|
HC REPLACE NON-MOLDED LACER
|
Facility
|
OP
|
$526.00
|
|
|
Service Code
|
CPT L4055
|
| Hospital Charge Code |
905354055
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$172.26 |
| Max. Negotiated Rate |
$473.40 |
| Rate for Payer: Adventist Health Commercial |
$215.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$447.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$289.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$394.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$305.97
|
| Rate for Payer: Blue Shield of California Commercial |
$421.85
|
| Rate for Payer: Blue Shield of California EPN |
$265.10
|
| Rate for Payer: Cash Price |
$236.70
|
| Rate for Payer: Cash Price |
$236.70
|
| Rate for Payer: Central Health Plan Commercial |
$420.80
|
| Rate for Payer: Cigna of CA HMO |
$368.20
|
| Rate for Payer: Cigna of CA PPO |
$368.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$447.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$447.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$447.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$368.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$210.40
|
| Rate for Payer: EPIC Health Plan Senior |
$210.40
|
| Rate for Payer: Galaxy Health WC |
$447.10
|
| Rate for Payer: Global Benefits Group Commercial |
$315.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$473.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$369.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$334.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$407.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$310.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$215.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$368.20
|
| Rate for Payer: Multiplan Commercial |
$394.50
|
| Rate for Payer: Networks By Design Commercial |
$263.00
|
| Rate for Payer: Prime Health Services Commercial |
$447.10
|
| Rate for Payer: Riverside University Health System MISP |
$210.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$315.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$315.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$197.41
|
| Rate for Payer: United Healthcare All Other HMO |
$192.15
|
| Rate for Payer: United Healthcare HMO Rider |
$187.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$172.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$447.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$447.10
|
| Rate for Payer: Vantage Medical Group Senior |
$447.10
|
|
|
HC REPLACE PORT THRU SAME ACCESS
|
Facility
|
OP
|
$11,754.00
|
|
|
Service Code
|
CPT 36585
|
| Hospital Charge Code |
909020012
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$718.48 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Commercial |
$2,350.80
|
| Rate for Payer: Adventist Health Medi-Cal |
$4,061.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| 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 |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,587.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$6,372.03
|
| Rate for Payer: Blue Shield of California Commercial |
$3,293.23
|
| Rate for Payer: Blue Shield of California EPN |
$2,069.82
|
| Rate for Payer: Cash Price |
$5,289.30
|
| Rate for Payer: Cash Price |
$5,289.30
|
| Rate for Payer: Cash Price |
$5,289.30
|
| Rate for Payer: Central Health Plan Commercial |
$9,403.20
|
| Rate for Payer: Cigna of CA HMO |
$7,522.56
|
| Rate for Payer: Cigna of CA PPO |
$8,697.96
|
| 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 |
$8,227.80
|
| 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 |
$9,990.90
|
| Rate for Payer: Global Benefits Group Commercial |
$7,052.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$10,578.60
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,660.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$718.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,061.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7,463.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$793.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,685.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,350.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,441.81
|
| Rate for Payer: Multiplan Commercial |
$8,815.50
|
| Rate for Payer: Multiplan WC |
$6,372.03
|
| Rate for Payer: Networks By Design Commercial |
$7,640.10
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$4,061.05
|
| Rate for Payer: Preferred Health Network WC |
$6,502.07
|
| Rate for Payer: Prime Health Services Commercial |
$9,990.90
|
| Rate for Payer: Prime Health Services Medicare |
$4,304.71
|
| Rate for Payer: Prime Health Services WC |
$6,307.01
|
| Rate for Payer: Riverside University Health System MISP |
$4,467.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7,052.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,877.00
|
| Rate for Payer: United Healthcare All Other HMO |
$20,902.00
|
| Rate for Payer: United Healthcare HMO Rider |
$13,066.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,971.00
|
| 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 REPLACE PORT THRU SAME ACCESS
|
Facility
|
IP
|
$11,754.00
|
|
|
Service Code
|
CPT 36585
|
| Hospital Charge Code |
909020012
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,350.80 |
| Max. Negotiated Rate |
$10,578.60 |
| Rate for Payer: Adventist Health Commercial |
$2,350.80
|
| Rate for Payer: Cash Price |
$5,289.30
|
| Rate for Payer: Central Health Plan Commercial |
