|
HC MRI UPPER EXTREM JOINT WO CONT
|
Facility
|
IP
|
$4,888.00
|
|
|
Service Code
|
CPT 73221
|
| Hospital Charge Code |
908801431
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$977.60 |
| Max. Negotiated Rate |
$4,154.80 |
| Rate for Payer: Adventist Health Commercial |
$977.60
|
| Rate for Payer: Cash Price |
$2,199.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,421.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,955.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1,955.20
|
| Rate for Payer: Galaxy Health WC |
$4,154.80
|
| Rate for Payer: Global Benefits Group Commercial |
$2,932.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3,103.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,883.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,173.12
|
| Rate for Payer: Multiplan Commercial |
$3,910.40
|
| Rate for Payer: Networks By Design Commercial |
$3,177.20
|
| Rate for Payer: Prime Health Services Commercial |
$4,154.80
|
|
|
HC MRI UPPER EXTREM W CONT
|
Facility
|
OP
|
$4,310.00
|
|
|
Service Code
|
CPT 73219
|
| Hospital Charge Code |
908801415
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$448.71 |
| Max. Negotiated Rate |
$3,663.50 |
| Rate for Payer: Adventist Health Commercial |
$862.00
|
| Rate for Payer: Adventist Health Commercial |
$1,035.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3,443.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3,443.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$673.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$673.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$493.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$493.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$448.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$448.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,765.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,321.44
|
| Rate for Payer: Blue Shield of California Commercial |
$2,179.10
|
| Rate for Payer: Blue Shield of California Commercial |
$1,814.51
|
| Rate for Payer: Blue Shield of California Commercial |
$2,749.78
|
| Rate for Payer: Blue Shield of California Commercial |
$3,302.29
|
| Rate for Payer: Cash Price |
$1,939.50
|
| Rate for Payer: Cash Price |
$1,939.50
|
| Rate for Payer: Cash Price |
$2,329.20
|
| Rate for Payer: Cash Price |
$1,939.50
|
| Rate for Payer: Cash Price |
$2,329.20
|
| Rate for Payer: Cash Price |
$2,329.20
|
| Rate for Payer: Cigna of CA HMO |
$2,758.40
|
| Rate for Payer: Cigna of CA HMO |
$3,312.64
|
| Rate for Payer: Cigna of CA PPO |
$3,189.40
|
| Rate for Payer: Cigna of CA PPO |
$3,830.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$673.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$673.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$493.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$493.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$448.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$448.71
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,623.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,017.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$740.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$740.37
|
| Rate for Payer: EPIC Health Plan Senior |
$493.58
|
| Rate for Payer: EPIC Health Plan Senior |
$493.58
|
| Rate for Payer: Galaxy Health WC |
$4,399.60
|
| Rate for Payer: Galaxy Health WC |
$3,663.50
|
| Rate for Payer: Global Benefits Group Commercial |
$2,586.00
|
| Rate for Payer: Global Benefits Group Commercial |
$3,105.60
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$735.88
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$735.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$554.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$554.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$448.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$448.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3,286.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,736.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$626.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$626.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$628.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$628.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,034.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,242.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$565.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$565.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$601.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$601.27
|
| Rate for Payer: Multiplan Commercial |
$3,448.00
|
| Rate for Payer: Multiplan Commercial |
$4,140.80
|
| Rate for Payer: Networks By Design Commercial |
$3,364.40
|
| Rate for Payer: Networks By Design Commercial |
$2,801.50
|
| Rate for Payer: Prime Health Services Commercial |
$3,663.50
|
| Rate for Payer: Prime Health Services Commercial |
$4,399.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,105.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,586.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,586.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,105.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,115.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,115.74
|
| Rate for Payer: United Healthcare All Other HMO |
$1,115.74
|
| Rate for Payer: United Healthcare All Other HMO |
$1,115.74
|
| Rate for Payer: United Healthcare HMO Rider |
$1,115.74
|
| Rate for Payer: United Healthcare HMO Rider |
$1,115.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,115.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,115.74
|
| Rate for Payer: Upland Medical Group Pediatric |
$448.71
|
| Rate for Payer: Upland Medical Group Pediatric |
$448.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$673.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$673.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$493.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$493.58
|
| Rate for Payer: Vantage Medical Group Senior |
$448.71
|
| Rate for Payer: Vantage Medical Group Senior |
$448.71
|
|
|
