|
SUMATRIPTAN 25 MG TABLET [15327]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
NDC 55111-291-09
|
| Hospital Charge Code |
1712200
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.25
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.81
|
| Rate for Payer: Dignity Health Senior |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Senior |
$1.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.85
|
| Rate for Payer: TriValley Medical Group Senior |
$0.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Vantage Medical Group Senior |
$1.81
|
|
|
SUMATRIPTAN 25 MG TABLET [15327]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 65862-146-36
|
| Hospital Charge Code |
1712200
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
|
OP
|
$2.11
|
|
|
Service Code
|
NDC 63304-098-19
|
| Hospital Charge Code |
1712201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.58
|
| Rate for Payer: Blue Shield of California Commercial |
$1.31
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.79
|
| Rate for Payer: Dignity Health Senior |
$1.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.84
|
| Rate for Payer: TriValley Medical Group Senior |
$0.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.79
|
| Rate for Payer: Vantage Medical Group Senior |
$1.79
|
|
|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
|
IP
|
$2.11
|
|
|
Service Code
|
NDC 63304-098-19
|
| Hospital Charge Code |
1712201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.58 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.45
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.43
|
| Rate for Payer: Heritage Provider Network Senior |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
|
|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 65862-147-36
|
| Hospital Charge Code |
1712201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.45
|
| Rate for Payer: Dignity Health Senior |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Senior |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 65862-147-36
|
| Hospital Charge Code |
1712201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
|
|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
NDC 62756-521-69
|
| Hospital Charge Code |
1712201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
|
|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
NDC 62756-521-69
|
| Hospital Charge Code |
1712201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.25
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.81
|
| Rate for Payer: Dignity Health Senior |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Senior |
$1.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.85
|
| Rate for Payer: TriValley Medical Group Senior |
$0.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Vantage Medical Group Senior |
$1.81
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR [11467]
|
Facility
|
IP
|
$183.60
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
NDG11467B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.23 |
| Max. Negotiated Rate |
$137.70 |
| Rate for Payer: Adventist Health Commercial |
$36.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$126.13
|
| Rate for Payer: Cash Price |
$82.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$84.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$99.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$124.30
|
| Rate for Payer: Heritage Provider Network Senior |
$124.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.90
|
| Rate for Payer: Multiplan Commercial |
$137.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$66.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$61.34
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR [11467]
|
Facility
|
OP
|
$183.60
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
NDG11467B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$156.06 |
| Rate for Payer: Adventist Health Commercial |
$36.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$152.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$126.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$156.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$100.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$137.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.64
|
| Rate for Payer: Blue Shield of California Commercial |
$25.50
|
| Rate for Payer: Blue Shield of California EPN |
$25.50
|
| Rate for Payer: Cash Price |
$82.62
|
| Rate for Payer: Cash Price |
$82.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$84.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$156.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$156.06
|
| Rate for Payer: Dignity Health Senior |
$156.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$117.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$85.01
|
| Rate for Payer: Heritage Provider Network Senior |
$85.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$88.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.90
|
| Rate for Payer: Multiplan Commercial |
$137.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$73.44
|
| Rate for Payer: TriValley Medical Group Senior |
$73.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$66.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$61.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$156.06
|
| Rate for Payer: Vantage Medical Group Senior |
$156.06
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97342]
|
Facility
|
OP
|
$26.40
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
1721041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.78 |
| Max. Negotiated Rate |
$152.02 |
| Rate for Payer: Adventist Health Commercial |
$5.28
|
| Rate for Payer: Adventist Health Commercial |
$23.52
|
| Rate for Payer: Adventist Health Commercial |
$32.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$152.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$152.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$152.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$112.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$99.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$138.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$64.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$89.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$88.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$122.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.64
|
| Rate for Payer: Blue Shield of California Commercial |
$25.50
|
| Rate for Payer: Blue Shield of California Commercial |
$25.50
|
| Rate for Payer: Blue Shield of California Commercial |
$25.50
|
| Rate for Payer: Blue Shield of California EPN |
$25.50
|
| Rate for Payer: Blue Shield of California EPN |
$25.50
|
| Rate for Payer: Blue Shield of California EPN |
$25.50
|
| Rate for Payer: Cash Price |
$52.92
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Cash Price |
$52.92
|
| Rate for Payer: Cash Price |
$73.58
|
| Rate for Payer: Cash Price |