$9,403.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8,227.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,701.60
|
| Rate for Payer: EPIC Health Plan Senior |
$4,701.60
|
| Rate for Payer: Galaxy Health WC |
$9,990.90
|
| Rate for Payer: Global Benefits Group Commercial |
$7,052.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$10,578.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7,463.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6,934.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,350.80
|
| Rate for Payer: Multiplan Commercial |
$8,815.50
|
| Rate for Payer: Networks By Design Commercial |
$7,640.10
|
| Rate for Payer: Prime Health Services Commercial |
$9,990.90
|
|
|
HC REPLACE PRETIBIAL SHELL
|
Facility
|
IP
|
$996.00
|
|
|
Service Code
|
CPT L4130
|
| Hospital Charge Code |
915354130
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$199.20 |
| Max. Negotiated Rate |
$896.40 |
| Rate for Payer: Adventist Health Commercial |
$199.20
|
| Rate for Payer: Blue Shield of California Commercial |
$798.79
|
| Rate for Payer: Blue Shield of California EPN |
$501.98
|
| Rate for Payer: Cash Price |
$448.20
|
| Rate for Payer: Central Health Plan Commercial |
$796.80
|
| Rate for Payer: Cigna of CA HMO |
$697.20
|
| Rate for Payer: Cigna of CA PPO |
$697.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$697.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$398.40
|
| Rate for Payer: EPIC Health Plan Senior |
$398.40
|
| Rate for Payer: Galaxy Health WC |
$846.60
|
| Rate for Payer: Global Benefits Group Commercial |
$597.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$896.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$632.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$587.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$199.20
|
| Rate for Payer: Multiplan Commercial |
$747.00
|
| Rate for Payer: Networks By Design Commercial |
$647.40
|
| Rate for Payer: Prime Health Services Commercial |
$846.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$373.80
|
| Rate for Payer: United Healthcare All Other HMO |
$363.84
|
| Rate for Payer: United Healthcare HMO Rider |
$355.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$326.19
|
|
|
HC REPLACE PRETIBIAL SHELL
|
Facility
|
OP
|
$996.00
|
|
|
Service Code
|
CPT L4130
|
| Hospital Charge Code |
915354130
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$326.19 |
| Max. Negotiated Rate |
$896.40 |
| Rate for Payer: Dignity Health Medi-Cal |
$846.60
|
| Rate for Payer: Adventist Health Commercial |
$408.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$846.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$547.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$747.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$579.37
|
| Rate for Payer: Blue Shield of California Commercial |
$798.79
|
| Rate for Payer: Blue Shield of California EPN |
$501.98
|
| Rate for Payer: Cash Price |
$448.20
|
| Rate for Payer: Cash Price |
$448.20
|
| Rate for Payer: Central Health Plan Commercial |
$796.80
|
| Rate for Payer: Cigna of CA HMO |
$697.20
|
| Rate for Payer: Cigna of CA PPO |
$697.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$846.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$846.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$697.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$398.40
|
| Rate for Payer: EPIC Health Plan Senior |
$398.40
|
| Rate for Payer: Galaxy Health WC |
$846.60
|
| Rate for Payer: Global Benefits Group Commercial |
$597.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$896.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$559.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$632.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$618.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$587.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$408.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$697.20
|
| Rate for Payer: Multiplan Commercial |
$747.00
|
| Rate for Payer: Networks By Design Commercial |
$498.00
|
| Rate for Payer: Prime Health Services Commercial |
$846.60
|
| Rate for Payer: Riverside University Health System MISP |
$398.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$597.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$597.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$373.80
|
| Rate for Payer: United Healthcare All Other HMO |
$363.84
|
| Rate for Payer: United Healthcare HMO Rider |
$355.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$326.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$846.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$846.60
|
| Rate for Payer: Vantage Medical Group Senior |
$846.60
|
|
|
HC REPLACE PRETIBIAL SHELL
|
Facility
|
IP
|
$996.00
|
|
|
Service Code
|
CPT L4130
|
| Hospital Charge Code |
905354130
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$199.20 |
| Max. Negotiated Rate |
$896.40 |
| Rate for Payer: Adventist Health Commercial |
$199.20
|
| Rate for Payer: Blue Shield of California Commercial |
$798.79
|
| Rate for Payer: Blue Shield of California EPN |
$501.98
|
| Rate for Payer: Cash Price |
$448.20
|
| Rate for Payer: Central Health Plan Commercial |
$796.80
|
| Rate for Payer: Cigna of CA HMO |
$697.20
|
| Rate for Payer: Cigna of CA PPO |
$697.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$697.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$398.40
|
| Rate for Payer: EPIC Health Plan Senior |
$398.40
|
| Rate for Payer: Galaxy Health WC |
$846.60
|
