|
HC REPLACE G-J TUBE PERC
|
Facility
|
OP
|
$2,585.00
|
|
|
Service Code
|
CPT 49452
|
| Hospital Charge Code |
906749452
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$517.00 |
| Max. Negotiated Rate |
$7,027.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$1,132.59
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,132.59
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Distinction Transplant |
$1,551.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$1,132.59
|
| Rate for Payer: Cash Price |
$1,163.25
|
| Rate for Payer: Cash Price |
$1,163.25
|
| Rate for Payer: Central Health Plan Commercial |
$2,068.00
|
| Rate for Payer: Cigna of CA PPO |
$1,912.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Dignity Health Media |
$1,132.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,245.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,529.00
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$1,132.59
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,132.59
|
| Rate for Payer: Galaxy Health WC |
$2,197.25
|
| Rate for Payer: Global Benefits Group Commercial |
$1,551.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,326.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,938.75
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$1,857.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1,868.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,132.59
|
| Rate for Payer: InnovAge PACE Commercial |
$1,698.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,724.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,573.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,132.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$517.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,517.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,517.67
|
| Rate for Payer: Multiplan Commercial |
$1,938.75
|
| Rate for Payer: Networks By Design Commercial |
$1,680.25
|
| Rate for Payer: Prime Health Services Commercial |
$2,197.25
|
| Rate for Payer: Prime Health Services Medicare |
$1,200.55
|
| Rate for Payer: Riverside University Health System MISP |
$1,245.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,551.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,359.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,893.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7,027.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,217.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1,132.59
|
|
|
HC REPLACE HIGH ROLL CUFF
|
Facility
|
IP
|
$503.00
|
|
|
Service Code
|
CPT L4060
|
| Hospital Charge Code |
905354060
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$100.60 |
| Max. Negotiated Rate |
$452.70 |
| Rate for Payer: Blue Shield of California EPN |
$268.60
|
| Rate for Payer: Cash Price |
$226.35
|
| Rate for Payer: Central Health Plan Commercial |
$402.40
|
| Rate for Payer: Cigna of CA HMO |
$352.10
|
| Rate for Payer: Cigna of CA PPO |
$352.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$201.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$201.20
|
| Rate for Payer: Galaxy Health WC |
$427.55
|
| Rate for Payer: Global Benefits Group Commercial |
$301.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$452.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$335.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$191.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$100.60
|
| Rate for Payer: Multiplan Commercial |
$377.25
|
| Rate for Payer: Networks By Design Commercial |
$251.50
|
| Rate for Payer: Prime Health Services Commercial |
$427.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$189.93
|
| Rate for Payer: United Healthcare All Other HMO |
$185.51
|
| Rate for Payer: United Healthcare HMO Rider |
$181.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$165.99
|
|
|
HC REPLACE HIGH ROLL CUFF
|
Facility
|
OP
|
$503.00
|
|
|
Service Code
|
CPT L4060
|
| Hospital Charge Code |
905354060
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$176.05 |
| Max. Negotiated Rate |
$452.70 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$427.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$276.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$276.65
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$243.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$297.17
|
| Rate for Payer: Blue Distinction Transplant |
$301.80
|
| Rate for Payer: Blue Shield of California Commercial |
$377.25
|
| Rate for Payer: Blue Shield of California EPN |
$273.63
|
| Rate for Payer: Cash Price |
$226.35
|
| Rate for Payer: Cash Price |
$226.35
|
| Rate for Payer: Central Health Plan Commercial |
$402.40
|
| Rate for Payer: Cigna of CA HMO |
$352.10
|
| Rate for Payer: Cigna of CA PPO |
$352.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$427.55
|
| Rate for Payer: Dignity Health Media |
$427.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$427.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$201.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$201.20
|
| Rate for Payer: Galaxy Health WC |
$427.55
|
| Rate for Payer: Global Benefits Group Commercial |
$301.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$452.70
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$377.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$176.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$335.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$446.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.23
