|
HC SHOE HIGHTOP CHILD
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
CPT L3206
|
| Hospital Charge Code |
905353206
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$25.68 |
| Max. Negotiated Rate |
$90.95 |
| Rate for Payer: Adventist Health Commercial |
$43.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$58.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$80.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.97
|
| Rate for Payer: Blue Shield of California Commercial |
$78.97
|
| Rate for Payer: Blue Shield of California EPN |
$52.00
|
| Rate for Payer: Cash Price |
$58.85
|
| Rate for Payer: Cash Price |
$58.85
|
| Rate for Payer: Cigna of CA HMO |
$74.90
|
| Rate for Payer: Cigna of CA PPO |
$74.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$90.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$90.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$90.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.80
|
| Rate for Payer: EPIC Health Plan Senior |
$42.80
|
| Rate for Payer: Galaxy Health WC |
$90.95
|
| Rate for Payer: Global Benefits Group Commercial |
$64.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$71.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$71.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.09
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$66.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$74.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$74.90
|
| Rate for Payer: Multiplan Commercial |
$85.60
|
| Rate for Payer: Networks By Design Commercial |
$53.50
|
| Rate for Payer: Prime Health Services Commercial |
$90.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$64.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$64.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$40.16
|
| Rate for Payer: United Healthcare All Other HMO |
$39.09
|
| Rate for Payer: United Healthcare HMO Rider |
$38.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$35.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$90.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$90.95
|
| Rate for Payer: Vantage Medical Group Senior |
$90.95
|
|
|
HC SHOE HIGHTOP INFANT
|
Facility
|
OP
|
$97.00
|
|
|
Service Code
|
CPT L3204
|
| Hospital Charge Code |
905353204
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$23.28 |
| Max. Negotiated Rate |
$82.45 |
| Rate for Payer: Adventist Health Commercial |
$39.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$82.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$72.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$56.18
|
| Rate for Payer: Blue Shield of California Commercial |
$71.59
|
| Rate for Payer: Blue Shield of California EPN |
$47.14
|
| Rate for Payer: Cash Price |
$53.35
|
| Rate for Payer: Cash Price |
$53.35
|
| Rate for Payer: Cigna of CA HMO |
$67.90
|
| Rate for Payer: Cigna of CA PPO |
$67.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$82.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$82.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$82.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.80
|
| Rate for Payer: EPIC Health Plan Senior |
$38.80
|
| Rate for Payer: Galaxy Health WC |
$82.45
|
| Rate for Payer: Global Benefits Group Commercial |
$58.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$67.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$76.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$60.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$67.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$67.90
|
| Rate for Payer: Multiplan Commercial |
$77.60
|
| Rate for Payer: Networks By Design Commercial |
$48.50
|
| Rate for Payer: Prime Health Services Commercial |
$82.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$58.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$58.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.40
|
| Rate for Payer: United Healthcare All Other HMO |
$35.43
|
| Rate for Payer: United Healthcare HMO Rider |
$34.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$82.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$82.45
|
| Rate for Payer: Vantage Medical Group Senior |
$82.45
|
|
|
HC SHOE HIGHTOP INFANT
|
Facility
|
IP
|
$97.00
|
|
|
Service Code
|
CPT L3204
|
| Hospital Charge Code |
905353204
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$19.40 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$19.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$53.35
|
| Rate for Payer: Cash Price |
$53.35
|
| Rate for Payer: Cigna of CA HMO |
$67.90
|
| Rate for Payer: Cigna of CA PPO |
$67.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.80
|
| Rate for Payer: EPIC Health Plan Senior |
$38.80
|
| Rate for Payer: Galaxy Health WC |
$82.45
|
| Rate for Payer: Global Benefits Group Commercial |
$58.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$60.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.28
|
| Rate for Payer: Multiplan Commercial |
$77.60
|
| Rate for Payer: Networks By Design Commercial |
$48.50
|
| Rate for Payer: Prime Health Services Commercial |
$82.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.40
|
| Rate for Payer: United Healthcare All Other HMO |
$35.43
|
| Rate for Payer: United Healthcare HMO Rider |
$34.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.77
|
|
|
HC SHOE HIGHTOP JUNIOR
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
CPT L3207
|