| Rate for Payer: Global Benefits Group Commercial |
$597.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$896.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$632.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$587.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$199.20
|
| Rate for Payer: Multiplan Commercial |
$747.00
|
| Rate for Payer: Networks By Design Commercial |
$647.40
|
| Rate for Payer: Prime Health Services Commercial |
$846.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$373.80
|
| Rate for Payer: United Healthcare All Other HMO |
$363.84
|
| Rate for Payer: United Healthcare HMO Rider |
$355.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$326.19
|
|
|
HC REPLACE PRETIBIAL SHELL
|
Facility
|
OP
|
$996.00
|
|
|
Service Code
|
CPT L4130
|
| Hospital Charge Code |
905354130
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$326.19 |
| Max. Negotiated Rate |
$896.40 |
| Rate for Payer: Adventist Health Commercial |
$408.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$846.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$547.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$747.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$579.37
|
| Rate for Payer: Blue Shield of California Commercial |
$798.79
|
| Rate for Payer: Blue Shield of California EPN |
$501.98
|
| Rate for Payer: Cash Price |
$448.20
|
| Rate for Payer: Cash Price |
$448.20
|
| Rate for Payer: Central Health Plan Commercial |
$796.80
|
| Rate for Payer: Cigna of CA HMO |
$697.20
|
| Rate for Payer: Cigna of CA PPO |
$697.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$846.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$846.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$846.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$697.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$398.40
|
| Rate for Payer: EPIC Health Plan Senior |
$398.40
|
| Rate for Payer: Galaxy Health WC |
$846.60
|
| Rate for Payer: Global Benefits Group Commercial |
$597.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$896.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$559.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$632.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$618.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$587.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$408.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$697.20
|
| Rate for Payer: Multiplan Commercial |
$747.00
|
| Rate for Payer: Networks By Design Commercial |
$498.00
|
| Rate for Payer: Prime Health Services Commercial |
$846.60
|
| Rate for Payer: Riverside University Health System MISP |
$398.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$597.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$597.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$373.80
|
| Rate for Payer: United Healthcare All Other HMO |
$363.84
|
| Rate for Payer: United Healthcare HMO Rider |
$355.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$326.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$846.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$846.60
|
| Rate for Payer: Vantage Medical Group Senior |
$846.60
|
|
|
HC REPLACE PROX/DIST UPRIGHT
|
Facility
|
OP
|
$576.00
|
|
|
Service Code
|
CPT L4070
|
| Hospital Charge Code |
905354070
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$188.64 |
| Max. Negotiated Rate |
$518.40 |
| Rate for Payer: Adventist Health Commercial |
$236.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$489.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$316.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$432.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$335.06
|
| Rate for Payer: Blue Shield of California Commercial |
$461.95
|
| Rate for Payer: Blue Shield of California EPN |
$290.30
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Central Health Plan Commercial |
$460.80
|
| Rate for Payer: Cigna of CA HMO |
$403.20
|
| Rate for Payer: Cigna of CA PPO |
$403.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$489.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$489.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$489.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$403.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$230.40
|
| Rate for Payer: EPIC Health Plan Senior |
$230.40
|
| Rate for Payer: Galaxy Health WC |
$489.60
|
| Rate for Payer: Global Benefits Group Commercial |
$345.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$518.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$388.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$365.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$429.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$339.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$236.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$403.20
|
| Rate for Payer: Multiplan Commercial |
$432.00
|
| Rate for Payer: Networks By Design Commercial |
$288.00
|
| Rate for Payer: Prime Health Services Commercial |
$489.60
|
| Rate for Payer: Riverside University Health System MISP |
$230.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$345.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$345.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$216.17
|
| Rate for Payer: United Healthcare All Other HMO |
$210.41
|
| Rate for Payer: United Healthcare HMO Rider |
$205.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$188.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$489.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$489.60