|
| Rate for Payer: Multiplan Commercial |
$377.25
|
| Rate for Payer: Networks By Design Commercial |
$251.50
|
| Rate for Payer: Prime Health Services Commercial |
$427.55
|
| Rate for Payer: Riverside University Health System MISP |
$201.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$301.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$301.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$251.50
|
| Rate for Payer: United Healthcare All Other HMO |
$251.50
|
| Rate for Payer: United Healthcare HMO Rider |
$251.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$251.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$427.55
|
| Rate for Payer: Vantage Medical Group Senior |
$427.55
|
|
|
HC REPLACE KAFO BAND
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
CPT L4090
|
| Hospital Charge Code |
905354090
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$170.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$110.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$110.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$96.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$118.16
|
| Rate for Payer: Blue Distinction Transplant |
$120.00
|
| Rate for Payer: Blue Shield of California Commercial |
$150.00
|
| Rate for Payer: Blue Shield of California EPN |
$108.80
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Central Health Plan Commercial |
$160.00
|
| Rate for Payer: Cigna of CA HMO |
$140.00
|
| Rate for Payer: Cigna of CA PPO |
$140.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.00
|
| Rate for Payer: Dignity Health Media |
$170.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$170.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$80.00
|
| Rate for Payer: Galaxy Health WC |
$170.00
|
| Rate for Payer: Global Benefits Group Commercial |
$120.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$180.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$150.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$70.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$133.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.00
|
| Rate for Payer: Multiplan Commercial |
$150.00
|
| Rate for Payer: Networks By Design Commercial |
$100.00
|
| Rate for Payer: Prime Health Services Commercial |
$170.00
|
| Rate for Payer: Riverside University Health System MISP |
$80.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$120.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$120.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO |
$100.00
|
| Rate for Payer: United Healthcare HMO Rider |
$100.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$100.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$170.00
|
| Rate for Payer: Vantage Medical Group Senior |
$170.00
|
|
|
HC REPLACE KAFO BAND
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
CPT L4090
|
| Hospital Charge Code |
905354090
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$40.00 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Blue Shield of California EPN |
$106.80
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Central Health Plan Commercial |
$160.00
|
| Rate for Payer: Cigna of CA HMO |
$140.00
|
| Rate for Payer: Cigna of CA PPO |
$140.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$80.00
|
| Rate for Payer: Galaxy Health WC |
$170.00
|
| Rate for Payer: Global Benefits Group Commercial |
$120.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$180.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$133.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$76.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.00
|
| Rate for Payer: Multiplan Commercial |
$150.00
|
| Rate for Payer: Networks By Design Commercial |
$100.00
|
| Rate for Payer: Prime Health Services Commercial |
$170.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$75.52
|
| Rate for Payer: United Healthcare All Other HMO |
$73.76
|
| Rate for Payer: United Healthcare HMO Rider |
$72.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$66.00
|
|
|
HC REPLACE LEATHER CUFF
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
CPT L4110
|
| Hospital Charge Code |
905354110
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$40.00 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Blue Shield of California EPN |
$106.80
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Central Health Plan Commercial |
$160.00
|
| Rate for Payer: Cigna of CA HMO |
$140.00
|
| Rate for Payer: Cigna of CA PPO |
$140.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$80.00
|
| Rate for Payer: Galaxy Health WC |
$170.00
|
| Rate for Payer: Global Benefits Group Commercial |
$120.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$180.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$133.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$76.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.00
|
| Rate for Payer: Multiplan Commercial |
$150.00
|
| Rate for Payer: Networks By Design Commercial |
$100.00
|
| Rate for Payer: Prime Health Services Commercial |
$170.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$75.52
|
| Rate for Payer: United Healthcare All Other HMO |
$73.76
|
| Rate for Payer: United Healthcare HMO Rider |
$72.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$66.00
|
|
|
HC REPLACE LEATHER CUFF
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
CPT L4110
|
| Hospital Charge Code |
905354110
