|
HC STENT ESOPHAGEAL EVO-20-25-10-E
|
Facility
|
OP
|
$3,800.00
|
|
|
Service Code
|
CPT C1876
|
| Hospital Charge Code |
900100389
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$760.00 |
| Max. Negotiated Rate |
$3,420.00 |
| Rate for Payer: Adventist Health Commercial |
$760.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,230.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,090.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,850.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,735.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,104.06
|
| Rate for Payer: Blue Shield of California Commercial |
$2,937.40
|
| Rate for Payer: Blue Shield of California EPN |
$1,915.20
|
| Rate for Payer: Cash Price |
$2,090.00
|
| Rate for Payer: Central Health Plan Commercial |
$3,040.00
|
| Rate for Payer: Cigna of CA HMO |
$2,660.00
|
| Rate for Payer: Cigna of CA PPO |
$2,660.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,230.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,230.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,230.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,520.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,520.00
|
| Rate for Payer: Galaxy Health WC |
$3,230.00
|
| Rate for Payer: Global Benefits Group Commercial |
$2,280.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,420.00
|
| Rate for Payer: InnovAge PACE Commercial |
$1,900.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,534.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,447.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,352.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$760.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,660.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,660.00
|
| Rate for Payer: Multiplan Commercial |
$2,850.00
|
| Rate for Payer: Networks By Design Commercial |
$1,900.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,230.00
|
| Rate for Payer: Riverside University Health System MISP |
$1,520.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,280.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,280.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,426.14
|
| Rate for Payer: United Healthcare All Other HMO |
$1,388.14
|
| Rate for Payer: United Healthcare HMO Rider |
$1,358.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,244.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,230.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,230.00
|
| Rate for Payer: Vantage Medical Group Senior |
$3,230.00
|
|
|
HC STENT ESOPHAGEAL EVO-20-25-10-E
|
Facility
|
IP
|
$3,800.00
|
|
|
Service Code
|
CPT C1876
|
| Hospital Charge Code |
900100389
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$760.00 |
| Max. Negotiated Rate |
$3,420.00 |
| Rate for Payer: Adventist Health Commercial |
$760.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,937.40
|
| Rate for Payer: Blue Shield of California EPN |
$1,915.20
|
| Rate for Payer: Cash Price |
$2,090.00
|
| Rate for Payer: Central Health Plan Commercial |
$3,040.00
|
| Rate for Payer: Cigna of CA HMO |
$2,660.00
|
| Rate for Payer: Cigna of CA PPO |
$2,660.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,520.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,520.00
|
| Rate for Payer: Galaxy Health WC |
$3,230.00
|
| Rate for Payer: Global Benefits Group Commercial |
$2,280.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,420.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,534.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,447.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,352.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$760.00
|
| Rate for Payer: Multiplan Commercial |
$2,850.00
|
| Rate for Payer: Networks By Design Commercial |
$1,900.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,230.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,426.14
|
| Rate for Payer: United Healthcare All Other HMO |
$1,388.14
|
| Rate for Payer: United Healthcare HMO Rider |
$1,358.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,244.50
|
|
|
HC STENT ESOPHAGEAL EVO-FC-20-25-10-E
|
Facility
|
OP
|
$3,800.00
|
|
|
Service Code
|
CPT C1894
|
| Hospital Charge Code |
900100391
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$760.00 |
| Max. Negotiated Rate |
$3,420.00 |
| Rate for Payer: Adventist Health Commercial |
$760.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,230.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,090.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,850.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,735.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,104.06
|
| Rate for Payer: Blue Shield of California Commercial |
$2,937.40
|
| Rate for Payer: Blue Shield of California EPN |
$1,915.20
|
| Rate for Payer: Cash Price |
$2,090.00
|
| Rate for Payer: Central Health Plan Commercial |
$3,040.00
|
| Rate for Payer: Cigna of CA HMO |
$2,660.00
|
| Rate for Payer: Cigna of CA PPO |
$2,660.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,230.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,230.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,230.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,520.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,520.00
|
| Rate for Payer: Galaxy Health WC |
$3,230.00
|
| Rate for Payer: Global Benefits Group Commercial |
$2,280.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,420.00
|
| Rate for Payer: InnovAge PACE Commercial |
$1,900.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,534.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,447.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,352.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$760.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,660.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,660.00
|
| Rate for Payer: Multiplan Commercial |
$2,850.00
|
| Rate for Payer: Networks By Design Commercial |
$1,900.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,230.00
|
| Rate for Payer: Riverside University Health System MISP |
$1,520.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,280.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,280.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,426.14
|
| Rate for Payer: United Healthcare All Other HMO |
$1,388.14
|
| Rate for Payer: United Healthcare HMO Rider |
$1,358.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,244.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,230.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,230.00