| Hospital Charge Code |
905353207
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$21.40 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$21.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$58.85
|
| Rate for Payer: Cash Price |
$58.85
|
| Rate for Payer: Cigna of CA HMO |
$74.90
|
| Rate for Payer: Cigna of CA PPO |
$74.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.80
|
| Rate for Payer: EPIC Health Plan Senior |
$42.80
|
| Rate for Payer: Galaxy Health WC |
$90.95
|
| Rate for Payer: Global Benefits Group Commercial |
$64.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$71.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$66.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.68
|
| Rate for Payer: Multiplan Commercial |
$85.60
|
| Rate for Payer: Networks By Design Commercial |
$53.50
|
| Rate for Payer: Prime Health Services Commercial |
$90.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$40.16
|
| Rate for Payer: United Healthcare All Other HMO |
$39.09
|
| Rate for Payer: United Healthcare HMO Rider |
$38.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$35.04
|
|
|
HC SHOE HIGHTOP JUNIOR
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
CPT L3207
|
| Hospital Charge Code |
905353207
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$25.68 |
| Max. Negotiated Rate |
$90.95 |
| Rate for Payer: Adventist Health Commercial |
$43.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$58.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$80.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.97
|
| Rate for Payer: Blue Shield of California Commercial |
$78.97
|
| Rate for Payer: Blue Shield of California EPN |
$52.00
|
| Rate for Payer: Cash Price |
$58.85
|
| Rate for Payer: Cash Price |
$58.85
|
| Rate for Payer: Cigna of CA HMO |
$74.90
|
| Rate for Payer: Cigna of CA PPO |
$74.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$90.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$90.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$90.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.80
|
| Rate for Payer: EPIC Health Plan Senior |
$42.80
|
| Rate for Payer: Galaxy Health WC |
$90.95
|
| Rate for Payer: Global Benefits Group Commercial |
$64.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$71.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$71.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.09
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$66.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$74.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$74.90
|
| Rate for Payer: Multiplan Commercial |
$85.60
|
| Rate for Payer: Networks By Design Commercial |
$53.50
|
| Rate for Payer: Prime Health Services Commercial |
$90.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$64.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$64.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$40.16
|
| Rate for Payer: United Healthcare All Other HMO |
$39.09
|
| Rate for Payer: United Healthcare HMO Rider |
$38.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$35.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$90.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$90.95
|
| Rate for Payer: Vantage Medical Group Senior |
$90.95
|
|
|
HC SHOE LADIES DEPTH INLAY
|
Facility
|
IP
|
$442.00
|
|
|
Service Code
|
CPT L3216
|
| Hospital Charge Code |
905353216
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$88.40 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$88.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$243.10
|
| Rate for Payer: Cash Price |
$243.10
|
| Rate for Payer: Cigna of CA HMO |
$309.40
|
| Rate for Payer: Cigna of CA PPO |
$309.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$176.80
|
| Rate for Payer: EPIC Health Plan Senior |
$176.80
|
| Rate for Payer: Galaxy Health WC |
$375.70
|
| Rate for Payer: Global Benefits Group Commercial |
$265.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$294.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$168.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$273.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$106.08
|
| Rate for Payer: Multiplan Commercial |
$353.60
|
| Rate for Payer: Networks By Design Commercial |
$221.00
|
| Rate for Payer: Prime Health Services Commercial |
$375.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$165.88
|
| Rate for Payer: United Healthcare All Other HMO |
$161.46
|
| Rate for Payer: United Healthcare HMO Rider |
$157.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$144.75
|
|
|
HC SHOE LADIES DEPTH INLAY
|
Facility
|
OP
|
$442.00
|
|
|
Service Code
|
CPT L3216
|
| Hospital Charge Code |
905353216
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$106.08 |
| Max. Negotiated Rate |
$375.70 |
| Rate for Payer: Adventist Health Commercial |
$181.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$375.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$243.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$331.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$256.01
|
| Rate for Payer: Blue Shield of California Commercial |
$326.20
|
| Rate for Payer: Blue Shield of California EPN |
$214.81
|
| Rate for Payer: Cash Price |
$243.10
|
| Rate for Payer: Cash Price |
$243.10
|
| Rate for Payer: Cigna of CA HMO |
$309.40
|
| Rate for Payer: Cigna of CA PPO |
