|
HC 3D RENDERING W/POSTPROCESSING
|
Facility
|
IP
|
$770.00
|
|
|
Service Code
|
CPT 76377
|
| Hospital Charge Code |
909201370
|
|
Hospital Revenue Code
|
400
|
| Min. Negotiated Rate |
$139.37 |
| Max. Negotiated Rate |
$577.50 |
| Rate for Payer: Adventist Health Commercial |
$154.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$528.99
|
| Rate for Payer: Cash Price |
$346.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$521.29
|
| Rate for Payer: Heritage Provider Network Senior |
$521.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$139.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$192.50
|
| Rate for Payer: Multiplan Commercial |
$577.50
|
|
|
HC 3-PHASE BONE SCAN
|
Facility
|
OP
|
$2,712.00
|
|
|
Service Code
|
CPT 78315
|
| Hospital Charge Code |
909301372
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$204.52 |
| Max. Negotiated Rate |
$2,034.00 |
| Rate for Payer: Adventist Health Commercial |
$542.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$544.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,863.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$772.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$566.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$515.32
|
| Rate for Payer: Blue Shield of California Commercial |
$976.36
|
| Rate for Payer: Blue Shield of California EPN |
$555.23
|
| Rate for Payer: Cash Price |
$1,220.40
|
| Rate for Payer: Cash Price |
$1,220.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,762.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$772.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$566.85
|
| Rate for Payer: Dignity Health Senior |
$515.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,762.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$515.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,678.73
|
| Rate for Payer: Heritage Provider Network Senior |
$1,678.73
|
| Rate for Payer: Humana Medicare |
$515.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$204.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$515.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$979.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$490.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$608.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$678.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$649.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$649.30
|
| Rate for Payer: Multiplan Commercial |
$2,034.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$566.85
|
| Rate for Payer: TriValley Medical Group Senior |
$515.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$772.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$566.85
|
| Rate for Payer: Vantage Medical Group Senior |
$515.32
|
|
|
HC 3-PHASE BONE SCAN
|
Facility
|
IP
|
$2,712.00
|
|
|
Service Code
|
CPT 78315
|
| Hospital Charge Code |
909301372
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$490.87 |
| Max. Negotiated Rate |
$2,034.00 |
| Rate for Payer: Adventist Health Commercial |
$542.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,863.14
|
| Rate for Payer: Cash Price |
$1,220.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,836.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1,836.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$490.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$678.00
|
| Rate for Payer: Multiplan Commercial |
$2,034.00
|
|
|
HC 59 FE CHLORIDE
|
Facility
|
OP
|
$1,217.00
|
|
|
Service Code
|
CPT A4641
|
| Hospital Charge Code |
909301497
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$220.28 |
| Max. Negotiated Rate |
$1,034.45 |
| Rate for Payer: Adventist Health Commercial |
$243.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,034.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$669.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$912.75
|
| Rate for Payer: Blue Shield of California Commercial |
$755.76
|
| Rate for Payer: Blue Shield of California EPN |
$714.38
|
| Rate for Payer: Cash Price |
$547.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$559.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,034.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,034.45
|
| Rate for Payer: Dignity Health Senior |
$1,034.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$778.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$563.47
|
| Rate for Payer: Heritage Provider Network Senior |
$563.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$586.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$220.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$304.25
|
| Rate for Payer: Multiplan Commercial |
$912.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$486.80
|
| Rate for Payer: TriValley Medical Group Senior |
$486.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$443.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$406.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,034.45
|
| Rate for Payer: Vantage Medical Group Senior |
$1,034.45
|
|
|
HC 59 FE CHLORIDE
|
Facility
|
IP
|
$1,217.00
|
|
|
Service Code
|
CPT A4641
|
| Hospital Charge Code |
909301497
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$220.28 |
| Max. Negotiated Rate |
$912.75 |
| Rate for Payer: Adventist Health Commercial |
$243.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$836.08
|
| Rate for Payer: Cash Price |
$547.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$559.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$657.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$823.91
|
| Rate for Payer: Heritage Provider Network Senior |
$823.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$220.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$304.25
|
| Rate for Payer: Multiplan Commercial |
$912.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$443.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$406.60
|
|
|
HC 5-HIAA BY HPLC
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
CPT 83497
|
| Hospital Charge Code |
900910535
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.87 |
| Max. Negotiated Rate |
$107.97 |
| Rate for Payer: Adventist Health Commercial |
$9.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$37.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$107.97
|
| Rate for Payer: Blue Shield of California Commercial |
$100.68
|
| Rate for Payer: Blue Shield of California EPN |
$78.70
|
| Rate for Payer: Cash Price |
$22.05
|
| Rate for Payer: Cash Price |
$22.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.19
|
| Rate for Payer: Dignity Health Senior |