|
| Rate for Payer: Vantage Medical Group Senior |
$489.60
|
|
|
HC REPLACE PROX/DIST UPRIGHT
|
Facility
|
IP
|
$576.00
|
|
|
Service Code
|
CPT L4070
|
| Hospital Charge Code |
905354070
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$115.20 |
| Max. Negotiated Rate |
$518.40 |
| Rate for Payer: Adventist Health Commercial |
$115.20
|
| Rate for Payer: Blue Shield of California Commercial |
$461.95
|
| Rate for Payer: Blue Shield of California EPN |
$290.30
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Central Health Plan Commercial |
$460.80
|
| Rate for Payer: Cigna of CA HMO |
$403.20
|
| Rate for Payer: Cigna of CA PPO |
$403.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$403.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$230.40
|
| Rate for Payer: EPIC Health Plan Senior |
$230.40
|
| Rate for Payer: Galaxy Health WC |
$489.60
|
| Rate for Payer: Global Benefits Group Commercial |
$345.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$518.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$365.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$339.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$115.20
|
| Rate for Payer: Multiplan Commercial |
$432.00
|
| Rate for Payer: Networks By Design Commercial |
$374.40
|
| Rate for Payer: Prime Health Services Commercial |
$489.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$216.17
|
| Rate for Payer: United Healthcare All Other HMO |
$210.41
|
| Rate for Payer: United Healthcare HMO Rider |
$205.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$188.64
|
|
|
HC REPLACE PROX/DIST UPRIGHT
|
Facility
|
IP
|
$576.00
|
|
|
Service Code
|
CPT L4070
|
| Hospital Charge Code |
915354070
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$115.20 |
| Max. Negotiated Rate |
$518.40 |
| Rate for Payer: Adventist Health Commercial |
$115.20
|
| Rate for Payer: Blue Shield of California Commercial |
$461.95
|
| Rate for Payer: Blue Shield of California EPN |
$290.30
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Central Health Plan Commercial |
$460.80
|
| Rate for Payer: Cigna of CA HMO |
$403.20
|
| Rate for Payer: Cigna of CA PPO |
$403.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$403.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$230.40
|
| Rate for Payer: EPIC Health Plan Senior |
$230.40
|
| Rate for Payer: Galaxy Health WC |
$489.60
|
| Rate for Payer: Global Benefits Group Commercial |
$345.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$518.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$365.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$339.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$115.20
|
| Rate for Payer: Multiplan Commercial |
$432.00
|
| Rate for Payer: Networks By Design Commercial |
$374.40
|
| Rate for Payer: Prime Health Services Commercial |
$489.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$216.17
|
| Rate for Payer: United Healthcare All Other HMO |
$210.41
|
| Rate for Payer: United Healthcare HMO Rider |
$205.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$188.64
|
|
|
HC REPLACE PROX/DIST UPRIGHT
|
Facility
|
OP
|
$576.00
|
|
|
Service Code
|
CPT L4070
|
| Hospital Charge Code |
915354070
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$188.64 |
| Max. Negotiated Rate |
$518.40 |
| Rate for Payer: Dignity Health Medi-Cal |
$489.60
|
| Rate for Payer: Adventist Health Commercial |
$236.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$489.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$316.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$432.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$335.06
|
| Rate for Payer: Blue Shield of California Commercial |
$461.95
|
| Rate for Payer: Blue Shield of California EPN |
$290.30
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Central Health Plan Commercial |
$460.80
|
| Rate for Payer: Cigna of CA HMO |
$403.20
|
| Rate for Payer: Cigna of CA PPO |
$403.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$489.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$489.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$403.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$230.40
|
| Rate for Payer: EPIC Health Plan Senior |
$230.40
|
| Rate for Payer: Galaxy Health WC |
$489.60
|
| Rate for Payer: Global Benefits Group Commercial |
$345.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$518.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$388.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$365.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$429.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$339.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$236.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$403.20
|
| Rate for Payer: Multiplan Commercial |
$432.00
|
| Rate for Payer: Networks By Design Commercial |
$288.00
|
| Rate for Payer: Prime Health Services Commercial |
$489.60
|
| Rate for Payer: Riverside University Health System MISP |
$230.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$345.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$345.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$216.17
|
| Rate for Payer: United Healthcare All Other HMO |
$210.41
|
| Rate for Payer: United Healthcare HMO Rider |
$205.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$188.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$489.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$489.60