$309.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$375.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$375.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$176.80
|
| Rate for Payer: EPIC Health Plan Senior |
$176.80
|
| Rate for Payer: Galaxy Health WC |
$375.70
|
| Rate for Payer: Global Benefits Group Commercial |
$265.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$124.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$294.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$140.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$273.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$106.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$309.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$309.40
|
| Rate for Payer: Multiplan Commercial |
$353.60
|
| Rate for Payer: Networks By Design Commercial |
$221.00
|
| Rate for Payer: Prime Health Services Commercial |
$375.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$265.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$265.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$165.88
|
| Rate for Payer: United Healthcare All Other HMO |
$161.46
|
| Rate for Payer: United Healthcare HMO Rider |
$157.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$144.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$375.70
|
| Rate for Payer: Vantage Medical Group Senior |
$375.70
|
|
|
HC SHOE LADIES DEPTH INLAY
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
CPT L3216
|
| Hospital Charge Code |
915353216
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$30.00 |
| Max. Negotiated Rate |
$13,501.00 |
| Rate for Payer: Adventist Health Commercial |
$30.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,501.00
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna of CA HMO |
$105.00
|
| Rate for Payer: Cigna of CA PPO |
$105.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.00
|
| Rate for Payer: EPIC Health Plan Senior |
$60.00
|
| Rate for Payer: Galaxy Health WC |
$127.50
|
| Rate for Payer: Global Benefits Group Commercial |
$90.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$100.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$57.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$92.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: Networks By Design Commercial |
$75.00
|
| Rate for Payer: Prime Health Services Commercial |
$127.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$56.30
|
| Rate for Payer: United Healthcare All Other HMO |
$54.80
|
| Rate for Payer: United Healthcare HMO Rider |
$53.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$49.12
|
|
|
HC SHOE LADIES DEPTH INLAY
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
CPT L3216
|
| Hospital Charge Code |
915353216
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$140.45 |
| Rate for Payer: Adventist Health Commercial |
$61.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$127.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$82.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$112.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$86.88
|
| Rate for Payer: Blue Shield of California Commercial |
$110.70
|
| Rate for Payer: Blue Shield of California EPN |
$72.90
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna of CA HMO |
$105.00
|
| Rate for Payer: Cigna of CA PPO |
$105.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$127.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$127.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$127.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.00
|
| Rate for Payer: EPIC Health Plan Senior |
$60.00
|
| Rate for Payer: Galaxy Health WC |
$127.50
|
| Rate for Payer: Global Benefits Group Commercial |
$90.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$124.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$100.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$140.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$92.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$105.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$105.00
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: Networks By Design Commercial |
$75.00
|
| Rate for Payer: Prime Health Services Commercial |
$127.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$90.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$90.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$56.30
|
| Rate for Payer: United Healthcare All Other HMO |
$54.80
|
| Rate for Payer: United Healthcare HMO Rider |
$53.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$49.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$127.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$127.50
|
| Rate for Payer: Vantage Medical Group Senior |
$127.50
|
|
|
HC SHOE MOD-METATARSAL BAR
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT A5505
|
| Hospital Charge Code |
915365505
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$42.50 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$32.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.70
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna of CA HMO |
$32.00
|
| Rate for Payer: Cigna of CA PPO |
$37.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$42.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.00
|
| Rate for Payer: EPIC Health Plan Senior |
$20.00
|
| Rate for Payer: Galaxy Health WC |
$42.50
|
| Rate for Payer: Global Benefits Group Commercial |
