID PANEL PREFAB
|
Facility
|
IP
|
$710.00
|
|
|
Service Code
|
CPT L0627
|
| Hospital Charge Code |
915350627
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$142.00 |
| Max. Negotiated Rate |
$639.00 |
| Rate for Payer: Adventist Health Commercial |
$142.00
|
| Rate for Payer: Blue Shield of California Commercial |
$548.83
|
| Rate for Payer: Blue Shield of California EPN |
$357.84
|
| Rate for Payer: Cash Price |
$390.50
|
| Rate for Payer: Central Health Plan Commercial |
$568.00
|
| Rate for Payer: Cigna of CA HMO |
$497.00
|
| Rate for Payer: Cigna of CA PPO |
$497.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$284.00
|
| Rate for Payer: EPIC Health Plan Senior |
$284.00
|
| Rate for Payer: Galaxy Health WC |
$603.50
|
| Rate for Payer: Global Benefits Group Commercial |
$426.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$639.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$473.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$270.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$439.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$142.00
|
| Rate for Payer: Multiplan Commercial |
$532.50
|
| Rate for Payer: Networks By Design Commercial |
$461.50
|
| Rate for Payer: Prime Health Services Commercial |
$603.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$266.46
|
| Rate for Payer: United Healthcare All Other HMO |
$259.36
|
| Rate for Payer: United Healthcare HMO Rider |
$253.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$232.53
|
|
|
HC LO SAGITT RIGID PANEL PREFAB
|
Facility
|
OP
|
$710.00
|
|
|
Service Code
|
CPT L0627
|
| Hospital Charge Code |
915350627
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$232.53 |
| Max. Negotiated Rate |
$639.00 |
| Rate for Payer: Adventist Health Commercial |
$291.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$603.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$390.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$532.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$416.98
|
| Rate for Payer: Blue Shield of California Commercial |
$548.83
|
| Rate for Payer: Blue Shield of California EPN |
$357.84
|
| Rate for Payer: Cash Price |
$390.50
|
| Rate for Payer: Cash Price |
$390.50
|
| Rate for Payer: Central Health Plan Commercial |
$568.00
|
| Rate for Payer: Cigna of CA HMO |
$497.00
|
| Rate for Payer: Cigna of CA PPO |
$497.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$603.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$603.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$603.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$284.00
|
| Rate for Payer: EPIC Health Plan Senior |
$284.00
|
| Rate for Payer: Galaxy Health WC |
$603.50
|
| Rate for Payer: Global Benefits Group Commercial |
$426.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$639.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$444.41
|
| Rate for Payer: InnovAge PACE Commercial |
$355.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$473.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$490.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$439.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$291.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$497.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$497.00
|
| Rate for Payer: Multiplan Commercial |
$532.50
|
| Rate for Payer: Networks By Design Commercial |
$355.00
|
| Rate for Payer: Prime Health Services Commercial |
$603.50
|
| Rate for Payer: Riverside University Health System MISP |
$284.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$426.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$426.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$266.46
|
| Rate for Payer: United Healthcare All Other HMO |
$259.36
|
| Rate for Payer: United Healthcare HMO Rider |
$253.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$232.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$603.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$603.50
|
| Rate for Payer: Vantage Medical Group Senior |
$603.50
|
|
|
HC LO SAGITT RIGID PANEL PREFAB
|
Facility
|
OP
|
$710.00
|
|
|
Service Code
|
CPT L0627
|
| Hospital Charge Code |
905350627
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$232.53 |
| Max. Negotiated Rate |
$639.00 |
| Rate for Payer: Adventist Health Commercial |
$291.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$603.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$390.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$532.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$416.98
|
| Rate for Payer: Blue Shield of California Commercial |
$548.83
|
| Rate for Payer: Blue Shield of California EPN |
$357.84
|
| Rate for Payer: Cash Price |
$390.50
|
| Rate for Payer: Cash Price |
$390.50
|
| Rate for Payer: Central Health Plan Commercial |
$568.00
|
| Rate for Payer: Cigna of CA HMO |
$497.00
|
| Rate for Payer: Cigna of CA PPO |
$497.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$603.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$603.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$603.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$284.00
|
| Rate for Payer: EPIC Health Plan Senior |
$284.00
|
| Rate for Payer: Galaxy Health WC |
$603.50
|
| Rate for Payer: Global Benefits Group Commercial |
$426.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$639.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$444.41