|
| Rate for Payer: Vantage Medical Group Senior |
$489.60
|
|
|
HC REPLACE PROX THIGH BAND
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
CPT L4080
|
| Hospital Charge Code |
915354080
|
|
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 REPLACE PROX THIGH BAND
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
CPT L4080
|
| Hospital Charge Code |
905354080
|
|
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: 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: Inland Empire Health Plan (IEHP) medi-cal |
$80.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$101.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$89.15
|
| 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 REPLACE PROX THIGH BAND
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
CPT L4080
|
| Hospital Charge Code |
905354080
|
|
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 REPLACE PROX THIGH BAND
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
CPT L4080
|
| Hospital Charge Code |
915354080
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$52.40 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Networks By Design Commercial |
$80.00
|
| 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: 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: Inland Empire Health Plan (IEHP) medi-cal |
$80.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$101.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$89.15
|
| 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: 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 REPLACE QUAD SOCKET BRIM
|
Facility
|
IP
|
$1,412.00
|
|
|
Service Code
|
CPT L4030
|
| Hospital Charge Code |
915354030
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$282.40 |
| Max. Negotiated Rate |
$1,270.80 |
| Rate for Payer: United Healthcare HMO Rider |
$504.65
|
| Rate for Payer: Adventist Health Commercial |
$282.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1,132.42
|
| Rate for Payer: Blue Shield of California EPN |
$711.65
|
| Rate for Payer: Cash Price |
$635.40
|
| Rate for Payer: Central Health Plan Commercial |
$1,129.60
|
| Rate for Payer: Cigna of CA HMO |
$988.40
|
| Rate for Payer: Cigna of CA PPO |
$988.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$988.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$564.80
|
| Rate for Payer: EPIC Health Plan Senior |
$564.80
|
| Rate for Payer: Galaxy Health WC |
$1,200.20
|
| Rate for Payer: Global Benefits Group Commercial |
$847.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,270.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$896.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$833.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$282.40
|
| Rate for Payer: Multiplan Commercial |
$1,059.00
|
| Rate for Payer: Networks By Design Commercial |
$917.80
|
| Rate for Payer: Prime Health Services Commercial |
$1,200.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$529.92
|
| Rate for Payer: United Healthcare All Other HMO |
$515.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$462.43
|
|
|
HC REPLACE QUAD SOCKET BRIM
|
Facility
|
OP
|
$1,412.00
|
|
|
Service Code
|
CPT L4030
|
| Hospital Charge Code |
915354030
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$462.43 |
| Max. Negotiated Rate |
$1,270.80 |
| Rate for Payer: Adventist Health Commercial |
$578.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,200.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$776.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,059.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$821.36
|
| Rate for Payer: Blue Shield of California Commercial |
$1,132.42
|
| Rate for Payer: Blue Shield of California EPN |
$711.65
|
| Rate for Payer: Cash Price |
$635.40
|
| Rate for Payer: Cash Price |
$635.40
|
| Rate for Payer: Central Health Plan Commercial |
$1,129.60
|
| Rate for Payer: Cigna of CA HMO |
$988.40
|
| Rate for Payer: Cigna of CA PPO |
$988.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,200.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,200.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,200.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$988.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$564.80
|
| Rate for Payer: EPIC Health Plan Senior |
$564.80
|
| Rate for Payer: Galaxy Health WC |
$1,200.20
|
| Rate for Payer: Global Benefits Group Commercial |
$847.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,270.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$539.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$896.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$595.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$833.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$578.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$988.40
|
| Rate for Payer: Multiplan Commercial |
$1,059.00
|
| Rate for Payer: Networks By Design Commercial |
$706.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,200.20
|
| Rate for Payer: Riverside University Health System MISP |
$564.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$847.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$847.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$529.92
|
| Rate for Payer: United Healthcare All Other HMO |
$515.80
|
| Rate for Payer: United Healthcare HMO Rider |
$504.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$462.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,200.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,200.20