$30.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$35.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$33.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$30.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$35.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$35.00
|
| Rate for Payer: Multiplan Commercial |
$40.00
|
| Rate for Payer: Networks By Design Commercial |
$32.50
|
| Rate for Payer: Prime Health Services Commercial |
$42.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$30.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$30.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$25.00
|
| Rate for Payer: United Healthcare All Other HMO |
$25.00
|
| Rate for Payer: United Healthcare HMO Rider |
$25.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$25.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.50
|
| Rate for Payer: Vantage Medical Group Senior |
$42.50
|
|
|
HC SHOE MOD-METATARSAL BAR
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT A5505
|
| Hospital Charge Code |
905365505
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$42.50 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.00
|
| Rate for Payer: EPIC Health Plan Senior |
$20.00
|
| Rate for Payer: Galaxy Health WC |
$42.50
|
| Rate for Payer: Global Benefits Group Commercial |
$30.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$33.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$30.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$40.00
|
| Rate for Payer: Networks By Design Commercial |
$32.50
|
| Rate for Payer: Prime Health Services Commercial |
$42.50
|
|
|
HC SHOE MOD-METATARSAL BAR
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT A5505
|
| Hospital Charge Code |
915365505
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$42.50 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.00
|
| Rate for Payer: EPIC Health Plan Senior |
$20.00
|
| Rate for Payer: Galaxy Health WC |
$42.50
|
| Rate for Payer: Global Benefits Group Commercial |
$30.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$33.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$30.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$40.00
|
| Rate for Payer: Networks By Design Commercial |
$32.50
|
| Rate for Payer: Prime Health Services Commercial |
$42.50
|
|
|
HC SHOE MOD-METATARSAL BAR
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT A5505
|
| Hospital Charge Code |
905365505
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$42.50 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$32.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.70
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna of CA HMO |
$32.00
|
| Rate for Payer: Cigna of CA PPO |
$37.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$42.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.00
|
| Rate for Payer: EPIC Health Plan Senior |
$20.00
|
| Rate for Payer: Galaxy Health WC |
$42.50
|
| Rate for Payer: Global Benefits Group Commercial |
$30.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$35.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$33.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$30.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$35.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$35.00
|
| Rate for Payer: Multiplan Commercial |
$40.00
|
| Rate for Payer: Networks By Design Commercial |
$32.50
|
| Rate for Payer: Prime Health Services Commercial |
$42.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$30.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$30.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$25.00
|
| Rate for Payer: United Healthcare All Other HMO |
$25.00
|
| Rate for Payer: United Healthcare HMO Rider |
$25.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$25.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.50
|
| Rate for Payer: Vantage Medical Group Senior |
$42.50
|
|
|
HC SHOE MOD-OFF SET HEELS
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT A5506
|
| Hospital Charge Code |
905365506
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$27.40 |
| Max. Negotiated Rate |
$116.45 |
| Rate for Payer: Adventist Health Commercial |
$27.40
|
| Rate for Payer: Cash Price |
$75.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.80
|
| Rate for Payer: EPIC Health Plan Senior |
$54.80
|
| Rate for Payer: Galaxy Health WC |
$116.45
|
| Rate for Payer: Global Benefits Group Commercial |
$82.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$91.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$84.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.88
|
| Rate for Payer: Multiplan Commercial |
$109.60
|
| Rate for Payer: Networks By Design Commercial |
$89.05
|
| Rate for Payer: Prime Health Services Commercial |
$116.45
|
|
|
HC SHOE MOD-OFF SET HEELS
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT A5506
|
| Hospital Charge Code |
915365506
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$27.40 |
| Max. Negotiated Rate |
$116.45 |
| Rate for Payer: Adventist Health Commercial |
$27.40
|
| Rate for Payer: Cash Price |
$75.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.80
|
| Rate for Payer: EPIC Health Plan Senior |
$54.80
|
| Rate for Payer: Galaxy Health WC |
$116.45
|
| Rate for Payer: Global Benefits Group Commercial |
$82.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$91.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$84.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.88