|
| Rate for Payer: InnovAge PACE Commercial |
$355.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$473.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$490.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$439.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$291.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$497.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$497.00
|
| Rate for Payer: Multiplan Commercial |
$532.50
|
| Rate for Payer: Networks By Design Commercial |
$355.00
|
| Rate for Payer: Prime Health Services Commercial |
$603.50
|
| Rate for Payer: Riverside University Health System MISP |
$284.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$426.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$426.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$266.46
|
| Rate for Payer: United Healthcare All Other HMO |
$259.36
|
| Rate for Payer: United Healthcare HMO Rider |
$253.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$232.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$603.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$603.50
|
| Rate for Payer: Vantage Medical Group Senior |
$603.50
|
|
|
HC LO SAG STAYS/PANELS PRE-FAB
|
Facility
|
OP
|
$9,608.00
|
|
|
Service Code
|
CPT L0626
|
| Hospital Charge Code |
905350626
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$84.28 |
| Max. Negotiated Rate |
$8,647.20 |
| Rate for Payer: Adventist Health Commercial |
$3,939.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8,166.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,284.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,206.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,642.78
|
| Rate for Payer: Blue Shield of California Commercial |
$7,426.98
|
| Rate for Payer: Blue Shield of California EPN |
$4,842.43
|
| Rate for Payer: Cash Price |
$5,284.40
|
| Rate for Payer: Cash Price |
$5,284.40
|
| Rate for Payer: Central Health Plan Commercial |
$7,686.40
|
| Rate for Payer: Cigna of CA HMO |
$6,725.60
|
| Rate for Payer: Cigna of CA PPO |
$6,725.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8,166.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,166.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8,166.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,843.20
|
| Rate for Payer: EPIC Health Plan Senior |
$3,843.20
|
| Rate for Payer: Galaxy Health WC |
$8,166.80
|
| Rate for Payer: Global Benefits Group Commercial |
$5,764.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$8,647.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$84.28
|
| Rate for Payer: InnovAge PACE Commercial |
$4,804.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6,408.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$93.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,947.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,939.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,725.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,725.60
|
| Rate for Payer: Multiplan Commercial |
$7,206.00
|
| Rate for Payer: Networks By Design Commercial |
$4,804.00
|
| Rate for Payer: Prime Health Services Commercial |
$8,166.80
|
| Rate for Payer: Riverside University Health System MISP |
$3,843.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5,764.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5,764.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,605.88
|
| Rate for Payer: United Healthcare All Other HMO |
$3,509.80
|
| Rate for Payer: United Healthcare HMO Rider |
$3,433.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,146.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8,166.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,166.80
|
| Rate for Payer: Vantage Medical Group Senior |
$8,166.80
|
|
|
HC LO SAG STAYS/PANELS PRE-FAB
|
Facility
|
IP
|
$9,608.00
|
|
|
Service Code
|
CPT L0626
|
| Hospital Charge Code |
905350626
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,921.60 |
| Max. Negotiated Rate |
$8,647.20 |
| Rate for Payer: Adventist Health Commercial |
$1,921.60
|
| Rate for Payer: Blue Shield of California Commercial |
$7,426.98
|
| Rate for Payer: Blue Shield of California EPN |
$4,842.43
|
| Rate for Payer: Cash Price |
$5,284.40
|
| Rate for Payer: Central Health Plan Commercial |
$7,686.40
|
| Rate for Payer: Cigna of CA HMO |
$6,725.60
|
| Rate for Payer: Cigna of CA PPO |
$6,725.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,843.20
|
| Rate for Payer: EPIC Health Plan Senior |
$3,843.20
|
| Rate for Payer: Galaxy Health WC |
$8,166.80
|
| Rate for Payer: Global Benefits Group Commercial |
$5,764.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$8,647.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6,408.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,660.65
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,947.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,921.60
|
| Rate for Payer: Multiplan Commercial |
$7,206.00
|
| Rate for Payer: Networks By Design Commercial |
$6,245.20
|
| Rate for Payer: Prime Health Services Commercial |
$8,166.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,605.88
|
| Rate for Payer: United Healthcare All Other HMO |
$3,509.80
|
| Rate for Payer: United Healthcare HMO Rider |
$3,433.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,146.62
|
|