|
| Rate for Payer: Vantage Medical Group Senior |
$3,230.00
|
|
|
HC STENT ESOPHAGEAL EVO-FC-20-25-10-E
|
Facility
|
IP
|
$3,800.00
|
|
|
Service Code
|
CPT C1894
|
| Hospital Charge Code |
900100391
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$760.00 |
| Max. Negotiated Rate |
$3,420.00 |
| Rate for Payer: Adventist Health Commercial |
$760.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,937.40
|
| Rate for Payer: Blue Shield of California EPN |
$1,915.20
|
| Rate for Payer: Cash Price |
$2,090.00
|
| Rate for Payer: Central Health Plan Commercial |
$3,040.00
|
| Rate for Payer: Cigna of CA HMO |
$2,660.00
|
| Rate for Payer: Cigna of CA PPO |
$2,660.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,520.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,520.00
|
| Rate for Payer: Galaxy Health WC |
$3,230.00
|
| Rate for Payer: Global Benefits Group Commercial |
$2,280.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,420.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,534.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,447.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,352.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$760.00
|
| Rate for Payer: Multiplan Commercial |
$2,850.00
|
| Rate for Payer: Networks By Design Commercial |
$1,900.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,230.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,426.14
|
| Rate for Payer: United Healthcare All Other HMO |
$1,388.14
|
| Rate for Payer: United Healthcare HMO Rider |
$1,358.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,244.50
|
|
|
HC STENT ESOPHAGEAL EVO-FC-20-25-12-E
|
Facility
|
IP
|
$3,687.50
|
|
|
Service Code
|
CPT C1894
|
| Hospital Charge Code |
900100390
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$737.50 |
| Max. Negotiated Rate |
$3,318.75 |
| Rate for Payer: Adventist Health Commercial |
$737.50
|
| Rate for Payer: Blue Shield of California Commercial |
$2,850.44
|
| Rate for Payer: Blue Shield of California EPN |
$1,858.50
|
| Rate for Payer: Cash Price |
$2,028.13
|
| Rate for Payer: Central Health Plan Commercial |
$2,950.00
|
| Rate for Payer: Cigna of CA HMO |
$2,581.25
|
| Rate for Payer: Cigna of CA PPO |
$2,581.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,475.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,475.00
|
| Rate for Payer: Galaxy Health WC |
$3,134.38
|
| Rate for Payer: Global Benefits Group Commercial |
$2,212.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,318.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,459.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,404.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,282.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$737.50
|
| Rate for Payer: Multiplan Commercial |
$2,765.62
|
| Rate for Payer: Networks By Design Commercial |
$1,843.75
|
| Rate for Payer: Prime Health Services Commercial |
$3,134.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,383.92
|
| Rate for Payer: United Healthcare All Other HMO |
$1,347.04
|
| Rate for Payer: United Healthcare HMO Rider |
$1,317.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,207.66
|
|
|
HC STENT ESOPHAGEAL EVO-FC-20-25-12-E
|
Facility
|
OP
|
$3,687.50
|
|
|
Service Code
|
CPT C1894
|
| Hospital Charge Code |
900100390
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$737.50 |
| Max. Negotiated Rate |
$3,318.75 |
| Rate for Payer: Adventist Health Commercial |
$737.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,134.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,028.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,765.62
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,683.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,041.77
|
| Rate for Payer: Blue Shield of California Commercial |
$2,850.44
|
| Rate for Payer: Blue Shield of California EPN |
$1,858.50
|
| Rate for Payer: Cash Price |
$2,028.13
|
| Rate for Payer: Central Health Plan Commercial |
$2,950.00
|
| Rate for Payer: Cigna of CA HMO |
$2,581.25
|
| Rate for Payer: Cigna of CA PPO |
$2,581.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,134.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,134.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,134.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,475.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,475.00
|
| Rate for Payer: Galaxy Health WC |
$3,134.38
|
| Rate for Payer: Global Benefits Group Commercial |
$2,212.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,318.75
|
| Rate for Payer: InnovAge PACE Commercial |
$1,843.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,459.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,404.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,282.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$737.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,581.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,581.25
|
| Rate for Payer: Multiplan Commercial |
$2,765.62
|
| Rate for Payer: Networks By Design Commercial |
$1,843.75
|
| Rate for Payer: Prime Health Services Commercial |
$3,134.38
|
| Rate for Payer: Riverside University Health System MISP |
$1,475.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,212.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,212.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,383.92
|
| Rate for Payer: United Healthcare All Other HMO |
$1,347.04
|
| Rate for Payer: United Healthcare HMO Rider |
$1,317.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,207.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,134.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,134.38
|
| Rate for Payer: Vantage Medical Group Senior |
$3,134.38
|
|
|
HC STENT ESOPHOGEAL 8CM LONG
|
Facility
|
IP
|
$4,275.00
|
|
|
Service Code
|
CPT C1876
|
| Hospital Charge Code |
900100383
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$855.00 |
| Max. Negotiated Rate |
$3,847.50 |
| Rate for Payer: Adventist Health Commercial |
$855.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,304.57
|
| Rate for Payer: Blue Shield of California EPN |
$2,154.60
|
| Rate for Payer: Cash Price |
$2,351.25
|
| Rate for Payer: Central Health Plan Commercial |
$3,420.00
|
| Rate for Payer: Cigna of CA HMO |
$2,992.50
|
| Rate for Payer: Cigna of CA PPO |
$2,992.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,710.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,710.00
|
| Rate for Payer: Galaxy Health WC |