|
| Rate for Payer: Multiplan Commercial |
$109.60
|
| Rate for Payer: Networks By Design Commercial |
$89.05
|
| Rate for Payer: Prime Health Services Commercial |
$116.45
|
|
|
HC SHOE MOD-OFF SET HEELS
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT A5506
|
| Hospital Charge Code |
905365506
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$27.40 |
| Max. Negotiated Rate |
$116.45 |
| Rate for Payer: Adventist Health Commercial |
$27.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$89.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$116.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$75.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$102.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$84.13
|
| Rate for Payer: Cash Price |
$75.35
|
| Rate for Payer: Cash Price |
$75.35
|
| Rate for Payer: Cigna of CA HMO |
$87.68
|
| Rate for Payer: Cigna of CA PPO |
$101.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$116.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$116.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$116.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.80
|
| Rate for Payer: EPIC Health Plan Senior |
$54.80
|
| Rate for Payer: Galaxy Health WC |
$116.45
|
| Rate for Payer: Global Benefits Group Commercial |
$82.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$35.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$91.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$84.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$95.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$95.90
|
| Rate for Payer: Multiplan Commercial |
$109.60
|
| Rate for Payer: Networks By Design Commercial |
$89.05
|
| Rate for Payer: Prime Health Services Commercial |
$116.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$82.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$82.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$68.50
|
| Rate for Payer: United Healthcare All Other HMO |
$68.50
|
| Rate for Payer: United Healthcare HMO Rider |
$68.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$68.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$116.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$116.45
|
| Rate for Payer: Vantage Medical Group Senior |
$116.45
|
|
|
HC SHOE MOD-OFF SET HEELS
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT A5506
|
| Hospital Charge Code |
915365506
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$27.40 |
| Max. Negotiated Rate |
$116.45 |
| Rate for Payer: Adventist Health Commercial |
$27.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$89.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$116.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$75.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$102.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$84.13
|
| Rate for Payer: Cash Price |
$75.35
|
| Rate for Payer: Cash Price |
$75.35
|
| Rate for Payer: Cigna of CA HMO |
$87.68
|
| Rate for Payer: Cigna of CA PPO |
$101.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$116.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$116.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$116.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.80
|
| Rate for Payer: EPIC Health Plan Senior |
$54.80
|
| Rate for Payer: Galaxy Health WC |
$116.45
|
| Rate for Payer: Global Benefits Group Commercial |
$82.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$35.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$91.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$84.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$95.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$95.90
|
| Rate for Payer: Multiplan Commercial |
$109.60
|
| Rate for Payer: Networks By Design Commercial |
$89.05
|
| Rate for Payer: Prime Health Services Commercial |
$116.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$82.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$82.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$68.50
|
| Rate for Payer: United Healthcare All Other HMO |
$68.50
|
| Rate for Payer: United Healthcare HMO Rider |
$68.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$68.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$116.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$116.45
|
| Rate for Payer: Vantage Medical Group Senior |
$116.45
|
|
|
HC SHOE MOD-ROCKER BOTTOM
|
Facility
|
OP
|
$282.00
|
|
|
Service Code
|
CPT A5503
|
| Hospital Charge Code |
905365503
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.48 |
| Max. Negotiated Rate |
$239.70 |
| Rate for Payer: Adventist Health Commercial |
$56.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$184.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$239.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$155.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$211.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$173.18
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cigna of CA HMO |
$180.48
|
| Rate for Payer: Cigna of CA PPO |
$208.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$239.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$239.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$239.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$112.80
|
| Rate for Payer: EPIC Health Plan Senior |
$112.80
|
| Rate for Payer: Galaxy Health WC |
$239.70