HC MRI UPPER EXTREM W CONT
|
Facility
|
IP
|
$5,176.00
|
|
|
Service Code
|
CPT 73219
|
| Hospital Charge Code |
908801415
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,035.20 |
| Max. Negotiated Rate |
$4,399.60 |
| Rate for Payer: Adventist Health Commercial |
$1,035.20
|
| Rate for Payer: Cash Price |
$2,329.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,623.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,070.40
|
| Rate for Payer: EPIC Health Plan Senior |
$2,070.40
|
| Rate for Payer: Galaxy Health WC |
$4,399.60
|
| Rate for Payer: Global Benefits Group Commercial |
$3,105.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3,286.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,053.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,242.24
|
| Rate for Payer: Multiplan Commercial |
$4,140.80
|
| Rate for Payer: Networks By Design Commercial |
$3,364.40
|
| Rate for Payer: Prime Health Services Commercial |
$4,399.60
|
|
|
HC MRI UPPER EXTREM W/O CONT
|
Facility
|
OP
|
$3,852.00
|
|
|
Service Code
|
CPT 73218
|
| Hospital Charge Code |
908801413
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$306.88 |
| Max. Negotiated Rate |
$3,443.00 |
| Rate for Payer: Adventist Health Commercial |
$770.40
|
| Rate for Payer: Adventist Health Commercial |
$990.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3,443.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3,443.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$460.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$460.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$337.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$337.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$306.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$306.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,471.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,178.98
|
| Rate for Payer: Blue Shield of California Commercial |
$2,085.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1,621.69
|
| Rate for Payer: Blue Shield of California Commercial |
$2,457.58
|
| Rate for Payer: Blue Shield of California Commercial |
$3,160.65
|
| Rate for Payer: Cash Price |
$1,733.40
|
| Rate for Payer: Cash Price |
$1,733.40
|
| Rate for Payer: Cash Price |
$2,229.30
|
| Rate for Payer: Cash Price |
$1,733.40
|
| Rate for Payer: Cash Price |
$2,229.30
|
| Rate for Payer: Cash Price |
$2,229.30
|
| Rate for Payer: Cigna of CA HMO |
$2,465.28
|
| Rate for Payer: Cigna of CA HMO |
$3,170.56
|
| Rate for Payer: Cigna of CA PPO |
$2,850.48
|
| Rate for Payer: Cigna of CA PPO |
$3,665.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$460.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$460.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$337.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$337.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$306.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$306.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,467.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,696.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$506.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$506.35
|
| Rate for Payer: EPIC Health Plan Senior |
$337.57
|
| Rate for Payer: EPIC Health Plan Senior |
$337.57
|
| Rate for Payer: Galaxy Health WC |
$4,210.90
|
| Rate for Payer: Galaxy Health WC |
$3,274.20
|
| Rate for Payer: Global Benefits Group Commercial |
$2,311.20
|
| Rate for Payer: Global Benefits Group Commercial |
$2,972.40
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$503.28
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$503.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$509.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$509.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$306.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$306.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3,145.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,446.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$576.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$576.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$429.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$429.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$924.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,188.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$386.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$386.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$411.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$411.22
|
| Rate for Payer: Multiplan Commercial |
$3,081.60
|
| Rate for Payer: Multiplan Commercial |
$3,963.20
|
| Rate for Payer: Networks By Design Commercial |
$3,220.10
|
| Rate for Payer: Networks By Design Commercial |
$2,503.80
|
| Rate for Payer: Prime Health Services Commercial |
$3,274.20
|
| Rate for Payer: Prime Health Services Commercial |
$4,210.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,972.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,311.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,311.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,972.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$866.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$866.34
|
| Rate for Payer: United Healthcare All Other HMO |
$866.34
|
| Rate for Payer: United Healthcare All Other HMO |
$866.34
|
| Rate for Payer: United Healthcare HMO Rider |
$866.34
|
| Rate for Payer: United Healthcare HMO Rider |
$866.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$866.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$866.34
|
| Rate for Payer: Upland Medical Group Pediatric |
$306.88
|
| Rate for Payer: Upland Medical Group Pediatric |
$306.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$460.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$460.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$337.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$337.57
|
| Rate for Payer: Vantage Medical Group Senior |
$306.88
|
| Rate for Payer: Vantage Medical Group Senior |
$306.88
|
|
|
HC MRI UPPER EXTREM W/O CONT
|