$3,633.75
|
| Rate for Payer: Global Benefits Group Commercial |
$2,565.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,847.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,851.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,628.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,646.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$855.00
|
| Rate for Payer: Multiplan Commercial |
$3,206.25
|
| Rate for Payer: Networks By Design Commercial |
$2,137.50
|
| Rate for Payer: Prime Health Services Commercial |
$3,633.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,604.41
|
| Rate for Payer: United Healthcare All Other HMO |
$1,561.66
|
| Rate for Payer: United Healthcare HMO Rider |
$1,527.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,400.06
|
|
|
HC STENT ESOPHOGEAL 8CM LONG
|
Facility
|
OP
|
$4,275.00
|
|
|
Service Code
|
CPT C1876
|
| Hospital Charge Code |
900100383
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$855.00 |
| Max. Negotiated Rate |
$3,847.50 |
| Rate for Payer: Adventist Health Commercial |
$855.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,633.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,351.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,206.25
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,951.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,367.07
|
| Rate for Payer: Blue Shield of California Commercial |
$3,304.57
|
| Rate for Payer: Blue Shield of California EPN |
$2,154.60
|
| Rate for Payer: Cash Price |
$2,351.25
|
| Rate for Payer: Central Health Plan Commercial |
$3,420.00
|
| Rate for Payer: Cigna of CA HMO |
$2,992.50
|
| Rate for Payer: Cigna of CA PPO |
$2,992.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,633.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,633.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,633.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,710.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,710.00
|
| Rate for Payer: Galaxy Health WC |
$3,633.75
|
| Rate for Payer: Global Benefits Group Commercial |
$2,565.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,847.50
|
| Rate for Payer: InnovAge PACE Commercial |
$2,137.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,851.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,628.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,646.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$855.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,992.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,992.50
|
| Rate for Payer: Multiplan Commercial |
$3,206.25
|
| Rate for Payer: Networks By Design Commercial |
$2,137.50
|
| Rate for Payer: Prime Health Services Commercial |
$3,633.75
|
| Rate for Payer: Riverside University Health System MISP |
$1,710.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,565.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,565.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,604.41
|
| Rate for Payer: United Healthcare All Other HMO |
$1,561.66
|
| Rate for Payer: United Healthcare HMO Rider |
$1,527.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,400.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,633.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,633.75
|
| Rate for Payer: Vantage Medical Group Senior |
$3,633.75
|
|
|
HC STENT EV3 VISI PRO
|
Facility
|
OP
|
$3,705.00
|
|
|
Service Code
|
CPT C1876
|
| Hospital Charge Code |
909020092
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$741.00 |
| Max. Negotiated Rate |
$3,334.50 |
| Rate for Payer: Adventist Health Commercial |
$741.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,149.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,037.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,778.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,691.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,051.46
|
| Rate for Payer: Blue Shield of California Commercial |
$2,863.97
|
| Rate for Payer: Blue Shield of California EPN |
$1,867.32
|
| Rate for Payer: Cash Price |
$2,037.75
|
| Rate for Payer: Central Health Plan Commercial |
$2,964.00
|
| Rate for Payer: Cigna of CA HMO |
$2,593.50
|
| Rate for Payer: Cigna of CA PPO |
$2,593.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,149.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,149.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,149.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,482.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,482.00
|
| Rate for Payer: Galaxy Health WC |
$3,149.25
|
| Rate for Payer: Global Benefits Group Commercial |
$2,223.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,334.50
|
| Rate for Payer: InnovAge PACE Commercial |
$1,852.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,471.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,411.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,293.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$741.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,593.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,593.50
|
| Rate for Payer: Multiplan Commercial |
$2,778.75
|
| Rate for Payer: Networks By Design Commercial |
$1,852.50
|
| Rate for Payer: Prime Health Services Commercial |
$3,149.25
|
| Rate for Payer: Riverside University Health System MISP |
$1,482.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,223.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,223.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,390.49
|
| Rate for Payer: United Healthcare All Other HMO |
$1,353.44
|
| Rate for Payer: United Healthcare HMO Rider |
$1,324.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,213.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,149.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,149.25
|
| Rate for Payer: Vantage Medical Group Senior |
$3,149.25
|
|
|
HC STENT EV3 VISI PRO
|
Facility
|
IP
|
$3,705.00
|
|
|
Service Code
|
CPT C1876
|
| Hospital Charge Code |
909020092
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$741.00 |
| Max. Negotiated Rate |
$3,334.50 |
| Rate for Payer: Adventist Health Commercial |
$741.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,863.97
|
| Rate for Payer: Blue Shield of California EPN |
$1,867.32
|
| Rate for Payer: Cash Price |
$2,037.75
|
| Rate for Payer: Central Health Plan Commercial |
$2,964.00
|
| Rate for Payer: Cigna of CA HMO |
$2,593.50
|
| Rate for Payer: Cigna of CA PPO |