$12.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.33
|
| Rate for Payer: Heritage Provider Network Senior |
$30.33
|
| Rate for Payer: Humana Medicare |
$12.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$17.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$24.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.25
|
| Rate for Payer: Multiplan Commercial |
$36.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.90
|
| Rate for Payer: TriValley Medical Group Senior |
$12.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.19
|
| Rate for Payer: Vantage Medical Group Senior |
$12.90
|
|
|
HC 5-HIAA BY HPLC
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
CPT 83497
|
| Hospital Charge Code |
900910535
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.53 |
| Max. Negotiated Rate |
$97.50 |
| Rate for Payer: Adventist Health Commercial |
$26.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$89.31
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$88.01
|
| Rate for Payer: Heritage Provider Network Senior |
$88.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.50
|
| Rate for Payer: Multiplan Commercial |
$97.50
|
|
|
HC 5-HYDROXYINDOLACETIC ACID URINE 24 HOURS
|
Facility
|
IP
|
$153.00
|
|
|
Service Code
|
CPT 83497
|
| Hospital Charge Code |
900912191
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$27.69 |
| Max. Negotiated Rate |
$114.75 |
| Rate for Payer: Adventist Health Commercial |
$30.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$105.11
|
| Rate for Payer: Cash Price |
$68.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$103.58
|
| Rate for Payer: Heritage Provider Network Senior |
$103.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.25
|
| Rate for Payer: Multiplan Commercial |
$114.75
|
|
|
HC 5-HYDROXYINDOLACETIC ACID URINE 24 HOURS
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 83497
|
| Hospital Charge Code |
900912191
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$107.97 |
| Rate for Payer: Adventist Health Commercial |
$11.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$37.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$39.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$107.97
|
| Rate for Payer: Blue Shield of California Commercial |
$100.68
|
| Rate for Payer: Blue Shield of California EPN |
$78.70
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$37.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.19
|
| Rate for Payer: Dignity Health Senior |
$12.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.70
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.90
|
| Rate for Payer: Heritage Provider Network Senior |
$35.90
|
| Rate for Payer: Humana Medicare |
$12.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$17.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$24.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.25
|
| Rate for Payer: Multiplan Commercial |
$43.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.90
|
| Rate for Payer: TriValley Medical Group Senior |
$12.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.19
|
| Rate for Payer: Vantage Medical Group Senior |
$12.90
|
|
|
HC 5-HYDROXYINDOLACETIC ACID URINE RANDOM
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
CPT 83497
|
| Hospital Charge Code |
900912190
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.53 |
| Max. Negotiated Rate |
$97.50 |
| Rate for Payer: Adventist Health Commercial |
$26.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$89.31
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$88.01
|
| Rate for Payer: Heritage Provider Network Senior |
$88.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.50
|
| Rate for Payer: Multiplan Commercial |
$97.50
|
|
|
HC 5-HYDROXYINDOLACETIC ACID URINE RANDOM
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
CPT 83497
|
| Hospital Charge Code |
900912190
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.87 |
| Max. Negotiated Rate |
$107.97 |
| Rate for Payer: Adventist Health Commercial |
$9.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$37.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$107.97
|
| Rate for Payer: Blue Shield of California Commercial |
$100.68
|
| Rate for Payer: Blue Shield of California EPN |
$78.70
|
| Rate for Payer: Cash Price |
$22.05
|
| Rate for Payer: Cash Price |
$22.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.19
|
| Rate for Payer: Dignity Health Senior |
$12.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.33
|
| Rate for Payer: Heritage Provider Network Senior |
$30.33
|
| Rate for Payer: Humana Medicare |
$12.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$17.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$24.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.25
|
| Rate for Payer: Multiplan Commercial |
$36.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.90
|
| Rate for Payer: TriValley Medical Group Senior |
$12.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.19
|
| Rate for Payer: Vantage Medical Group Senior |
$12.90
|
|
|
HC ABCESS CATH EXCHANGE
|
Facility
|
IP
|
$1,826.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
909001859
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$330.51 |
| Max. Negotiated Rate |
$1,369.50 |
| Rate for Payer: Adventist Health Commercial |
$365.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,254.46
|
| Rate for Payer: Cash Price |
$821.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,236.20
|
| Rate for Payer: Heritage Provider Network Senior |
$1,236.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$330.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$456.50
|
| Rate for Payer: Multiplan Commercial |
$1,369.50
|
|
|
HC ABCESS CATH EXCHANGE
|
Facility
|
OP
|
$1,826.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
909001859
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$163.05 |
| Max. Negotiated Rate |
$1,552.10 |
| Rate for Payer: Adventist Health Commercial |
$365.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,024.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,254.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,552.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,004.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,369.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$750.14
|
| Rate for Payer: Blue Shield of California Commercial |
$645.50
|
| Rate for Payer: Blue Shield of California EPN |
$367.08
|
| Rate for Payer: Cash Price |
$821.70
|
| Rate for Payer: Cash Price |
$821.70
|
| Rate for Payer: Cash Price |