Facility
|
IP
|
$4,954.00
|
|
|
Service Code
|
CPT 73218
|
| Hospital Charge Code |
908801413
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$990.80 |
| Max. Negotiated Rate |
$4,210.90 |
| Rate for Payer: Adventist Health Commercial |
$990.80
|
| Rate for Payer: Cash Price |
$2,229.30
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,467.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,981.60
|
| Rate for Payer: EPIC Health Plan Senior |
$1,981.60
|
| Rate for Payer: Galaxy Health WC |
$4,210.90
|
| Rate for Payer: Global Benefits Group Commercial |
$2,972.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3,145.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,922.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,188.96
|
| Rate for Payer: Multiplan Commercial |
$3,963.20
|
| Rate for Payer: Networks By Design Commercial |
$3,220.10
|
| Rate for Payer: Prime Health Services Commercial |
$4,210.90
|
|
|
HC MRI UPPER EXTREM W & WO CONT
|
Facility
|
OP
|
$4,533.00
|
|
|
Service Code
|
CPT 73220
|
| Hospital Charge Code |
908801411
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$448.71 |
| Max. Negotiated Rate |
$3,853.05 |
| Rate for Payer: Adventist Health Commercial |
$906.60
|
| Rate for Payer: Adventist Health Commercial |
$1,325.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3,443.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3,443.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$673.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$673.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$493.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$493.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$448.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$448.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,908.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,252.55
|
| Rate for Payer: Blue Shield of California Commercial |
$2,789.97
|
| Rate for Payer: Blue Shield of California Commercial |
$1,908.39
|
| Rate for Payer: Blue Shield of California Commercial |
$2,892.05
|
| Rate for Payer: Blue Shield of California Commercial |
$4,228.03
|
| Rate for Payer: Cash Price |
$2,039.85
|
| Rate for Payer: Cash Price |
$2,039.85
|
| Rate for Payer: Cash Price |
$2,982.15
|
| Rate for Payer: Cash Price |
$2,039.85
|
| Rate for Payer: Cash Price |
$2,982.15
|
| Rate for Payer: Cash Price |
$2,982.15
|
| Rate for Payer: Cigna of CA HMO |
$2,901.12
|
| Rate for Payer: Cigna of CA HMO |
$4,241.28
|
| Rate for Payer: Cigna of CA PPO |
$3,354.42
|
| Rate for Payer: Cigna of CA PPO |
$4,903.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$673.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$673.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$493.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$493.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$448.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$448.71
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4,638.90
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,173.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$740.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$740.37
|
| Rate for Payer: EPIC Health Plan Senior |
$493.58
|
| Rate for Payer: EPIC Health Plan Senior |
$493.58
|
| Rate for Payer: Galaxy Health WC |
$5,632.95
|
| Rate for Payer: Galaxy Health WC |
$3,853.05
|
| Rate for Payer: Global Benefits Group Commercial |
$2,719.80
|
| Rate for Payer: Global Benefits Group Commercial |
$3,976.20
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$735.88
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$735.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$656.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$656.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$448.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$448.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4,208.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,878.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$741.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$741.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$628.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$628.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,087.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,590.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$565.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$565.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$601.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$601.27
|
| Rate for Payer: Multiplan Commercial |
$3,626.40
|
| Rate for Payer: Multiplan Commercial |
$5,301.60
|
| Rate for Payer: Networks By Design Commercial |
$4,307.55
|
| Rate for Payer: Networks By Design Commercial |
$2,946.45
|
| Rate for Payer: Prime Health Services Commercial |
$3,853.05
|
| Rate for Payer: Prime Health Services Commercial |
$5,632.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,976.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,719.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,719.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,976.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,367.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,367.12
|
| Rate for Payer: United Healthcare All Other HMO |
$1,367.12
|
| Rate for Payer: United Healthcare All Other HMO |
$1,367.12
|
| Rate for Payer: United Healthcare HMO Rider |
$1,367.12
|
| Rate for Payer: United Healthcare HMO Rider |
$1,367.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,367.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,367.12
|
| Rate for Payer: Upland Medical Group Pediatric |
$448.71
|
| Rate for Payer: Upland Medical Group Pediatric |
$448.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$673.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$673.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$493.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$493.58
|
| Rate for Payer: Vantage Medical Group Senior |
$448.71
|
| Rate for Payer: Vantage Medical Group Senior |
$448.71
|
|
|
HC MRI UPPER EXTREM W & WO CONT
|