$2,593.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,482.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,482.00
|
| Rate for Payer: Galaxy Health WC |
$3,149.25
|
| Rate for Payer: Global Benefits Group Commercial |
$2,223.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,334.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,471.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,411.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,293.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$741.00
|
| Rate for Payer: Multiplan Commercial |
$2,778.75
|
| Rate for Payer: Networks By Design Commercial |
$1,852.50
|
| Rate for Payer: Prime Health Services Commercial |
$3,149.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,390.49
|
| Rate for Payer: United Healthcare All Other HMO |
$1,353.44
|
| Rate for Payer: United Healthcare HMO Rider |
$1,324.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,213.39
|
|
|
HC STENT EVO-25-30-10-C UNCOVERED
|
Facility
|
IP
|
$5,200.00
|
|
|
Service Code
|
CPT C1876
|
| Hospital Charge Code |
900100396
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,040.00 |
| Max. Negotiated Rate |
$4,680.00 |
| Rate for Payer: Adventist Health Commercial |
$1,040.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,019.60
|
| Rate for Payer: Blue Shield of California EPN |
$2,620.80
|
| Rate for Payer: Cash Price |
$2,860.00
|
| Rate for Payer: Central Health Plan Commercial |
$4,160.00
|
| Rate for Payer: Cigna of CA HMO |
$3,640.00
|
| Rate for Payer: Cigna of CA PPO |
$3,640.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,080.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2,080.00
|
| Rate for Payer: Galaxy Health WC |
$4,420.00
|
| Rate for Payer: Global Benefits Group Commercial |
$3,120.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$4,680.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,468.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,981.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,218.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,040.00
|
| Rate for Payer: Multiplan Commercial |
$3,900.00
|
| Rate for Payer: Networks By Design Commercial |
$2,600.00
|
| Rate for Payer: Prime Health Services Commercial |
$4,420.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,951.56
|
| Rate for Payer: United Healthcare All Other HMO |
$1,899.56
|
| Rate for Payer: United Healthcare HMO Rider |
$1,858.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,703.00
|
|
|
HC STENT EVO-25-30-10-C UNCOVERED
|
Facility
|
OP
|
$5,200.00
|
|
|
Service Code
|
CPT C1876
|
| Hospital Charge Code |
900100396
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,040.00 |
| Max. Negotiated Rate |
$4,680.00 |
| Rate for Payer: Adventist Health Commercial |
$1,040.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,420.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,860.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,900.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2,374.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,879.24
|
| Rate for Payer: Blue Shield of California Commercial |
$4,019.60
|
| Rate for Payer: Blue Shield of California EPN |
$2,620.80
|
| Rate for Payer: Cash Price |
$2,860.00
|
| Rate for Payer: Central Health Plan Commercial |
$4,160.00
|
| Rate for Payer: Cigna of CA HMO |
$3,640.00
|
| Rate for Payer: Cigna of CA PPO |
$3,640.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,420.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,420.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,420.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,080.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2,080.00
|
| Rate for Payer: Galaxy Health WC |
$4,420.00
|
| Rate for Payer: Global Benefits Group Commercial |
$3,120.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$4,680.00
|
| Rate for Payer: InnovAge PACE Commercial |
$2,600.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,468.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,981.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,218.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,040.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,640.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,640.00
|
| Rate for Payer: Multiplan Commercial |
$3,900.00
|
| Rate for Payer: Networks By Design Commercial |
$2,600.00
|
| Rate for Payer: Prime Health Services Commercial |
$4,420.00
|
| Rate for Payer: Riverside University Health System MISP |
$2,080.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,120.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,120.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,951.56
|
| Rate for Payer: United Healthcare All Other HMO |
$1,899.56
|
| Rate for Payer: United Healthcare HMO Rider |
$1,858.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,703.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,420.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,420.00
|
| Rate for Payer: Vantage Medical Group Senior |
$4,420.00
|
|
|
HC STENT EVO-25-30-8-C UNCOVERED
|
Facility
|
IP
|
$5,200.00
|
|
|
Service Code
|
CPT C1876
|
| Hospital Charge Code |
900100397
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,040.00 |
| Max. Negotiated Rate |
$4,680.00 |
| Rate for Payer: Adventist Health Commercial |
$1,040.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,019.60
|
| Rate for Payer: Blue Shield of California EPN |
$2,620.80
|
| Rate for Payer: Cash Price |
$2,860.00
|
| Rate for Payer: Central Health Plan Commercial |
$4,160.00
|
| Rate for Payer: Cigna of CA HMO |
$3,640.00
|
| Rate for Payer: Cigna of CA PPO |
$3,640.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,080.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2,080.00
|
| Rate for Payer: Galaxy Health WC |
$4,420.00
|
| Rate for Payer: Global Benefits Group Commercial |
$3,120.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$4,680.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,468.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,981.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,218.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,040.00
|
| Rate for Payer: Multiplan Commercial |
$3,900.00
|
| Rate for Payer: Networks By Design Commercial |
$2,600.00
|
| Rate for Payer: Prime Health Services Commercial |
$4,420.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,951.56
|
| Rate for Payer: United Healthcare All Other HMO |
$1,899.56
|
| Rate for Payer: United Healthcare HMO Rider |