|
| Rate for Payer: Vantage Medical Group Senior |
$1,200.20
|
|
|
HC REPLACE QUAD SOCKET BRIM
|
Facility
|
OP
|
$1,412.00
|
|
|
Service Code
|
CPT L4030
|
| Hospital Charge Code |
905354030
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$462.43 |
| Max. Negotiated Rate |
$1,270.80 |
| Rate for Payer: Adventist Health Commercial |
$578.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,200.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$776.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,059.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$821.36
|
| Rate for Payer: Blue Shield of California Commercial |
$1,132.42
|
| Rate for Payer: Blue Shield of California EPN |
$711.65
|
| Rate for Payer: Cash Price |
$635.40
|
| Rate for Payer: Cash Price |
$635.40
|
| Rate for Payer: Central Health Plan Commercial |
$1,129.60
|
| Rate for Payer: Cigna of CA HMO |
$988.40
|
| Rate for Payer: Cigna of CA PPO |
$988.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,200.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,200.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,200.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$988.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$564.80
|
| Rate for Payer: EPIC Health Plan Senior |
$564.80
|
| Rate for Payer: Galaxy Health WC |
$1,200.20
|
| Rate for Payer: Global Benefits Group Commercial |
$847.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,270.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$539.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$896.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$595.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$833.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$578.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$988.40
|
| Rate for Payer: Multiplan Commercial |
$1,059.00
|
| Rate for Payer: Networks By Design Commercial |
$706.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,200.20
|
| Rate for Payer: Riverside University Health System MISP |
$564.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$847.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$847.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$529.92
|
| Rate for Payer: United Healthcare All Other HMO |
$515.80
|
| Rate for Payer: United Healthcare HMO Rider |
$504.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$462.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,200.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,200.20
|
| Rate for Payer: Vantage Medical Group Senior |
$1,200.20
|
|
|
HC REPLACE QUAD SOCKET BRIM
|
Facility
|
IP
|
$1,412.00
|
|
|
Service Code
|
CPT L4030
|
| Hospital Charge Code |
905354030
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$282.40 |
| Max. Negotiated Rate |
$1,270.80 |
| Rate for Payer: Adventist Health Commercial |
$282.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1,132.42
|
| Rate for Payer: Blue Shield of California EPN |
$711.65
|
| Rate for Payer: Cash Price |
$635.40
|
| Rate for Payer: Central Health Plan Commercial |
$1,129.60
|
| Rate for Payer: Cigna of CA HMO |
$988.40
|
| Rate for Payer: Cigna of CA PPO |
$988.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$988.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$564.80
|
| Rate for Payer: EPIC Health Plan Senior |
$564.80
|
| Rate for Payer: Galaxy Health WC |
$1,200.20
|
| Rate for Payer: Global Benefits Group Commercial |
$847.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,270.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$896.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$833.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$282.40
|
| Rate for Payer: Multiplan Commercial |
$1,059.00
|
| Rate for Payer: Networks By Design Commercial |
$917.80
|
| Rate for Payer: Prime Health Services Commercial |
$1,200.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$529.92
|
| Rate for Payer: United Healthcare All Other HMO |
$515.80
|
| Rate for Payer: United Healthcare HMO Rider |
$504.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$462.43
|
|
|
HC REPLACE QUAD SOCKET CUSTOM
|
Facility
|
IP
|
$1,958.00
|
|
|
Service Code
|
CPT L4020
|
| Hospital Charge Code |
915354020
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$391.60 |
| Max. Negotiated Rate |
$1,762.20 |
| Rate for Payer: Cash Price |
$881.10
|
| Rate for Payer: Central Health Plan Commercial |
$1,566.40
|
| Rate for Payer: Cigna of CA HMO |
$1,370.60
|
| Rate for Payer: Cigna of CA PPO |
$1,370.60
|
| Rate for Payer: Adventist Health Commercial |
$391.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1,570.32
|
| Rate for Payer: Blue Shield of California EPN |
$986.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,370.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$783.20
|
| Rate for Payer: EPIC Health Plan Senior |
$783.20
|
| Rate for Payer: Galaxy Health WC |
$1,664.30
|
| Rate for Payer: Global Benefits Group Commercial |
$1,174.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,762.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,243.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,155.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$391.60
|
| Rate for Payer: Multiplan Commercial |
$1,468.50
|
| Rate for Payer: Networks By Design Commercial |
$1,272.70
|
| Rate for Payer: Prime Health Services Commercial |
$1,664.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$734.84
|
| Rate for Payer: United Healthcare All Other HMO |