Facility
|
IP
|
$6,627.00
|
|
|
Service Code
|
CPT 73220
|
| Hospital Charge Code |
908801411
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,325.40 |
| Max. Negotiated Rate |
$5,632.95 |
| Rate for Payer: Adventist Health Commercial |
$1,325.40
|
| Rate for Payer: Cash Price |
$2,982.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4,638.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,650.80
|
| Rate for Payer: EPIC Health Plan Senior |
$2,650.80
|
| Rate for Payer: Galaxy Health WC |
$5,632.95
|
| Rate for Payer: Global Benefits Group Commercial |
$3,976.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4,208.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,909.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,590.48
|
| Rate for Payer: Multiplan Commercial |
$5,301.60
|
| Rate for Payer: Networks By Design Commercial |
$4,307.55
|
| Rate for Payer: Prime Health Services Commercial |
$5,632.95
|
|
|
HC MRSA DNA
|
Facility
|
IP
|
$184.00
|
|
|
Service Code
|
CPT 87641
|
| Hospital Charge Code |
900912328
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$36.80 |
| Max. Negotiated Rate |
$156.40 |
| Rate for Payer: Adventist Health Commercial |
$36.80
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$128.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.60
|
| Rate for Payer: EPIC Health Plan Senior |
$73.60
|
| Rate for Payer: Galaxy Health WC |
$156.40
|
| Rate for Payer: Global Benefits Group Commercial |
$110.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$116.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$108.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.16
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: Networks By Design Commercial |
$119.60
|
| Rate for Payer: Prime Health Services Commercial |
$156.40
|
|
|
HC MRSA DNA
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 87641
|
| Hospital Charge Code |
900912328
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$354.39 |
| Rate for Payer: Adventist Health Commercial |
$20.00
|
| Rate for Payer: Adventist Health Commercial |
$36.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$291.85
|
| Rate for Payer: Aetna of CA HMO/PPO |
$291.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$52.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$52.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$354.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$354.39
|
| Rate for Payer: Blue Shield of California Commercial |
$128.25
|
| Rate for Payer: Blue Shield of California Commercial |
$46.10
|
| Rate for Payer: Blue Shield of California Commercial |
$84.82
|
| Rate for Payer: Blue Shield of California Commercial |
$69.70
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna of CA HMO |
$117.76
|
| Rate for Payer: Cigna of CA HMO |
$64.00
|
| Rate for Payer: Cigna of CA PPO |
$74.00
|
| Rate for Payer: Cigna of CA PPO |
$136.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$35.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$35.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$70.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$128.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.90
|
| Rate for Payer: EPIC Health Plan Senior |
$38.60
|
| Rate for Payer: EPIC Health Plan Senior |
$38.60
|
| Rate for Payer: Galaxy Health WC |
$85.00
|
| Rate for Payer: Galaxy Health WC |
$156.40
|
| Rate for Payer: Global Benefits Group Commercial |
$60.00
|
| Rate for Payer: Global Benefits Group Commercial |
$110.40
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$57.55
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$57.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$51.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$51.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$63.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$116.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$58.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$58.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$49.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$49.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$44.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$44.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$47.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$47.02
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: Networks By Design Commercial |
$119.60
|
| Rate for Payer: Networks By Design Commercial |
$65.00
|
| Rate for Payer: Prime Health Services Commercial |
$85.00
|
| Rate for Payer: Prime Health Services Commercial |
$156.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$60.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$110.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$60.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$110.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$28.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$28.42
|
| Rate for Payer: United Healthcare All Other HMO |
$28.42
|
| Rate for Payer: United Healthcare All Other HMO |
$28.42
|
| Rate for Payer: United Healthcare HMO Rider |
$28.42
|
| Rate for Payer: United Healthcare HMO Rider |
$28.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$28.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$28.42
|
| Rate for Payer: Upland Medical Group Pediatric |
$35.09
|
| Rate for Payer: Upland Medical Group Pediatric |
$35.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$52.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$52.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Vantage Medical Group Senior |
$35.09
|
| Rate for Payer: Vantage Medical Group Senior |
$35.09
|
|
|
HC MR SAFETY DETERMINATION PHYSICIAN/OTHER QHP
|
Facility
|
OP
|
$238.00
|
|
|
Service Code
|
CPT 76016
|
| Hospital Charge Code |
908801502
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$376.91 |
| Rate for Payer: Adventist Health Commercial |
$47.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$308.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$167.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$123.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$111.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$376.91