$1,858.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,703.00
|
|
|
HC STENT EVO-25-30-8-C UNCOVERED
|
Facility
|
OP
|
$5,200.00
|
|
|
Service Code
|
CPT C1876
|
| Hospital Charge Code |
900100397
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,040.00 |
| Max. Negotiated Rate |
$4,680.00 |
| Rate for Payer: Adventist Health Commercial |
$1,040.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,420.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,860.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,900.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2,374.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,879.24
|
| Rate for Payer: Blue Shield of California Commercial |
$4,019.60
|
| Rate for Payer: Blue Shield of California EPN |
$2,620.80
|
| Rate for Payer: Cash Price |
$2,860.00
|
| Rate for Payer: Central Health Plan Commercial |
$4,160.00
|
| Rate for Payer: Cigna of CA HMO |
$3,640.00
|
| Rate for Payer: Cigna of CA PPO |
$3,640.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,420.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,420.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,420.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,080.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2,080.00
|
| Rate for Payer: Galaxy Health WC |
$4,420.00
|
| Rate for Payer: Global Benefits Group Commercial |
$3,120.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$4,680.00
|
| Rate for Payer: InnovAge PACE Commercial |
$2,600.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,468.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,981.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,218.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,040.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,640.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,640.00
|
| Rate for Payer: Multiplan Commercial |
$3,900.00
|
| Rate for Payer: Networks By Design Commercial |
$2,600.00
|
| Rate for Payer: Prime Health Services Commercial |
$4,420.00
|
| Rate for Payer: Riverside University Health System MISP |
$2,080.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,120.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,120.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,951.56
|
| Rate for Payer: United Healthcare All Other HMO |
$1,899.56
|
| Rate for Payer: United Healthcare HMO Rider |
$1,858.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,703.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,420.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,420.00
|
| Rate for Payer: Vantage Medical Group Senior |
$4,420.00
|
|
|
HC STENT FEM/POP
|
Facility
|
IP
|
$19,952.00
|
|
|
Service Code
|
CPT 37226
|
| Hospital Charge Code |
906820150
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$3,990.40 |
| Max. Negotiated Rate |
$17,956.80 |
| Rate for Payer: Adventist Health Commercial |
$3,990.40
|
| Rate for Payer: Cash Price |
$10,973.60
|
| Rate for Payer: Central Health Plan Commercial |
$15,961.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,980.80
|
| Rate for Payer: EPIC Health Plan Senior |
$7,980.80
|
| Rate for Payer: Galaxy Health WC |
$16,959.20
|
| Rate for Payer: Global Benefits Group Commercial |
$11,971.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$17,956.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13,307.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7,601.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$12,350.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,990.40
|
| Rate for Payer: Multiplan Commercial |
$14,964.00
|
| Rate for Payer: Networks By Design Commercial |
$12,968.80
|
| Rate for Payer: Prime Health Services Commercial |
$16,959.20
|
|
|
HC STENT FEM/POP
|
Facility
|
OP
|
$16,959.00
|
|
|
Service Code
|
CPT 37226
|
| Hospital Charge Code |
909020067
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$758.83 |
| Max. Negotiated Rate |
$50,447.00 |
| Rate for Payer: Adventist Health Commercial |
$3,391.80
|
| Rate for Payer: Adventist Health Medi-Cal |
$14,409.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10,567.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21,613.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15,850.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14,409.33
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,581.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$22,958.69
|
| Rate for Payer: Blue Shield of California Commercial |
$5,999.40
|
| Rate for Payer: Blue Shield of California EPN |
$3,914.40
|
| Rate for Payer: Cash Price |
$9,327.45
|
| Rate for Payer: Cash Price |
$9,327.45
|
| Rate for Payer: Cash Price |
$9,327.45
|
| Rate for Payer: Central Health Plan Commercial |
$13,567.20
|
| Rate for Payer: Cigna of CA HMO |
$10,853.76
|
| Rate for Payer: Cigna of CA PPO |
$12,549.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21,613.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$15,850.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14,409.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$19,452.60
|
| Rate for Payer: EPIC Health Plan Senior |
$14,409.33
|
| Rate for Payer: Galaxy Health WC |
$14,415.15
|
| Rate for Payer: Global Benefits Group Commercial |
$10,175.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$15,263.10
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$23,631.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$758.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14,409.33
|
| Rate for Payer: InnovAge PACE Commercial |
$21,613.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11,311.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$838.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14,409.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,391.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19,308.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$19,308.50
|
| Rate for Payer: Multiplan Commercial |
$12,719.25
|
| Rate for Payer: Multiplan WC |
$22,958.69
|
| Rate for Payer: Networks By Design Commercial |
$11,023.35
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$14,409.33
|
| Rate for Payer: Preferred Health Network WC |
$23,427.23
|
| Rate for Payer: Prime Health Services Commercial |
$14,415.15
|
| Rate for Payer: Prime Health Services Medicare |
$15,273.89
|
| Rate for Payer: Prime Health Services WC |
$22,724.41
|
| Rate for Payer: Riverside University Health System MISP |
$15,850.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10,175.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$31,261.00