$715.26
|
| Rate for Payer: United Healthcare HMO Rider |
$699.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$641.25
|
|
|
HC REPLACE QUAD SOCKET CUSTOM
|
Facility
|
IP
|
$1,958.00
|
|
|
Service Code
|
CPT L4020
|
| Hospital Charge Code |
905354020
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$391.60 |
| Max. Negotiated Rate |
$1,762.20 |
| Rate for Payer: Adventist Health Commercial |
$391.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1,570.32
|
| Rate for Payer: Blue Shield of California EPN |
$986.83
|
| Rate for Payer: Cash Price |
$881.10
|
| Rate for Payer: Central Health Plan Commercial |
$1,566.40
|
| Rate for Payer: Cigna of CA HMO |
$1,370.60
|
| Rate for Payer: Cigna of CA PPO |
$1,370.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,370.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$783.20
|
| Rate for Payer: EPIC Health Plan Senior |
$783.20
|
| Rate for Payer: Galaxy Health WC |
$1,664.30
|
| Rate for Payer: Global Benefits Group Commercial |
$1,174.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,762.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,243.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,155.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$391.60
|
| Rate for Payer: Multiplan Commercial |
$1,468.50
|
| Rate for Payer: Networks By Design Commercial |
$1,272.70
|
| Rate for Payer: Prime Health Services Commercial |
$1,664.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$734.84
|
| Rate for Payer: United Healthcare All Other HMO |
$715.26
|
| Rate for Payer: United Healthcare HMO Rider |
$699.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$641.25
|
|
|
HC REPLACE QUAD SOCKET CUSTOM
|
Facility
|
OP
|
$1,958.00
|
|
|
Service Code
|
CPT L4020
|
| Hospital Charge Code |
905354020
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$641.25 |
| Max. Negotiated Rate |
$1,762.20 |
| Rate for Payer: Adventist Health Commercial |
$802.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,664.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,076.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,468.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,138.97
|
| Rate for Payer: Blue Shield of California Commercial |
$1,570.32
|
| Rate for Payer: Blue Shield of California EPN |
$986.83
|
| Rate for Payer: Cash Price |
$881.10
|
| Rate for Payer: Cash Price |
$881.10
|
| Rate for Payer: Central Health Plan Commercial |
$1,566.40
|
| Rate for Payer: Cigna of CA HMO |
$1,370.60
|
| Rate for Payer: Cigna of CA PPO |
$1,370.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,664.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,664.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,664.30
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,370.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$783.20
|
| Rate for Payer: EPIC Health Plan Senior |
$783.20
|
| Rate for Payer: Galaxy Health WC |
$1,664.30
|
| Rate for Payer: Global Benefits Group Commercial |
$1,174.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,762.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$839.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,243.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$927.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,155.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$802.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,370.60
|
| Rate for Payer: Multiplan Commercial |
$1,468.50
|
| Rate for Payer: Networks By Design Commercial |
$979.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,664.30
|
| Rate for Payer: Riverside University Health System MISP |
$783.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,174.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,174.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$734.84
|
| Rate for Payer: United Healthcare All Other HMO |
$715.26
|
| Rate for Payer: United Healthcare HMO Rider |
$699.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$641.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,664.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,664.30
|
| Rate for Payer: Vantage Medical Group Senior |
$1,664.30
|
|
|
HC REPLACE QUAD SOCKET CUSTOM
|
Facility
|
OP
|
$1,958.00
|
|
|
Service Code
|
CPT L4020
|
| Hospital Charge Code |
915354020
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$641.25 |
| Max. Negotiated Rate |
$1,762.20 |
| Rate for Payer: Adventist Health Commercial |
$802.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,664.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,076.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,468.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,138.97
|
| Rate for Payer: Blue Shield of California Commercial |
$1,570.32
|
| Rate for Payer: Blue Shield of California EPN |
$986.83
|
| Rate for Payer: Cash Price |
$881.10
|
| Rate for Payer: Cash Price |
$881.10
|
| Rate for Payer: Central Health Plan Commercial |
$1,566.40
|
| Rate for Payer: Cigna of CA HMO |
$1,370.60
|
| Rate for Payer: Cigna of CA PPO |
$1,370.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,664.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,664.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,664.30
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,370.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$783.20
|
| Rate for Payer: EPIC Health Plan Senior |
$783.20
|
| Rate for Payer: Galaxy Health WC |
$1,664.30
|
| Rate for Payer: Global Benefits Group Commercial |
