|
IOPROMIDE 370 MG IODINE/ML INTRAVENOUS SOLUTION [247558]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
IOPROMIDE 370 MG IODINE/ML INTRAVENOUS SOLUTION [247558]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
IOTHALAMATE MEGLUMINE 60 % INJECTION SOLUTION [10333]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
HCPCS Q9961
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.63
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
IOTHALAMATE MEGLUMINE 60 % INJECTION SOLUTION [10333]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
HCPCS Q9961
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [108955]
|
Facility
|
IP
|
$1,108.30
|
|
|
Service Code
|
HCPCS J9228
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$200.60 |
| Max. Negotiated Rate |
$831.23 |
| Rate for Payer: Adventist Health Commercial |
$221.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$713.75
|
| Rate for Payer: Cash Price |
$498.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$509.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$598.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$513.14
|
| Rate for Payer: Heritage Provider Network Senior |
$513.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$200.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$277.07
|
| Rate for Payer: Multiplan Commercial |
$831.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$400.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$366.96
|
|
|
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [108955]
|
Facility
|
OP
|
$1,108.30
|
|
|
Service Code
|
HCPCS J9228
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$177.54 |
| Max. Negotiated Rate |
$831.23 |
| Rate for Payer: Adventist Health Commercial |
$221.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$684.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$285.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$209.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$190.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$290.83
|
| Rate for Payer: Blue Shield of California Commercial |
$177.54
|
| Rate for Payer: Blue Shield of California EPN |
$177.54
|
| Rate for Payer: Cash Price |
$498.74
|
| Rate for Payer: Cash Price |
$498.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$509.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$238.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$209.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$209.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$709.31
|
| Rate for Payer: EPIC Health Plan Medicare |
$190.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$513.14
|
| Rate for Payer: Heritage Provider Network Senior |
$513.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$190.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$528.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$200.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$218.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$277.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$255.18
|
| Rate for Payer: Multiplan Commercial |
$831.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$443.32
|
| Rate for Payer: TriValley Medical Group Senior |
$443.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$400.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$366.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$238.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$209.47
|
| Rate for Payer: Vantage Medical Group Senior |
$209.47
|
|
|
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 0378967131
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 0378967193
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 6068740579
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 6068740583
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 0378967193
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 6068740583
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 0378967131
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 6068740579
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION [207748]
|
Facility
|
OP
|
$155.74
|
|
|
Service Code
|
NDC 0597002402
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.19 |
| Max. Negotiated Rate |
$132.38 |
| Rate for Payer: Adventist Health Commercial |
$31.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$96.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$132.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$85.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$116.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$77.90
|
| Rate for Payer: Blue Shield of California Commercial |
$95.00
|
| Rate for Payer: Blue Shield of California EPN |
$76.00
|
| Rate for Payer: Cash Price |
$70.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$101.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$132.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$132.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$132.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$99.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$96.40
|
| Rate for Payer: Heritage Provider Network Senior |
$96.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$74.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$28.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$109.02
|
| Rate for Payer: Multiplan Commercial |
$116.81
|
| Rate for Payer: TriValley Medical Group Commercial |
$62.30
|
| Rate for Payer: TriValley Medical Group Senior |
$62.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$77.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$77.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$132.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$132.38
|
| Rate for Payer: Vantage Medical Group Senior |
$132.38
|
|
|
IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION [207748]
|
Facility
|
IP
|
$155.74
|
|
|
Service Code
|
NDC 0597002402
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.19 |
| Max. Negotiated Rate |
$116.81 |
| Rate for Payer: Adventist Health Commercial |
$31.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$100.30
|
| Rate for Payer: Cash Price |
$70.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$105.44
|
| Rate for Payer: Heritage Provider Network Senior |
$105.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$28.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.94
|
| Rate for Payer: Multiplan Commercial |
$116.81
|
|
|
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION [12580]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 7620410030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION [12580]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 7620410030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION [12580]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 6068739479
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION [12580]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0487980101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION [12580]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 6068739483
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION [12580]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 6068739483
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION [12580]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0487980101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION [12580]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 6068739479
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER [41142]
|
Facility
|
IP
|
$28.54
|
|
|
Service Code
|
NDC 0597008717
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.17 |
| Max. Negotiated Rate |
$21.41 |
| Rate for Payer: Adventist Health Commercial |
$5.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.38
|
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.32
|
| Rate for Payer: Heritage Provider Network Senior |
$19.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.13
|
| Rate for Payer: Multiplan Commercial |
$21.41
|
|