|
| Rate for Payer: Blue Shield of California Commercial |
$151.84
|
| Rate for Payer: Blue Shield of California Commercial |
$100.20
|
| Rate for Payer: Cash Price |
$107.10
|
| Rate for Payer: Cash Price |
$107.10
|
| Rate for Payer: Cigna of CA HMO |
$152.32
|
| Rate for Payer: Cigna of CA PPO |
$176.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$167.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$123.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$111.93
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$166.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$184.68
|
| Rate for Payer: EPIC Health Plan Senior |
$123.12
|
| Rate for Payer: Galaxy Health WC |
$202.30
|
| Rate for Payer: Global Benefits Group Commercial |
$142.80
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$183.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$111.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$151.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$156.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$141.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$149.99
|
| Rate for Payer: Multiplan Commercial |
$190.40
|
| Rate for Payer: Networks By Design Commercial |
$154.70
|
| Rate for Payer: Prime Health Services Commercial |
$202.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$142.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$142.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$119.00
|
| Rate for Payer: United Healthcare All Other HMO |
$119.00
|
| Rate for Payer: United Healthcare HMO Rider |
$119.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$119.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$111.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$167.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$123.12
|
| Rate for Payer: Vantage Medical Group Senior |
$111.93
|
|
|
HC MR SAFETY DETERMINATION PHYSICIAN/OTHER QHP
|
Facility
|
IP
|
$238.00
|
|
|
Service Code
|
CPT 76016
|
| Hospital Charge Code |
908801502
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$202.30 |
| Rate for Payer: Adventist Health Commercial |
$47.60
|
| Rate for Payer: Cash Price |
$107.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$166.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.20
|
| Rate for Payer: EPIC Health Plan Senior |
$95.20
|
| Rate for Payer: Galaxy Health WC |
$202.30
|
| Rate for Payer: Global Benefits Group Commercial |
$142.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$151.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$140.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.12
|
| Rate for Payer: Multiplan Commercial |
$190.40
|
| Rate for Payer: Networks By Design Commercial |
$154.70
|
| Rate for Payer: Prime Health Services Commercial |
$202.30
|
|
|
HC MR SAFETY IMPL AND FB ASSMT CLIN STAFF 1ST 15 MIN
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
CPT 76014
|
| Hospital Charge Code |
908801500
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$56.10 |
| Rate for Payer: Adventist Health Commercial |
$13.20
|
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$46.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.40
|
| Rate for Payer: EPIC Health Plan Senior |
$26.40
|
| Rate for Payer: Galaxy Health WC |
$56.10
|
| Rate for Payer: Global Benefits Group Commercial |
$39.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$41.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$38.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.84
|
| Rate for Payer: Multiplan Commercial |
$52.80
|
| Rate for Payer: Networks By Design Commercial |
$42.90
|
| Rate for Payer: Prime Health Services Commercial |
$56.10
|
|
|
HC MR SAFETY IMPL AND FB ASSMT CLIN STAFF 1ST 15 MIN
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
CPT 76014
|
| Hospital Charge Code |
908801500
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$90.75 |
| Rate for Payer: Adventist Health Commercial |
$13.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$74.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$55.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$40.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$90.75
|
| Rate for Payer: Blue Shield of California Commercial |
$42.11
|
| Rate for Payer: Blue Shield of California Commercial |
$27.79
|
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Cigna of CA HMO |
$42.24
|
| Rate for Payer: Cigna of CA PPO |
$48.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$55.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$37.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$46.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.38
|
| Rate for Payer: EPIC Health Plan Senior |
$40.92
|
| Rate for Payer: Galaxy Health WC |
$56.10
|
| Rate for Payer: Global Benefits Group Commercial |
$39.60
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$61.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$37.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$41.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$52.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$46.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$49.85
|
| Rate for Payer: Multiplan Commercial |
$52.80
|
| Rate for Payer: Networks By Design Commercial |
$42.90
|
| Rate for Payer: Prime Health Services Commercial |
$56.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$39.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$39.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$33.00
|
| Rate for Payer: United Healthcare All Other HMO |
$33.00
|
| Rate for Payer: United Healthcare HMO Rider |
$33.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$33.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$37.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$55.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.92
|
| Rate for Payer: Vantage Medical Group Senior |
$37.20
|
|
|
HC MR SAFETY IMPL AND FB ASSMT CLIN STAFF EA ADD 30 MIN
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
CPT 76015
|