$73.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$75.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$138.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$138.99
|
| Rate for Payer: Dignity Health Senior |
$99.96
|
| Rate for Payer: Dignity Health Senior |
$138.99
|
| Rate for Payer: Dignity Health Senior |
$22.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$75.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$104.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.22
|
| Rate for Payer: Heritage Provider Network Senior |
$12.22
|
| Rate for Payer: Heritage Provider Network Senior |
$54.45
|
| Rate for Payer: Heritage Provider Network Senior |
$75.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$78.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$56.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Commercial |
$88.20
|
| Rate for Payer: Multiplan Commercial |
$19.80
|
| Rate for Payer: Multiplan Commercial |
$122.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$65.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$47.04
|
| Rate for Payer: TriValley Medical Group Senior |
$47.04
|
| Rate for Payer: TriValley Medical Group Senior |
$10.56
|
| Rate for Payer: TriValley Medical Group Senior |
$65.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$59.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$54.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$138.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.96
|
| Rate for Payer: Vantage Medical Group Senior |
$99.96
|
| Rate for Payer: Vantage Medical Group Senior |
$138.99
|
| Rate for Payer: Vantage Medical Group Senior |
$22.44
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97342]
|
Facility
|
IP
|
$26.40
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
1721041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.78 |
| Max. Negotiated Rate |
$19.80 |
| Rate for Payer: Adventist Health Commercial |
$5.28
|
| Rate for Payer: Adventist Health Commercial |
$23.52
|
| Rate for Payer: Adventist Health Commercial |
$32.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$112.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.79
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Cash Price |
$73.58
|
| Rate for Payer: Cash Price |
$52.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$75.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$63.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$88.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$79.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$110.70
|
| Rate for Payer: Heritage Provider Network Senior |
$110.70
|
| Rate for Payer: Heritage Provider Network Senior |
$79.62
|
| Rate for Payer: Heritage Provider Network Senior |
$17.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Commercial |
$19.80
|
| Rate for Payer: Multiplan Commercial |
$88.20
|
| Rate for Payer: Multiplan Commercial |
$122.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$59.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$54.63
|
|
|
SUMATRIPTAN ORAL SUSPENSION COMPOUND 5 MG/ML [4080344]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
NDC 9994-0803-44
|
| Hospital Charge Code |
1715019
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Senior |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
SUMATRIPTAN ORAL SUSPENSION COMPOUND 5 MG/ML [4080344]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
NDC 9994-0803-44
|
| Hospital Charge Code |
1715019
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Blue Shield of California Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: Dignity Health Senior |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Senior |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Senior |
$0.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
SUNITINIB MALATE 12.5 MG CAPSULE [70424]
|
Facility
|
OP
|
$268.64
|
|
|
Service Code
|
NDC 0069-0550-38
|
| Hospital Charge Code |
1712626
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.62 |
| Max. Negotiated Rate |
$228.34 |
| Rate for Payer: Adventist Health Commercial |
$53.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$143.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$184.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$228.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$147.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$201.48
|
| Rate for Payer: Blue Shield of California Commercial |
$166.83
|
| Rate for Payer: Blue Shield of California EPN |
$157.69
|
| Rate for Payer: Cash Price |
$120.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$174.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$228.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.34
|
| Rate for Payer: Dignity Health Senior |
$228.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$171.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$166.29
|
| Rate for Payer: Heritage Provider Network Senior |
$166.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$129.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.16
|
| Rate for Payer: Multiplan Commercial |
$201.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$107.46
|
| Rate for Payer: TriValley Medical Group Senior |
$107.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.34
|
| Rate for Payer: Vantage Medical Group Senior |
$228.34
|
|
|
SUNITINIB MALATE 12.5 MG CAPSULE [70424]
|
Facility
|
IP
|
$268.64
|
|
|
Service Code
|
NDC 0069-0550-38
|
| Hospital Charge Code |
1712626
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.62 |
| Max. Negotiated Rate |
$201.48 |
| Rate for Payer: Adventist Health Commercial |
$53.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$184.56
|
| Rate for Payer: Cash Price |
$120.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$181.87
|
| Rate for Payer: Heritage Provider Network Senior |
$181.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.16
|
| Rate for Payer: Multiplan Commercial |
$201.48
|
|
|
SUNITINIB MALATE 25 MG CAPSULE [70425]
|
Facility
|
OP
|
$537.29
|
|
|
Service Code
|
NDC 0069-0770-38
|
| Hospital Charge Code |
1712627
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$97.25 |
| Max. Negotiated Rate |
$456.70 |
| Rate for Payer: Adventist Health Commercial |
$107.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$287.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$369.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$456.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$295.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$402.97
|
| Rate for Payer: Blue Shield of California Commercial |
$333.66
|
| Rate for Payer: Blue Shield of California EPN |
$315.39
|
| Rate for Payer: Cash Price |
$241.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$349.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$456.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$456.70
|
| Rate for Payer: Dignity Health Senior |
$456.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$343.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$332.58
|
| Rate for Payer: Heritage Provider Network Senior |