$1,174.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,762.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$839.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,243.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$927.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,155.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$802.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,370.60
|
| Rate for Payer: Multiplan Commercial |
$1,468.50
|
| Rate for Payer: Networks By Design Commercial |
$979.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,664.30
|
| Rate for Payer: Riverside University Health System MISP |
$783.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,174.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,174.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$734.84
|
| Rate for Payer: United Healthcare All Other HMO |
$715.26
|
| Rate for Payer: United Healthcare HMO Rider |
$699.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$641.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,664.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,664.30
|
| Rate for Payer: Vantage Medical Group Senior |
$1,664.30
|
|
|
HC REPLACE/REVISION/SHUNT SYSTEM
|
Facility
|
OP
|
$21,128.00
|
|
|
Service Code
|
CPT 62230
|
| Hospital Charge Code |
900501521
|
|
Hospital Revenue Code
|
456
|
| Min. Negotiated Rate |
$400.00 |
| Max. Negotiated Rate |
$19,015.20 |
| Rate for Payer: Adventist Health Commercial |
$8,662.48
|
| Rate for Payer: Adventist Health Medi-Cal |
$400.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4,594.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16,930.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12,415.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11,287.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,587.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$12,964.88
|
| Rate for Payer: Cash Price |
$9,507.60
|
| Rate for Payer: Cash Price |
$9,507.60
|
| Rate for Payer: Cash Price |
$9,507.60
|
| Rate for Payer: Cash Price |
$9,507.60
|
| Rate for Payer: Central Health Plan Commercial |
$16,902.40
|
| Rate for Payer: Cigna of CA HMO |
$13,521.92
|
| Rate for Payer: Cigna of CA PPO |
$15,634.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16,930.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$12,415.93
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11,287.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$14,789.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$18,623.90
|
| Rate for Payer: EPIC Health Plan Senior |
$12,415.93
|
| Rate for Payer: Galaxy Health WC |
$17,958.80
|
| Rate for Payer: Global Benefits Group Commercial |
$12,676.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$19,015.20
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$18,511.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$973.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11,287.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$13,416.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,414.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$12,133.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4,225.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$15,124.86
|
| Rate for Payer: Multiplan Commercial |
$15,846.00
|
| Rate for Payer: Multiplan WC |
$12,964.88
|
| Rate for Payer: Networks By Design Commercial |
$13,733.20
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$11,287.21
|
| Rate for Payer: Preferred Health Network WC |
$13,229.47
|
| Rate for Payer: Prime Health Services Commercial |
$17,958.80
|
| Rate for Payer: Prime Health Services Medicare |
$11,964.44
|
| Rate for Payer: Prime Health Services WC |
$12,832.59
|
| Rate for Payer: Riverside University Health System MISP |
$12,415.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12,676.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12,676.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$796.00
|
| Rate for Payer: United Healthcare All Other HMO |
$608.00
|
| Rate for Payer: United Healthcare HMO Rider |
$480.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$440.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$11,287.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16,930.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12,415.93
|
| Rate for Payer: Vantage Medical Group Senior |
$11,287.21
|
|
|
HC REPLACE/REVISION/SHUNT SYSTEM
|
Facility
|
IP
|
$21,128.00
|
|
|
Service Code
|
CPT 62230
|
| Hospital Charge Code |
900501521
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$4,225.60 |
| Max. Negotiated Rate |
$19,015.20 |
| Rate for Payer: Adventist Health Commercial |
$4,225.60
|
| Rate for Payer: Cash Price |
$9,507.60
|
| Rate for Payer: Central Health Plan Commercial |
$16,902.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$14,789.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,451.20
|
| Rate for Payer: EPIC Health Plan Senior |
$8,451.20
|
| Rate for Payer: Galaxy Health WC |
$17,958.80
|
| Rate for Payer: Global Benefits Group Commercial |
$12,676.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$19,015.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$13,416.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$12,465.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4,225.60
|
| Rate for Payer: Multiplan Commercial |
$15,846.00
|
| Rate for Payer: Networks By Design Commercial |
$13,733.20
|
| Rate for Payer: Prime Health Services Commercial |
$17,958.80
|
|