| Hospital Charge Code |
908801501
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$437.16 |
| Rate for Payer: Adventist Health Commercial |
$6.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$358.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$437.16
|
| Rate for Payer: Blue Shield of California Commercial |
$13.89
|
| Rate for Payer: Blue Shield of California Commercial |
$21.05
|
| Rate for Payer: Cash Price |
$14.85
|
| Rate for Payer: Cash Price |
$14.85
|
| Rate for Payer: Cigna of CA HMO |
$21.12
|
| Rate for Payer: Cigna of CA PPO |
$24.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$28.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$23.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.20
|
| Rate for Payer: EPIC Health Plan Senior |
$13.20
|
| Rate for Payer: Galaxy Health WC |
$28.05
|
| Rate for Payer: Global Benefits Group Commercial |
$19.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$20.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.10
|
| Rate for Payer: Multiplan Commercial |
$26.40
|
| Rate for Payer: Networks By Design Commercial |
$21.45
|
| Rate for Payer: Prime Health Services Commercial |
$28.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$19.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$19.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.50
|
| Rate for Payer: United Healthcare All Other HMO |
$16.50
|
| Rate for Payer: United Healthcare HMO Rider |
$16.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.05
|
| Rate for Payer: Vantage Medical Group Senior |
$28.05
|
|
|
HC MR SAFETY IMPL AND FB ASSMT CLIN STAFF EA ADD 30 MIN
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
CPT 76015
|
| Hospital Charge Code |
908801501
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$28.05 |
| Rate for Payer: Adventist Health Commercial |
$6.60
|
| Rate for Payer: Cash Price |
$14.85
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$23.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.20
|
| Rate for Payer: EPIC Health Plan Senior |
$13.20
|
| Rate for Payer: Galaxy Health WC |
$28.05
|
| Rate for Payer: Global Benefits Group Commercial |
$19.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$20.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.92
|
| Rate for Payer: Multiplan Commercial |
$26.40
|
| Rate for Payer: Networks By Design Commercial |
$21.45
|
| Rate for Payer: Prime Health Services Commercial |
$28.05
|
|
|
HC MR SAFETY IMPL ELECTRONICS PREP SUP PHYS/QHP
|
Facility
|
IP
|
$248.00
|
|
|
Service Code
|
CPT 76018
|
| Hospital Charge Code |
908801504
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$49.60 |
| Max. Negotiated Rate |
$210.80 |
| Rate for Payer: Adventist Health Commercial |
$49.60
|
| Rate for Payer: Cash Price |
$111.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$173.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$99.20
|
| Rate for Payer: EPIC Health Plan Senior |
$99.20
|
| Rate for Payer: Galaxy Health WC |
$210.80
|
| Rate for Payer: Global Benefits Group Commercial |
$148.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$157.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$146.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.52
|
| Rate for Payer: Multiplan Commercial |
$198.40
|
| Rate for Payer: Networks By Design Commercial |
$161.20
|
| Rate for Payer: Prime Health Services Commercial |
$210.80
|
|
|
HC MR SAFETY IMPL ELECTRONICS PREP SUP PHYS/QHP
|
Facility
|
OP
|
$248.00
|
|
|
Service Code
|
CPT 76018
|
| Hospital Charge Code |
908801504
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$49.60 |
| Max. Negotiated Rate |
$669.04 |
| Rate for Payer: Adventist Health Commercial |
$49.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$546.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$183.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$134.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$122.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$669.04
|
| Rate for Payer: Blue Shield of California Commercial |
$158.22
|
| Rate for Payer: Blue Shield of California Commercial |
$104.41
|
| Rate for Payer: Cash Price |
$111.60
|
| Rate for Payer: Cash Price |
$111.60
|
| Rate for Payer: Cigna of CA HMO |
$158.72
|
| Rate for Payer: Cigna of CA PPO |
$183.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$183.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$134.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$122.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$173.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$201.76
|
| Rate for Payer: EPIC Health Plan Senior |
$134.51
|
| Rate for Payer: Galaxy Health WC |
$210.80
|
| Rate for Payer: Global Benefits Group Commercial |
$148.80
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$200.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$122.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$157.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$171.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$154.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$163.86
|
| Rate for Payer: Multiplan Commercial |
$198.40
|
| Rate for Payer: Networks By Design Commercial |
$161.20
|
| Rate for Payer: Prime Health Services Commercial |
$210.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$148.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$148.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$124.00
|
| Rate for Payer: United Healthcare All Other HMO |
$124.00
|
| Rate for Payer: United Healthcare HMO Rider |
$124.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$124.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$122.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$183.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$134.51
|
| Rate for Payer: Vantage Medical Group Senior |
$122.28
|
|
|
HC MR SAFETY IMPL POS/IMMOBL SUP PHYS/QHP
|
Facility
|
OP
|
$161.00
|
|
|
Service Code
|
CPT 76019
|
| Hospital Charge Code |
908801505
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$32.20 |
| Max. Negotiated Rate |
$1,024.27 |
| Rate for Payer: Adventist Health Commercial |