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$170.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$110.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$110.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$96.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$118.16
|
| Rate for Payer: Blue Distinction Transplant |
$120.00
|
| Rate for Payer: Blue Shield of California Commercial |
$150.00
|
| Rate for Payer: Blue Shield of California EPN |
$108.80
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Central Health Plan Commercial |
$160.00
|
| Rate for Payer: Cigna of CA HMO |
$140.00
|
| Rate for Payer: Cigna of CA PPO |
$140.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.00
|
| Rate for Payer: Dignity Health Media |
$170.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$170.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$80.00
|
| Rate for Payer: Galaxy Health WC |
$170.00
|
| Rate for Payer: Global Benefits Group Commercial |
$120.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$180.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$150.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$70.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$133.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.00
|
| Rate for Payer: Multiplan Commercial |
$150.00
|
| Rate for Payer: Networks By Design Commercial |
$100.00
|
| Rate for Payer: Prime Health Services Commercial |
$170.00
|
| Rate for Payer: Riverside University Health System MISP |
$80.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$120.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$120.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO |
$100.00
|
| Rate for Payer: United Healthcare HMO Rider |
$100.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$100.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$170.00
|
| Rate for Payer: Vantage Medical Group Senior |
$170.00
|
|
|
HC REPLACE MOLDED CALF LACER
|
Facility
|
IP
|
$1,068.00
|
|
|
Service Code
|
CPT L4050
|
| Hospital Charge Code |
905354050
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$213.60 |
| Max. Negotiated Rate |
$961.20 |
| Rate for Payer: Blue Shield of California EPN |
$570.31
|
| Rate for Payer: Cash Price |
$480.60
|
| Rate for Payer: Central Health Plan Commercial |
$854.40
|
| Rate for Payer: Cigna of CA HMO |
$747.60
|
| Rate for Payer: Cigna of CA PPO |
$747.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$427.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$427.20
|
| Rate for Payer: Galaxy Health WC |
$907.80
|
| Rate for Payer: Global Benefits Group Commercial |
$640.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$961.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$712.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$406.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.60
|
| Rate for Payer: Multiplan Commercial |
$801.00
|
| Rate for Payer: Networks By Design Commercial |
$534.00
|
| Rate for Payer: Prime Health Services Commercial |
$907.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$403.28
|
| Rate for Payer: United Healthcare All Other HMO |
$393.88
|
| Rate for Payer: United Healthcare HMO Rider |
$385.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$352.44
|
|
|
HC REPLACE MOLDED CALF LACER
|
Facility
|
OP
|
$1,068.00
|
|
|
Service Code
|
CPT L4050
|
| Hospital Charge Code |
905354050
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$373.80 |
| Max. Negotiated Rate |
$961.20 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$907.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$587.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$587.40
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$517.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$630.97
|
| Rate for Payer: Blue Distinction Transplant |
$640.80
|
| Rate for Payer: Blue Shield of California Commercial |
$801.00
|
| Rate for Payer: Blue Shield of California EPN |
$580.99
|
| Rate for Payer: Cash Price |
$480.60
|
| Rate for Payer: Cash Price |
$480.60
|
| Rate for Payer: Central Health Plan Commercial |
$854.40
|
| Rate for Payer: Cigna of CA HMO |
$747.60
|
| Rate for Payer: Cigna of CA PPO |
$747.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$907.80
|
| Rate for Payer: Dignity Health Media |
$907.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$907.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$427.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$427.20
|
| Rate for Payer: Galaxy Health WC |
$907.80
|
| Rate for Payer: Global Benefits Group Commercial |
$640.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$961.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$801.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$373.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$712.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$629.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$437.88
|
| Rate for Payer: Multiplan Commercial |
$801.00
|
| Rate for Payer: Networks By Design Commercial |
$534.00
|
| Rate for Payer: Prime Health Services Commercial |
$907.80
|
| Rate for Payer: Riverside University Health System MISP |
$427.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$640.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$640.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$534.00
|
| Rate for Payer: United Healthcare All Other HMO |
$534.00
|
| Rate for Payer: United Healthcare HMO Rider |
$534.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$534.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$907.80