|
| Rate for Payer: United Healthcare All Other HMO |
$50,447.00
|
| Rate for Payer: United Healthcare HMO Rider |
$32,656.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$30,398.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$14,409.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21,613.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15,850.26
|
| Rate for Payer: Vantage Medical Group Senior |
$14,409.33
|
|
|
HC STENT FEM/POP
|
Facility
|
IP
|
$16,959.00
|
|
|
Service Code
|
CPT 37226
|
| Hospital Charge Code |
909020067
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$3,391.80 |
| Max. Negotiated Rate |
$15,263.10 |
| Rate for Payer: Adventist Health Commercial |
$3,391.80
|
| Rate for Payer: Cash Price |
$9,327.45
|
| Rate for Payer: Central Health Plan Commercial |
$13,567.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,783.60
|
| Rate for Payer: EPIC Health Plan Senior |
$6,783.60
|
| Rate for Payer: Galaxy Health WC |
$14,415.15
|
| Rate for Payer: Global Benefits Group Commercial |
$10,175.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$15,263.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11,311.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6,461.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10,497.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,391.80
|
| Rate for Payer: Multiplan Commercial |
$12,719.25
|
| Rate for Payer: Networks By Design Commercial |
$11,023.35
|
| Rate for Payer: Prime Health Services Commercial |
$14,415.15
|
|
|
HC STENT FEM/POP
|
Facility
|
OP
|
$19,952.00
|
|
|
Service Code
|
CPT 37226
|
| Hospital Charge Code |
906820150
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$758.83 |
| Max. Negotiated Rate |
$50,447.00 |
| Rate for Payer: Adventist Health Commercial |
$3,990.40
|
| Rate for Payer: Adventist Health Medi-Cal |
$14,409.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10,567.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21,613.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15,850.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14,409.33
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,581.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$22,958.69
|
| Rate for Payer: Blue Shield of California Commercial |
$5,999.40
|
| Rate for Payer: Blue Shield of California EPN |
$3,914.40
|
| Rate for Payer: Cash Price |
$10,973.60
|
| Rate for Payer: Cash Price |
$10,973.60
|
| Rate for Payer: Cash Price |
$10,973.60
|
| Rate for Payer: Central Health Plan Commercial |
$15,961.60
|
| Rate for Payer: Cigna of CA HMO |
$12,769.28
|
| Rate for Payer: Cigna of CA PPO |
$14,764.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21,613.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$15,850.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14,409.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$19,452.60
|
| Rate for Payer: EPIC Health Plan Senior |
$14,409.33
|
| Rate for Payer: Galaxy Health WC |
$16,959.20
|
| Rate for Payer: Global Benefits Group Commercial |
$11,971.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$17,956.80
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$23,631.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$758.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14,409.33
|
| Rate for Payer: InnovAge PACE Commercial |
$21,613.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13,307.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$838.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14,409.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,990.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19,308.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$19,308.50
|
| Rate for Payer: Multiplan Commercial |
$14,964.00
|
| Rate for Payer: Multiplan WC |
$22,958.69
|
| Rate for Payer: Networks By Design Commercial |
$12,968.80
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$14,409.33
|
| Rate for Payer: Preferred Health Network WC |
$23,427.23
|
| Rate for Payer: Prime Health Services Commercial |
$16,959.20
|
| Rate for Payer: Prime Health Services Medicare |
$15,273.89
|
| Rate for Payer: Prime Health Services WC |
$22,724.41
|
| Rate for Payer: Riverside University Health System MISP |
$15,850.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11,971.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$31,261.00
|
| Rate for Payer: United Healthcare All Other HMO |
$50,447.00
|
| Rate for Payer: United Healthcare HMO Rider |
$32,656.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$30,398.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$14,409.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21,613.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15,850.26
|
| Rate for Payer: Vantage Medical Group Senior |
$14,409.33
|
|
|
HC STENT FLAIR
|
Facility
|
IP
|
$6,250.00
|
|
|
Service Code
|
CPT C1876
|
| Hospital Charge Code |
909020120
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,250.00 |
| Max. Negotiated Rate |
$5,625.00 |
| Rate for Payer: Adventist Health Commercial |
$1,250.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,831.25
|
| Rate for Payer: Blue Shield of California EPN |
$3,150.00
|
| Rate for Payer: Cash Price |
$3,437.50
|
| Rate for Payer: Central Health Plan Commercial |
$5,000.00
|
| Rate for Payer: Cigna of CA HMO |
$4,375.00
|
| Rate for Payer: Cigna of CA PPO |
$4,375.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,500.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2,500.00
|
| Rate for Payer: Galaxy Health WC |
$5,312.50
|
| Rate for Payer: Global Benefits Group Commercial |
$3,750.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$5,625.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,168.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,381.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,868.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,250.00
|
| Rate for Payer: Multiplan Commercial |
$4,687.50
|
| Rate for Payer: Networks By Design Commercial |
$3,125.00
|
| Rate for Payer: Prime Health Services Commercial |
$5,312.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,345.62
|
| Rate for Payer: United Healthcare All Other HMO |
$2,283.12
|
| Rate for Payer: United Healthcare HMO Rider |
$2,233.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,046.88
|
|
|
HC STENT FLAIR
|
Facility
|
OP
|
$6,250.00
|
|
|
Service Code
|
CPT C1876
|
| Hospital Charge Code |
909020120
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,250.00 |