$32.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$836.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$113.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$83.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$75.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,024.27
|
| Rate for Payer: Blue Shield of California Commercial |
$67.78
|
| Rate for Payer: Blue Shield of California Commercial |
$102.72
|
| Rate for Payer: Cash Price |
$72.45
|
| Rate for Payer: Cash Price |
$72.45
|
| Rate for Payer: Cigna of CA HMO |
$103.04
|
| Rate for Payer: Cigna of CA PPO |
$119.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$113.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$83.46
|
| Rate for Payer: Dignity Health Medicare Advantage |
$75.87
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$112.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$125.19
|
| Rate for Payer: EPIC Health Plan Senior |
$83.46
|
| Rate for Payer: Galaxy Health WC |
$136.85
|
| Rate for Payer: Global Benefits Group Commercial |
$96.60
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$124.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$75.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$102.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$106.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$95.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$101.67
|
| Rate for Payer: Multiplan Commercial |
$128.80
|
| Rate for Payer: Networks By Design Commercial |
$104.65
|
| Rate for Payer: Prime Health Services Commercial |
$136.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$96.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$96.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$80.50
|
| Rate for Payer: United Healthcare All Other HMO |
$80.50
|
| Rate for Payer: United Healthcare HMO Rider |
$80.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$80.50
|
| Rate for Payer: Upland Medical Group Pediatric |
$75.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$113.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$83.46
|
| Rate for Payer: Vantage Medical Group Senior |
$75.87
|
|
|
HC MR SAFETY IMPL POS/IMMOBL SUP PHYS/QHP
|
Facility
|
IP
|
$161.00
|
|
|
Service Code
|
CPT 76019
|
| Hospital Charge Code |
908801505
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$32.20 |
| Max. Negotiated Rate |
$136.85 |
| Rate for Payer: Adventist Health Commercial |
$32.20
|
| Rate for Payer: Cash Price |
$72.45
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$112.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.40
|
| Rate for Payer: EPIC Health Plan Senior |
$64.40
|
| Rate for Payer: Galaxy Health WC |
$136.85
|
| Rate for Payer: Global Benefits Group Commercial |
$96.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$102.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$94.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.64
|
| Rate for Payer: Multiplan Commercial |
$128.80
|
| Rate for Payer: Networks By Design Commercial |
$104.65
|
| Rate for Payer: Prime Health Services Commercial |
$136.85
|
|
|
HC MR SAFETY MED PHYSICS EXAM CUSTOM PLN/MTR
|
Facility
|
OP
|
$653.00
|
|
|
Service Code
|
CPT 76017
|
| Hospital Charge Code |
908801503
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$130.60 |
| Max. Negotiated Rate |
$1,587.68 |
| Rate for Payer: Adventist Health Commercial |
$130.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,298.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$460.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$337.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$306.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,587.68
|
| Rate for Payer: Blue Shield of California Commercial |
$416.61
|
| Rate for Payer: Blue Shield of California Commercial |
$274.91
|
| Rate for Payer: Cash Price |
$293.85
|
| Rate for Payer: Cash Price |
$293.85
|
| Rate for Payer: Cigna of CA HMO |
$417.92
|
| Rate for Payer: Cigna of CA PPO |
$483.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$460.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$337.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$306.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$457.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$506.35
|
| Rate for Payer: EPIC Health Plan Senior |
$337.57
|
| Rate for Payer: Galaxy Health WC |
$555.05
|
| Rate for Payer: Global Benefits Group Commercial |
$391.80
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$503.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$306.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$414.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$429.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$156.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$386.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$411.22
|
| Rate for Payer: Multiplan Commercial |
$522.40
|
| Rate for Payer: Networks By Design Commercial |
$424.45
|
| Rate for Payer: Prime Health Services Commercial |
$555.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$391.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$391.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$326.50
|
| Rate for Payer: United Healthcare All Other HMO |
$326.50
|
| Rate for Payer: United Healthcare HMO Rider |
$326.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$326.50
|
| Rate for Payer: Upland Medical Group Pediatric |
$306.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$460.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$337.57
|
| Rate for Payer: Vantage Medical Group Senior |
$306.88
|
|
|
HC MR SAFETY MED PHYSICS EXAM CUSTOM PLN/MTR
|
Facility
|
IP
|
$653.00
|
|
|
Service Code
|
CPT 76017
|
| Hospital Charge Code |
908801503
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$130.60 |
| Max. Negotiated Rate |
$555.05 |
| Rate for Payer: Adventist Health Commercial |
$130.60
|
| Rate for Payer: Cash Price |
$293.85
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$457.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$261.20
|
| Rate for Payer: EPIC Health Plan Senior |