|
| Rate for Payer: Vantage Medical Group Senior |
$907.80
|
|
|
HC REPLACE MOLDED THIGH LACER
|
Facility
|
IP
|
$1,068.00
|
|
|
Service Code
|
CPT L4040
|
| Hospital Charge Code |
905354040
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$213.60 |
| Max. Negotiated Rate |
$961.20 |
| Rate for Payer: Blue Shield of California EPN |
$570.31
|
| Rate for Payer: Cash Price |
$480.60
|
| Rate for Payer: Central Health Plan Commercial |
$854.40
|
| Rate for Payer: Cigna of CA HMO |
$747.60
|
| Rate for Payer: Cigna of CA PPO |
$747.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$427.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$427.20
|
| Rate for Payer: Galaxy Health WC |
$907.80
|
| Rate for Payer: Global Benefits Group Commercial |
$640.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$961.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$712.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$406.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.60
|
| Rate for Payer: Multiplan Commercial |
$801.00
|
| Rate for Payer: Networks By Design Commercial |
$534.00
|
| Rate for Payer: Prime Health Services Commercial |
$907.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$403.28
|
| Rate for Payer: United Healthcare All Other HMO |
$393.88
|
| Rate for Payer: United Healthcare HMO Rider |
$385.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$352.44
|
|
|
HC REPLACE MOLDED THIGH LACER
|
Facility
|
OP
|
$1,068.00
|
|
|
Service Code
|
CPT L4040
|
| Hospital Charge Code |
905354040
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$373.80 |
| Max. Negotiated Rate |
$961.20 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$907.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$587.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$587.40
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$517.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$630.97
|
| Rate for Payer: Blue Distinction Transplant |
$640.80
|
| Rate for Payer: Blue Shield of California Commercial |
$801.00
|
| Rate for Payer: Blue Shield of California EPN |
$580.99
|
| Rate for Payer: Cash Price |
$480.60
|
| Rate for Payer: Cash Price |
$480.60
|
| Rate for Payer: Central Health Plan Commercial |
$854.40
|
| Rate for Payer: Cigna of CA HMO |
$747.60
|
| Rate for Payer: Cigna of CA PPO |
$747.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$907.80
|
| Rate for Payer: Dignity Health Media |
$907.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$907.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$427.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$427.20
|
| Rate for Payer: Galaxy Health WC |
$907.80
|
| Rate for Payer: Global Benefits Group Commercial |
$640.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$961.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$801.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$373.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$712.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$622.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$437.88
|
| Rate for Payer: Multiplan Commercial |
$801.00
|
| Rate for Payer: Networks By Design Commercial |
$534.00
|
| Rate for Payer: Prime Health Services Commercial |
$907.80
|
| Rate for Payer: Riverside University Health System MISP |
$427.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$640.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$640.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$534.00
|
| Rate for Payer: United Healthcare All Other HMO |
$534.00
|
| Rate for Payer: United Healthcare HMO Rider |
$534.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$534.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$907.80
|
| Rate for Payer: Vantage Medical Group Senior |
$907.80
|
|
|
HC REPLACE NON-MOLDED LACER
|
Facility
|
OP
|
$526.00
|
|
|
Service Code
|
CPT L4055
|
| Hospital Charge Code |
905354055
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$184.10 |
| Max. Negotiated Rate |
$473.40 |
| 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 |
$289.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$254.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$310.76
|
| Rate for Payer: Blue Distinction Transplant |
$315.60
|
| Rate for Payer: Blue Shield of California Commercial |
$394.50
|
| Rate for Payer: Blue Shield of California EPN |
$286.14
|
| 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 Media |
$447.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$447.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$210.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$394.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$184.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$350.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$407.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$215.66
|
| 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 |
$263.00
|
| Rate for Payer: United Healthcare All Other HMO |
$263.00
|
| Rate for Payer: United Healthcare HMO Rider |
$263.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$263.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$447.10
|
| Rate for Payer: Vantage Medical Group Senior |
$447.10
|
|
|
HC REPLACE NON-MOLDED LACER
|
Facility
|
OP
|
$616.00
|
|
|
Service Code
|
CPT L4045
|
| Hospital Charge Code |
905354045
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$215.60 |
| Max. Negotiated Rate |