| Max. Negotiated Rate |
$5,625.00 |
| Rate for Payer: Adventist Health Commercial |
$1,250.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,312.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,437.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,687.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2,853.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,460.62
|
| Rate for Payer: Blue Shield of California Commercial |
$4,831.25
|
| Rate for Payer: Blue Shield of California EPN |
$3,150.00
|
| Rate for Payer: Cash Price |
$3,437.50
|
| Rate for Payer: Central Health Plan Commercial |
$5,000.00
|
| Rate for Payer: Cigna of CA HMO |
$4,375.00
|
| Rate for Payer: Cigna of CA PPO |
$4,375.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,312.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,312.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5,312.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,500.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2,500.00
|
| Rate for Payer: Galaxy Health WC |
$5,312.50
|
| Rate for Payer: Global Benefits Group Commercial |
$3,750.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$5,625.00
|
| Rate for Payer: InnovAge PACE Commercial |
$3,125.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,168.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,381.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,868.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,250.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,375.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,375.00
|
| Rate for Payer: Multiplan Commercial |
$4,687.50
|
| Rate for Payer: Networks By Design Commercial |
$3,125.00
|
| Rate for Payer: Prime Health Services Commercial |
$5,312.50
|
| Rate for Payer: Riverside University Health System MISP |
$2,500.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,750.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,750.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,345.62
|
| Rate for Payer: United Healthcare All Other HMO |
$2,283.12
|
| Rate for Payer: United Healthcare HMO Rider |
$2,233.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,046.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,312.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,312.50
|
| Rate for Payer: Vantage Medical Group Senior |
$5,312.50
|
|
|
HC STENT GENESIS MOUNTED
|
Facility
|
OP
|
$3,900.00
|
|
|
Service Code
|
CPT C1876
|
| Hospital Charge Code |
909020089
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$780.00 |
| Max. Negotiated Rate |
$3,510.00 |
| Rate for Payer: Adventist Health Commercial |
$780.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,315.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,145.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,925.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,780.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,159.43
|
| Rate for Payer: Blue Shield of California Commercial |
$3,014.70
|
| Rate for Payer: Blue Shield of California EPN |
$1,965.60
|
| Rate for Payer: Cash Price |
$2,145.00
|
| Rate for Payer: Central Health Plan Commercial |
$3,120.00
|
| Rate for Payer: Cigna of CA HMO |
$2,730.00
|
| Rate for Payer: Cigna of CA PPO |
$2,730.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,315.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,315.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,315.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,560.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,560.00
|
| Rate for Payer: Galaxy Health WC |
$3,315.00
|
| Rate for Payer: Global Benefits Group Commercial |
$2,340.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,510.00
|
| Rate for Payer: InnovAge PACE Commercial |
$1,950.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,601.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,485.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,414.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$780.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,730.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,730.00
|
| Rate for Payer: Multiplan Commercial |
$2,925.00
|
| Rate for Payer: Networks By Design Commercial |
$1,950.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,315.00
|
| Rate for Payer: Riverside University Health System MISP |
$1,560.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,340.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,340.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,463.67
|
| Rate for Payer: United Healthcare All Other HMO |
$1,424.67
|
| Rate for Payer: United Healthcare HMO Rider |
$1,393.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,277.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,315.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,315.00
|
| Rate for Payer: Vantage Medical Group Senior |
$3,315.00
|
|
|
HC STENT GENESIS MOUNTED
|
Facility
|
IP
|
$3,900.00
|
|
|
Service Code
|
CPT C1876
|
| Hospital Charge Code |
909020089
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$780.00 |
| Max. Negotiated Rate |
$3,510.00 |
| Rate for Payer: Adventist Health Commercial |
$780.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,014.70
|
| Rate for Payer: Blue Shield of California EPN |
$1,965.60
|
| Rate for Payer: Cash Price |
$2,145.00
|
| Rate for Payer: Central Health Plan Commercial |
$3,120.00
|
| Rate for Payer: Cigna of CA HMO |
$2,730.00
|
| Rate for Payer: Cigna of CA PPO |
$2,730.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,560.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,560.00
|
| Rate for Payer: Galaxy Health WC |
$3,315.00
|
| Rate for Payer: Global Benefits Group Commercial |
$2,340.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,510.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,601.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,485.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,414.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$780.00
|
| Rate for Payer: Multiplan Commercial |
$2,925.00
|
| Rate for Payer: Networks By Design Commercial |
$1,950.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,315.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,463.67
|
| Rate for Payer: United Healthcare All Other HMO |
$1,424.67
|
| Rate for Payer: United Healthcare HMO Rider |
$1,393.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,277.25
|
|
|
HC STENT GENESIS UNMOUNTED
|
Facility
|
IP
|
$3,900.00
|
|
|
Service Code
|
CPT C1877