|
| Rate for Payer: Global Benefits Group Commercial |
$169.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$35.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$188.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$174.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$197.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$197.40
|
| Rate for Payer: Multiplan Commercial |
$225.60
|
| Rate for Payer: Networks By Design Commercial |
$183.30
|
| Rate for Payer: Prime Health Services Commercial |
$239.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$169.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$169.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$141.00
|
| Rate for Payer: United Healthcare All Other HMO |
$141.00
|
| Rate for Payer: United Healthcare HMO Rider |
$141.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$141.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$239.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$239.70
|
| Rate for Payer: Vantage Medical Group Senior |
$239.70
|
|
|
HC SHOE MOD-ROCKER BOTTOM
|
Facility
|
OP
|
$282.00
|
|
|
Service Code
|
CPT A5503
|
| Hospital Charge Code |
915365503
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.48 |
| Max. Negotiated Rate |
$239.70 |
| Rate for Payer: Cigna of CA HMO |
$180.48
|
| Rate for Payer: Adventist Health Commercial |
$56.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$184.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$239.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$155.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$211.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$173.18
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cigna of CA PPO |
$208.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$239.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$239.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$239.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$112.80
|
| Rate for Payer: EPIC Health Plan Senior |
$112.80
|
| Rate for Payer: Galaxy Health WC |
$239.70
|
| Rate for Payer: Global Benefits Group Commercial |
$169.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$35.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$188.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$174.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$197.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$197.40
|
| Rate for Payer: Multiplan Commercial |
$225.60
|
| Rate for Payer: Networks By Design Commercial |
$183.30
|
| Rate for Payer: Prime Health Services Commercial |
$239.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$169.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$169.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$141.00
|
| Rate for Payer: United Healthcare All Other HMO |
$141.00
|
| Rate for Payer: United Healthcare HMO Rider |
$141.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$141.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$239.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$239.70
|
| Rate for Payer: Vantage Medical Group Senior |
$239.70
|
|
|
HC SHOE MOD-ROCKER BOTTOM
|
Facility
|
IP
|
$282.00
|
|
|
Service Code
|
CPT A5503
|
| Hospital Charge Code |
905365503
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$56.40 |
| Max. Negotiated Rate |
$239.70 |
| Rate for Payer: Adventist Health Commercial |
$56.40
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$112.80
|
| Rate for Payer: EPIC Health Plan Senior |
$112.80
|
| Rate for Payer: Galaxy Health WC |
$239.70
|
| Rate for Payer: Global Benefits Group Commercial |
$169.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$188.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$174.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.68
|
| Rate for Payer: Multiplan Commercial |
$225.60
|
| Rate for Payer: Networks By Design Commercial |
$183.30
|
| Rate for Payer: Prime Health Services Commercial |
$239.70
|
|
|
HC SHOE MOD-ROCKER BOTTOM
|
Facility
|
IP
|
$282.00
|
|
|
Service Code
|
CPT A5503
|
| Hospital Charge Code |
915365503
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$56.40 |
| Max. Negotiated Rate |
$239.70 |
| Rate for Payer: Adventist Health Commercial |
$56.40
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$112.80
|
| Rate for Payer: EPIC Health Plan Senior |
$112.80
|
| Rate for Payer: Galaxy Health WC |
$239.70
|
| Rate for Payer: Global Benefits Group Commercial |
$169.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$188.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$174.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.68
|
| Rate for Payer: Multiplan Commercial |
$225.60
|
| Rate for Payer: Networks By Design Commercial |
$183.30
|
| Rate for Payer: Prime Health Services Commercial |
$239.70
|
|
|
HC SHOE MOD-SOLE WEDGE
|
Facility
|
OP
|
$338.00
|
|
|
Service Code
|
CPT A5504
|
| Hospital Charge Code |
905365504
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.48 |
| Max. Negotiated Rate |
$287.30 |
| Rate for Payer: Adventist Health Commercial |
$67.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$221.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$287.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$185.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$253.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$207.57
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cigna of CA HMO |