$554.40 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$523.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$338.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$338.80
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$298.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$363.93
|
| Rate for Payer: Blue Distinction Transplant |
$369.60
|
| Rate for Payer: Blue Shield of California Commercial |
$462.00
|
| Rate for Payer: Blue Shield of California EPN |
$335.10
|
| Rate for Payer: Cash Price |
$277.20
|
| Rate for Payer: Cash Price |
$277.20
|
| Rate for Payer: Central Health Plan Commercial |
$492.80
|
| Rate for Payer: Cigna of CA HMO |
$431.20
|
| Rate for Payer: Cigna of CA PPO |
$431.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$523.60
|
| Rate for Payer: Dignity Health Media |
$523.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$523.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$246.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$246.40
|
| Rate for Payer: Galaxy Health WC |
$523.60
|
| Rate for Payer: Global Benefits Group Commercial |
$369.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$554.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$462.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$215.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$410.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$477.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$252.56
|
| Rate for Payer: Multiplan Commercial |
$462.00
|
| Rate for Payer: Networks By Design Commercial |
$308.00
|
| Rate for Payer: Prime Health Services Commercial |
$523.60
|
| Rate for Payer: Riverside University Health System MISP |
$246.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$369.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$369.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$308.00
|
| Rate for Payer: United Healthcare All Other HMO |
$308.00
|
| Rate for Payer: United Healthcare HMO Rider |
$308.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$308.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$523.60
|
| Rate for Payer: Vantage Medical Group Senior |
$523.60
|
|
|
HC REPLACE NON-MOLDED LACER
|
Facility
|
IP
|
$616.00
|
|
|
Service Code
|
CPT L4045
|
| Hospital Charge Code |
905354045
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$123.20 |
| Max. Negotiated Rate |
$554.40 |
| Rate for Payer: Blue Shield of California EPN |
$328.94
|
| Rate for Payer: Cash Price |
$277.20
|
| Rate for Payer: Central Health Plan Commercial |
$492.80
|
| Rate for Payer: Cigna of CA HMO |
$431.20
|
| Rate for Payer: Cigna of CA PPO |
$431.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$246.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$246.40
|
| Rate for Payer: Galaxy Health WC |
$523.60
|
| Rate for Payer: Global Benefits Group Commercial |
$369.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$554.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$410.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$234.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$123.20
|
| Rate for Payer: Multiplan Commercial |
$462.00
|
| Rate for Payer: Networks By Design Commercial |
$308.00
|
| Rate for Payer: Prime Health Services Commercial |
$523.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$232.60
|
| Rate for Payer: United Healthcare All Other HMO |
$227.18
|
| Rate for Payer: United Healthcare HMO Rider |
$222.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$203.28
|
|
|
HC REPLACE NON-MOLDED LACER
|
Facility
|
IP
|
$526.00
|
|
|
Service Code
|
CPT L4055
|
| Hospital Charge Code |
905354055
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$105.20 |
| Max. Negotiated Rate |
$473.40 |
| Rate for Payer: Blue Shield of California EPN |
$280.88
|
| 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: EPIC Health Plan Commercial |
$210.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Kaiser Permanente of CA Commercial/Self Funded |
$350.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$200.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$105.20
|
| 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: United Healthcare All Other Commercial |
$198.62
|
| Rate for Payer: United Healthcare All Other HMO |
$193.99
|
| Rate for Payer: United Healthcare HMO Rider |
$189.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$173.58
|
|
|
HC REPLACE PORT THRU SAME ACCESS
|
Facility
|
IP
|
$10,759.00
|
|
|
Service Code
|
CPT 36585
|
| Hospital Charge Code |
909020012
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,151.80 |
| Max. Negotiated Rate |
$9,683.10 |
| Rate for Payer: Cash Price |
$4,841.55
|
| Rate for Payer: Central Health Plan Commercial |
$8,607.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,303.60
|
| Rate for Payer: Galaxy Health WC |
$9,145.15
|
| Rate for Payer: Global Benefits Group Commercial |
$6,455.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$9,683.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7,176.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,099.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,151.80
|
| Rate for Payer: Multiplan Commercial |
$8,069.25
|
| Rate for Payer: Networks By Design Commercial |
$6,993.35
|
| Rate for Payer: Prime Health Services Commercial |
$9,145.15
|
|
|
HC REPLACE PORT THRU SAME ACCESS
|
Facility
|
OP
|
$10,759.00
|
|
|
Service Code
|
CPT 36585
|
| Hospital Charge Code |
909020012
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$793.95 |