|
| Hospital Charge Code |
909020090
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$780.00 |
| Max. Negotiated Rate |
$3,510.00 |
| Rate for Payer: Adventist Health Commercial |
$780.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,014.70
|
| Rate for Payer: Blue Shield of California EPN |
$1,965.60
|
| Rate for Payer: Cash Price |
$2,145.00
|
| Rate for Payer: Central Health Plan Commercial |
$3,120.00
|
| Rate for Payer: Cigna of CA HMO |
$2,730.00
|
| Rate for Payer: Cigna of CA PPO |
$2,730.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,560.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,560.00
|
| Rate for Payer: Galaxy Health WC |
$3,315.00
|
| Rate for Payer: Global Benefits Group Commercial |
$2,340.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,510.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,601.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,485.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,414.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$780.00
|
| Rate for Payer: Multiplan Commercial |
$2,925.00
|
| Rate for Payer: Networks By Design Commercial |
$1,950.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,315.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,463.67
|
| Rate for Payer: United Healthcare All Other HMO |
$1,424.67
|
| Rate for Payer: United Healthcare HMO Rider |
$1,393.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,277.25
|
|
|
HC STENT GENESIS UNMOUNTED
|
Facility
|
OP
|
$3,900.00
|
|
|
Service Code
|
CPT C1877
|
| Hospital Charge Code |
909020090
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$780.00 |
| Max. Negotiated Rate |
$3,510.00 |
| Rate for Payer: Adventist Health Commercial |
$780.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,315.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,145.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,925.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,780.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,159.43
|
| Rate for Payer: Blue Shield of California Commercial |
$3,014.70
|
| Rate for Payer: Blue Shield of California EPN |
$1,965.60
|
| Rate for Payer: Cash Price |
$2,145.00
|
| Rate for Payer: Central Health Plan Commercial |
$3,120.00
|
| Rate for Payer: Cigna of CA HMO |
$2,730.00
|
| Rate for Payer: Cigna of CA PPO |
$2,730.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,315.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,315.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,315.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,560.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,560.00
|
| Rate for Payer: Galaxy Health WC |
$3,315.00
|
| Rate for Payer: Global Benefits Group Commercial |
$2,340.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,510.00
|
| Rate for Payer: InnovAge PACE Commercial |
$1,950.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,601.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,485.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,414.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$780.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,730.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,730.00
|
| Rate for Payer: Multiplan Commercial |
$2,925.00
|
| Rate for Payer: Networks By Design Commercial |
$1,950.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,315.00
|
| Rate for Payer: Riverside University Health System MISP |
$1,560.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,340.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,340.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,463.67
|
| Rate for Payer: United Healthcare All Other HMO |
$1,424.67
|
| Rate for Payer: United Healthcare HMO Rider |
$1,393.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,277.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,315.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,315.00
|
| Rate for Payer: Vantage Medical Group Senior |
$3,315.00
|
|
|
HC STENT GENESIS XLG
|
Facility
|
OP
|
$4,500.00
|
|
|
Service Code
|
CPT C1877
|
| Hospital Charge Code |
909020091
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$900.00 |
| Max. Negotiated Rate |
$4,050.00 |
| Rate for Payer: Adventist Health Commercial |
$900.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,825.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,475.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,375.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2,054.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,491.65
|
| Rate for Payer: Blue Shield of California Commercial |
$3,478.50
|
| Rate for Payer: Blue Shield of California EPN |
$2,268.00
|
| Rate for Payer: Cash Price |
$2,475.00
|
| Rate for Payer: Central Health Plan Commercial |
$3,600.00
|
| Rate for Payer: Cigna of CA HMO |
$3,150.00
|
| Rate for Payer: Cigna of CA PPO |
$3,150.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,825.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,825.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,825.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,800.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,800.00
|
| Rate for Payer: Galaxy Health WC |
$3,825.00
|
| Rate for Payer: Global Benefits Group Commercial |
$2,700.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$4,050.00
|
| Rate for Payer: InnovAge PACE Commercial |
$2,250.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,001.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,714.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,785.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$900.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,150.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,150.00
|
| Rate for Payer: Multiplan Commercial |
$3,375.00
|
| Rate for Payer: Networks By Design Commercial |
$2,250.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,825.00
|
| Rate for Payer: Riverside University Health System MISP |
$1,800.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,700.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,700.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,688.85
|
| Rate for Payer: United Healthcare All Other HMO |
$1,643.85
|
| Rate for Payer: United Healthcare HMO Rider |
$1,608.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,473.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,825.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,825.00
|
| Rate for Payer: Vantage Medical Group Senior |
$3,825.00
|
|