$821.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,186.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,552.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,552.10
|
| Rate for Payer: Dignity Health Senior |
$1,552.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,186.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,130.29
|
| Rate for Payer: Heritage Provider Network Senior |
$1,130.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$163.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$880.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$330.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$456.50
|
| Rate for Payer: Multiplan Commercial |
$1,369.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,552.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1,552.10
|
|
|
HC ABDOMEN KUB SUPINE
|
Facility
|
OP
|
$539.00
|
|
|
Service Code
|
CPT 74018
|
| Hospital Charge Code |
909001702
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$38.42 |
| Max. Negotiated Rate |
$404.25 |
| Rate for Payer: Adventist Health Commercial |
$107.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$40.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$370.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$113.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$164.83
|
| Rate for Payer: Blue Shield of California Commercial |
$99.44
|
| Rate for Payer: Blue Shield of California EPN |
$56.55
|
| Rate for Payer: Cash Price |
$242.55
|
| Rate for Payer: Cash Price |
$242.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$350.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.89
|
| Rate for Payer: Dignity Health Senior |
$113.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$350.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$333.64
|
| Rate for Payer: Heritage Provider Network Senior |
$333.64
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$38.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$113.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$143.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$143.06
|
| Rate for Payer: Multiplan Commercial |
$404.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$113.54
|
| Rate for Payer: TriValley Medical Group Senior |
$113.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$99.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$99.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Vantage Medical Group Senior |
$113.54
|
|
|
HC ABDOMEN KUB SUPINE
|
Facility
|
IP
|
$539.00
|
|
|
Service Code
|
CPT 74018
|
| Hospital Charge Code |
909001702
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$97.56 |
| Max. Negotiated Rate |
$404.25 |
| Rate for Payer: Adventist Health Commercial |
$107.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$370.29
|
| Rate for Payer: Cash Price |
$242.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$364.90
|
| Rate for Payer: Heritage Provider Network Senior |
$364.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.75
|
| Rate for Payer: Multiplan Commercial |
$404.25
|
|
|
HC ABDOMEN/RETROPERIT PERC BIO
|
Facility
|
IP
|
$3,157.00
|
|
|
Service Code
|
CPT 49180
|
| Hospital Charge Code |
909000161
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$571.42 |
| Max. Negotiated Rate |
$2,367.75 |
| Rate for Payer: Adventist Health Commercial |
$631.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,168.86
|
| Rate for Payer: Cash Price |
$1,420.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,137.29
|
| Rate for Payer: Heritage Provider Network Senior |
$2,137.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$571.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$789.25
|
| Rate for Payer: Multiplan Commercial |
$2,367.75
|
|
|
HC ABDOMEN/RETROPERIT PERC BIO
|
Facility
|
OP
|
$3,157.00
|
|
|
Service Code
|
CPT 49180
|
| Hospital Charge Code |
909000161
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$389.70 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$631.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,168.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,025.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,517.28
|
| Rate for Payer: Blue Shield of California EPN |
$3,022.94
|
| Rate for Payer: Cash Price |
$1,420.65
|
| Rate for Payer: Cash Price |
$1,420.65
|
| Rate for Payer: Cash Price |
$1,420.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,052.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,228.26
|
| Rate for Payer: Dignity Health Senior |
$2,025.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,025.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,954.18
|
| Rate for Payer: Heritage Provider Network Senior |
$2,491.60
|
| Rate for Payer: Humana Medicare |
$2,025.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$389.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,025.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,848.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$571.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,390.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$789.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,552.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,552.37
|
| Rate for Payer: Multiplan Commercial |
$2,367.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,228.26
|
| Rate for Payer: TriValley Medical Group Senior |
$2,228.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,374.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,841.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: Vantage Medical Group Senior |
$2,025.69
|
|
|
HC ABDOMEN SINGLE AP VIEW
|
Facility
|
IP
|
$464.00
|
|
|
Service Code
|
CPT 74018
|
| Hospital Charge Code |
909001175
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$83.98 |
| Max. Negotiated Rate |
$348.00 |
| Rate for Payer: Adventist Health Commercial |
$92.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$318.77
|
| Rate for Payer: Cash Price |
$208.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$314.13
|
| Rate for Payer: Heritage Provider Network Senior |
$314.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$83.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.00
|
| Rate for Payer: Multiplan Commercial |
$348.00
|
|
|
HC ABDOMEN SINGLE AP VIEW
|
Facility
|
OP
|
$464.00
|
|
|
Service Code
|
CPT 74018
|
| Hospital Charge Code |
909001175
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$38.42 |
| Max. Negotiated Rate |
$348.00 |
| Rate for Payer: Adventist Health Commercial |