| Max. Negotiated Rate |
$19,907.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$3,982.55
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,973.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,380.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,982.55
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Distinction Transplant |
$6,455.40
|
| Rate for Payer: Blue Shield of California Commercial |
$3,079.84
|
| Rate for Payer: Blue Shield of California EPN |
$2,212.08
|
| Rate for Payer: Caremore Medicare Advantage |
$3,982.55
|
| Rate for Payer: Cash Price |
$4,841.55
|
| Rate for Payer: Cash Price |
$4,841.55
|
| Rate for Payer: Central Health Plan Commercial |
$8,607.20
|
| Rate for Payer: Cigna of CA PPO |
$7,961.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,973.82
|
| Rate for Payer: Dignity Health Media |
$3,982.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,380.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,376.44
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$3,982.55
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,982.55
|
| Rate for Payer: Galaxy Health WC |
$9,145.15
|
| Rate for Payer: Global Benefits Group Commercial |
$6,455.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$9,683.10
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$8,069.25
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,531.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$6,571.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,982.55
|
| Rate for Payer: InnovAge PACE Commercial |
$5,973.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7,176.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$793.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,982.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,151.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,336.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,336.62
|
| Rate for Payer: Multiplan Commercial |
$8,069.25
|
| Rate for Payer: Networks By Design Commercial |
$6,993.35
|
| Rate for Payer: Prime Health Services Commercial |
$9,145.15
|
| Rate for Payer: Prime Health Services Medicare |
$4,221.50
|
| Rate for Payer: Riverside University Health System MISP |
$4,380.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6,455.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,537.00
|
| Rate for Payer: United Healthcare All Other HMO |
$19,907.00
|
| Rate for Payer: United Healthcare HMO Rider |
$12,444.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,379.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,973.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,380.80
|
| Rate for Payer: Vantage Medical Group Senior |
$3,982.55
|
|
|
HC REPLACE PRETIBIAL SHELL
|
Facility
|
OP
|
$996.00
|
|
|
Service Code
|
CPT L4130
|
| Hospital Charge Code |
905354130
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$348.60 |
| Max. Negotiated Rate |
$896.40 |
| 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 |
$547.80
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$482.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$588.44
|
| Rate for Payer: Blue Distinction Transplant |
$597.60
|
| Rate for Payer: Blue Shield of California Commercial |
$747.00
|
| Rate for Payer: Blue Shield of California EPN |
$541.82
|
| 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 Media |
$846.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$846.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$398.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$747.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$348.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$664.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$618.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$408.36
|
| 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 |
$498.00
|
| Rate for Payer: United Healthcare All Other HMO |
$498.00
|
| Rate for Payer: United Healthcare HMO Rider |
$498.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$498.00
|
| 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: Blue Shield of California EPN |
$531.86
|
| 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: EPIC Health Plan Commercial |
$398.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$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 Permanente of CA Commercial/Self Funded |
$664.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$379.48
|
| 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 |
$498.00
|
| Rate for Payer: Prime Health Services Commercial |
$846.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$376.09
|
| Rate for Payer: United Healthcare All Other HMO |
$367.32
|
| Rate for Payer: United Healthcare HMO Rider |
$359.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$328.68
|
|
|
HC REPLACE PROX/DIST UPRIGHT
|
Facility
|
OP
|
$576.00
|
|
|
Service Code
|
CPT L4070
|
| Hospital Charge Code |
905354070
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$201.60 |
| Max. Negotiated Rate |
$518.40 |
| 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 |
$316.80
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$278.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$340.30
|
| Rate for Payer: Blue Distinction Transplant |
$345.60
|
| Rate for Payer: Blue Shield of California Commercial |
$432.00
|
| Rate for Payer: Blue Shield of California EPN |
$313.34
|
| 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 Media |