$216.32
|
| Rate for Payer: Cigna of CA PPO |
$250.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$287.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$287.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$287.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$135.20
|
| Rate for Payer: EPIC Health Plan Senior |
$135.20
|
| Rate for Payer: Galaxy Health WC |
$287.30
|
| Rate for Payer: Global Benefits Group Commercial |
$202.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$35.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$225.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$209.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$81.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$236.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$236.60
|
| Rate for Payer: Multiplan Commercial |
$270.40
|
| Rate for Payer: Networks By Design Commercial |
$219.70
|
| Rate for Payer: Prime Health Services Commercial |
$287.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$202.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$202.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$169.00
|
| Rate for Payer: United Healthcare All Other HMO |
$169.00
|
| Rate for Payer: United Healthcare HMO Rider |
$169.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$169.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$287.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$287.30
|
| Rate for Payer: Vantage Medical Group Senior |
$287.30
|
|
|
HC SHOE MOD-SOLE WEDGE
|
Facility
|
IP
|
$338.00
|
|
|
Service Code
|
CPT A5504
|
| Hospital Charge Code |
905365504
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$67.60 |
| Max. Negotiated Rate |
$287.30 |
| Rate for Payer: Adventist Health Commercial |
$67.60
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$135.20
|
| Rate for Payer: EPIC Health Plan Senior |
$135.20
|
| Rate for Payer: Galaxy Health WC |
$287.30
|
| Rate for Payer: Global Benefits Group Commercial |
$202.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$225.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$128.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$209.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$81.12
|
| Rate for Payer: Multiplan Commercial |
$270.40
|
| Rate for Payer: Networks By Design Commercial |
$219.70
|
| Rate for Payer: Prime Health Services Commercial |
$287.30
|
|
|
HC SHOE MOD-SOLE WEDGE
|
Facility
|
OP
|
$338.00
|
|
|
Service Code
|
CPT A5504
|
| Hospital Charge Code |
915365504
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.48 |
| Max. Negotiated Rate |
$287.30 |
| Rate for Payer: Adventist Health Commercial |
$67.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$221.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$287.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$185.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$253.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$207.57
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cigna of CA HMO |
$216.32
|
| Rate for Payer: Cigna of CA PPO |
$250.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$287.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$287.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$287.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$135.20
|
| Rate for Payer: EPIC Health Plan Senior |
$135.20
|
| Rate for Payer: Galaxy Health WC |
$287.30
|
| Rate for Payer: Global Benefits Group Commercial |
$202.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$35.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$225.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$209.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$81.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$236.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$236.60
|
| Rate for Payer: Multiplan Commercial |
$270.40
|
| Rate for Payer: Networks By Design Commercial |
$219.70
|
| Rate for Payer: Prime Health Services Commercial |
$287.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$202.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$202.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$169.00
|
| Rate for Payer: United Healthcare All Other HMO |
$169.00
|
| Rate for Payer: United Healthcare HMO Rider |
$169.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$169.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$287.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$287.30
|
| Rate for Payer: Vantage Medical Group Senior |
$287.30
|
|
|
HC SHOE MOD-SOLE WEDGE
|
Facility
|
IP
|
$338.00
|
|
|
Service Code
|
CPT A5504
|
| Hospital Charge Code |
915365504
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$67.60 |
| Max. Negotiated Rate |
$287.30 |
| Rate for Payer: Adventist Health Commercial |
$67.60
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$135.20
|
| Rate for Payer: EPIC Health Plan Senior |
$135.20
|
| Rate for Payer: Galaxy Health WC |
$287.30
|
| Rate for Payer: Global Benefits Group Commercial |
$202.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$225.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$128.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$209.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$81.12
|
| Rate for Payer: Multiplan Commercial |
$270.40
|
| Rate for Payer: Networks By Design Commercial |
$219.70
|
| Rate for Payer: Prime Health Services Commercial |
$287.30
|
|