$332.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$258.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.32
|
| Rate for Payer: Multiplan Commercial |
$402.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$214.92
|
| Rate for Payer: TriValley Medical Group Senior |
$214.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$456.70
|
| Rate for Payer: Vantage Medical Group Senior |
$456.70
|
|
|
SUNITINIB MALATE 25 MG CAPSULE [70425]
|
Facility
|
IP
|
$537.29
|
|
|
Service Code
|
NDC 0069-0770-38
|
| Hospital Charge Code |
1712627
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$97.25 |
| Max. Negotiated Rate |
$402.97 |
| Rate for Payer: Adventist Health Commercial |
$107.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$369.12
|
| Rate for Payer: Cash Price |
$241.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$290.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$363.75
|
| Rate for Payer: Heritage Provider Network Senior |
$363.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.32
|
| Rate for Payer: Multiplan Commercial |
$402.97
|
|
|
SUNITINIB MALATE 50 MG CAPSULE [70426]
|
Facility
|
OP
|
$935.35
|
|
|
Service Code
|
NDC 0069-0980-38
|
| Hospital Charge Code |
1711857
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$169.30 |
| Max. Negotiated Rate |
$795.05 |
| Rate for Payer: Adventist Health Commercial |
$187.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$499.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$642.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$795.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$514.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$701.51
|
| Rate for Payer: Blue Shield of California Commercial |
$580.85
|
| Rate for Payer: Blue Shield of California EPN |
$549.05
|
| Rate for Payer: Cash Price |
$420.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$607.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$795.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$795.05
|
| Rate for Payer: Dignity Health Senior |
$795.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$598.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$578.98
|
| Rate for Payer: Heritage Provider Network Senior |
$578.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$450.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$169.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$233.84
|
| Rate for Payer: Multiplan Commercial |
$701.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$374.14
|
| Rate for Payer: TriValley Medical Group Senior |
$374.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$795.05
|
| Rate for Payer: Vantage Medical Group Senior |
$795.05
|
|
|
SUNITINIB MALATE 50 MG CAPSULE [70426]
|
Facility
|
IP
|
$935.35
|
|
|
Service Code
|
NDC 0069-0980-38
|
| Hospital Charge Code |
1711857
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$169.30 |
| Max. Negotiated Rate |
$701.51 |
| Rate for Payer: Adventist Health Commercial |
$187.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$642.59
|
| Rate for Payer: Cash Price |
$420.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$505.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$633.23
|
| Rate for Payer: Heritage Provider Network Senior |
$633.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$169.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$233.84
|
| Rate for Payer: Multiplan Commercial |
$701.51
|
|
|
Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 58180
|
| Min. Negotiated Rate |
$1,264.72 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,264.72
|
|
|
Suprahyoid lymphadenectomy
|
Facility
|
OP
|
$15,480.57
|
|
|
Service Code
|
CPT 38700
|
| Min. Negotiated Rate |
$157.98 |
| Max. Negotiated Rate |
$15,480.57 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12,221.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,962.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,147.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12,221.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,962.44
|
| Rate for Payer: Dignity Health Senior |
$8,147.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$8,147.67
|
| Rate for Payer: Humana Medicare |
$8,147.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$157.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,147.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15,480.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9,614.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10,266.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10,266.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,962.44
|
| Rate for Payer: TriValley Medical Group Senior |
$8,147.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12,221.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,962.44
|
| Rate for Payer: Vantage Medical Group Senior |
$8,147.67
|
|
|
Surgical closure tracheostomy or fistula; without plastic repair
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 31820
|
| Min. Negotiated Rate |
$323.50 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,022.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,424.96
|
| Rate for Payer: Dignity Health Senior |
$4,022.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,022.69
|
| Rate for Payer: Humana Medicare |
$4,022.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$323.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,022.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,643.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,746.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,068.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,068.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,424.96
|
| Rate for Payer: TriValley Medical Group Senior |
$4,022.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4,022.69
|
|
|
Surgical closure tracheostomy or fistula; with plastic repair
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 31825
|
| Min. Negotiated Rate |
$91.76 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,022.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,424.96
|
| Rate for Payer: Dignity Health Senior |
$4,022.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,022.69
|
| Rate for Payer: Humana Medicare |
$4,022.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$91.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,022.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,643.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,746.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,068.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,068.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,424.96
|
| Rate for Payer: TriValley Medical Group Senior |
$4,022.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4,022.69
|
|
|
SURGICAL LUBRICANT JELLY TOPICAL [112826]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 281020545
|
| Hospital Charge Code |
NDG112826C
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Senior |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