$489.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$489.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$230.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$432.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$201.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$384.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$429.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$236.16
|
| 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 |
$288.00
|
| Rate for Payer: United Healthcare All Other HMO |
$288.00
|
| Rate for Payer: United Healthcare HMO Rider |
$288.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$288.00
|
| 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: Blue Shield of California EPN |
$307.58
|
| 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: EPIC Health Plan Commercial |
$230.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$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 Permanente of CA Commercial/Self Funded |
$384.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$219.46
|
| 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 |
$288.00
|
| Rate for Payer: Prime Health Services Commercial |
$489.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$217.50
|
| Rate for Payer: United Healthcare All Other HMO |
$212.43
|
| Rate for Payer: United Healthcare HMO Rider |
$207.82
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$190.08
|
|
|
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: Blue Shield of California EPN |
$85.44
|
| 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: EPIC Health Plan Commercial |
$64.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$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 Permanente of CA Commercial/Self Funded |
$106.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.96
|
| 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 |
$80.00
|
| Rate for Payer: Prime Health Services Commercial |
$136.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.42
|
| Rate for Payer: United Healthcare All Other HMO |
$59.01
|
| Rate for Payer: United Healthcare HMO Rider |
$57.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.80
|
|
|
HC REPLACE PROX THIGH BAND
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
CPT L4080
|
| Hospital Charge Code |
905354080
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$144.00 |
| 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 |
$88.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$77.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$94.53
|
| Rate for Payer: Blue Distinction Transplant |
$96.00
|
| Rate for Payer: Blue Shield of California Commercial |
$120.00
|
| Rate for Payer: Blue Shield of California EPN |
$87.04
|
| 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 Media |
$136.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$136.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$120.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$56.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$106.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$89.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.60
|
| 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 |
$80.00
|
| Rate for Payer: United Healthcare All Other HMO |
$80.00
|
| Rate for Payer: United Healthcare HMO Rider |
$80.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$80.00
|
| 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
|
OP
|
$1,412.00
|
|
|
Service Code
|
CPT L4030
|
| Hospital Charge Code |
905354030
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$494.20 |
| Max. Negotiated Rate |
$1,270.80 |
| 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 |
$776.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$683.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$834.21
|
| Rate for Payer: Blue Distinction Transplant |
$847.20
|
| Rate for Payer: Blue Shield of California Commercial |
$1,059.00
|
| Rate for Payer: Blue Shield of California EPN |
$768.13
|
| 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 Media |
$1,200.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,200.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$564.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$1,059.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$494.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$941.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$595.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$578.92
|
| 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 |
$706.00
|
| Rate for Payer: United Healthcare All Other HMO |
$706.00
|
| Rate for Payer: United Healthcare HMO Rider |
$706.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$706.00
|
| 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: Blue Shield of California EPN |
$754.01
|
| 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: EPIC Health Plan Commercial |
$564.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$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 Permanente of CA Commercial/Self Funded |
$941.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$537.97
|
| 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 |
$706.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,200.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$533.17
|
| Rate for Payer: United Healthcare All Other HMO |
$520.75
|
| Rate for Payer: United Healthcare HMO Rider |
$509.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$465.96
|
|