$261.20
|
| Rate for Payer: Galaxy Health WC |
$555.05
|
| Rate for Payer: Global Benefits Group Commercial |
$391.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$414.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$385.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$156.72
|
| Rate for Payer: Multiplan Commercial |
$522.40
|
| Rate for Payer: Networks By Design Commercial |
$424.45
|
| Rate for Payer: Prime Health Services Commercial |
$555.05
|
|
|
HC MTR URN 400ML DRAIN BAG
|
Facility
|
IP
|
$75.69
|
|
| Hospital Charge Code |
901698821
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.14 |
| Max. Negotiated Rate |
$64.34 |
| Rate for Payer: Adventist Health Commercial |
$15.14
|
| Rate for Payer: Cash Price |
$34.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$52.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.28
|
| Rate for Payer: EPIC Health Plan Senior |
$30.28
|
| Rate for Payer: Galaxy Health WC |
$64.34
|
| Rate for Payer: Global Benefits Group Commercial |
$45.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$48.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$44.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.17
|
| Rate for Payer: Multiplan Commercial |
$60.55
|
| Rate for Payer: Networks By Design Commercial |
$49.20
|
| Rate for Payer: Prime Health Services Commercial |
$64.34
|
|
|
HC MTR URN 400ML DRAIN BAG
|
Facility
|
OP
|
$75.69
|
|
| Hospital Charge Code |
901698821
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.14 |
| Max. Negotiated Rate |
$64.34 |
| Rate for Payer: Adventist Health Commercial |
$15.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$49.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$64.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$41.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$56.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.57
|
| Rate for Payer: Cash Price |
$34.06
|
| Rate for Payer: Cigna of CA HMO |
$48.44
|
| Rate for Payer: Cigna of CA PPO |
$56.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$64.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$64.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$64.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$52.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.28
|
| Rate for Payer: EPIC Health Plan Senior |
$30.28
|
| Rate for Payer: Galaxy Health WC |
$64.34
|
| Rate for Payer: Global Benefits Group Commercial |
$45.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$48.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$27.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$44.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$52.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$52.98
|
| Rate for Payer: Multiplan Commercial |
$60.55
|
| Rate for Payer: Networks By Design Commercial |
$49.20
|
| Rate for Payer: Prime Health Services Commercial |
$64.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$45.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$45.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$37.84
|
| Rate for Payer: United Healthcare All Other HMO |
$37.84
|
| Rate for Payer: United Healthcare HMO Rider |
$37.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$37.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$64.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$64.34
|
| Rate for Payer: Vantage Medical Group Senior |
$64.34
|
|
|
HC MTR URN 400ML DRAIN BAG L/F LL
|
Facility
|
IP
|
$56.66
|
|
| Hospital Charge Code |
901607518
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.33 |
| Max. Negotiated Rate |
$48.16 |
| Rate for Payer: Adventist Health Commercial |
$11.33
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$39.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.66
|
| Rate for Payer: EPIC Health Plan Senior |
$22.66
|
| Rate for Payer: Galaxy Health WC |
$48.16
|
| Rate for Payer: Global Benefits Group Commercial |
$34.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$35.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$33.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.60
|
| Rate for Payer: Multiplan Commercial |
$45.33
|
| Rate for Payer: Networks By Design Commercial |
$36.83
|
| Rate for Payer: Prime Health Services Commercial |
$48.16
|
|
|
HC MTR URN 400ML DRAIN BAG L/F LL
|
Facility
|
OP
|
$56.66
|
|
| Hospital Charge Code |
901607518
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.33 |
| Max. Negotiated Rate |
$48.16 |
| Rate for Payer: Adventist Health Commercial |
$11.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$37.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$48.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$31.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$42.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$36.36
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna of CA HMO |
$36.26
|
| Rate for Payer: Cigna of CA PPO |
$41.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$48.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$39.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.66
|
| Rate for Payer: EPIC Health Plan Senior |
$22.66
|
| Rate for Payer: Galaxy Health WC |
$48.16
|
| Rate for Payer: Global Benefits Group Commercial |
$34.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$35.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$33.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39.66
|
| Rate for Payer: Multiplan Commercial |
$45.33
|
| Rate for Payer: Networks By Design Commercial |
$36.83
|
| Rate for Payer: Prime Health Services Commercial |
$48.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$34.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$34.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$28.33
|
| Rate for Payer: United Healthcare All Other HMO |
$28.33
|
| Rate for Payer: United Healthcare HMO Rider |
$28.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$28.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$48.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.16
|
| Rate for Payer: Vantage Medical Group Senior |
$48.16
|
|