$92.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$40.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$318.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$113.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$164.83
|
| Rate for Payer: Blue Shield of California Commercial |
$99.44
|
| Rate for Payer: Blue Shield of California EPN |
$56.55
|
| Rate for Payer: Cash Price |
$208.80
|
| Rate for Payer: Cash Price |
$208.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$301.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.89
|
| Rate for Payer: Dignity Health Senior |
$113.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$301.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$287.22
|
| Rate for Payer: Heritage Provider Network Senior |
$287.22
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$38.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$113.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$83.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$143.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$143.06
|
| Rate for Payer: Multiplan Commercial |
$348.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$113.54
|
| Rate for Payer: TriValley Medical Group Senior |
$113.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$99.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$99.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Vantage Medical Group Senior |
$113.54
|
|
|
HC ABDOMEN THREE OR MORE VIEWS
|
Facility
|
IP
|
$877.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
909074021
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$158.74 |
| Max. Negotiated Rate |
$657.75 |
| Rate for Payer: Adventist Health Commercial |
$175.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$602.50
|
| Rate for Payer: Cash Price |
$394.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$593.73
|
| Rate for Payer: Heritage Provider Network Senior |
$593.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$158.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$219.25
|
| Rate for Payer: Multiplan Commercial |
$657.75
|
|
|
HC ABDOMEN THREE OR MORE VIEWS
|
Facility
|
OP
|
$877.00
|
|
|
Service Code
|
CPT 74021
|
| Hospital Charge Code |
909074021
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$54.79 |
| Max. Negotiated Rate |
$657.75 |
| Rate for Payer: Adventist Health Commercial |
$175.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$56.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$602.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$206.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$151.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$137.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$230.48
|
| Rate for Payer: Blue Shield of California Commercial |
$138.68
|
| Rate for Payer: Blue Shield of California EPN |
$78.86
|
| Rate for Payer: Cash Price |
$394.65
|
| Rate for Payer: Cash Price |
$394.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$570.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$206.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$151.10
|
| Rate for Payer: Dignity Health Senior |
$137.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$570.05
|
| Rate for Payer: EPIC Health Plan Medicare |
$137.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$542.86
|
| Rate for Payer: Heritage Provider Network Senior |
$542.86
|
| Rate for Payer: Humana Medicare |
$137.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$54.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$137.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$260.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$158.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$162.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$219.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$173.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$173.07
|
| Rate for Payer: Multiplan Commercial |
$657.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$137.36
|
| Rate for Payer: TriValley Medical Group Senior |
$137.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$189.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$189.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$206.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$151.10
|
| Rate for Payer: Vantage Medical Group Senior |
$137.36
|
|
|
HC ABDOMEN TWO VIEWS
|
Facility
|
OP
|
$680.00
|
|
|
Service Code
|
CPT 74019
|
| Hospital Charge Code |
909074019
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$46.96 |
| Max. Negotiated Rate |
$510.00 |
| Rate for Payer: Adventist Health Commercial |
$136.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$48.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$467.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$206.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$151.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$137.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$197.62
|
| Rate for Payer: Blue Shield of California Commercial |
$119.06
|
| Rate for Payer: Blue Shield of California EPN |
$67.71
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$442.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$206.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$151.10
|
| Rate for Payer: Dignity Health Senior |
$137.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$442.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$137.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$420.92
|
| Rate for Payer: Heritage Provider Network Senior |
$420.92
|
| Rate for Payer: Humana Medicare |
$137.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$46.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$137.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$260.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$123.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$162.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$170.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$173.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$173.07
|
| Rate for Payer: Multiplan Commercial |
$510.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$137.36
|
| Rate for Payer: TriValley Medical Group Senior |
$137.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$189.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$189.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$206.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$151.10
|
| Rate for Payer: Vantage Medical Group Senior |
$137.36
|
|
|
HC ABDOMEN TWO VIEWS
|
Facility
|
IP
|
$680.00
|
|
|
Service Code
|
CPT 74019
|
| Hospital Charge Code |
909074019
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$123.08 |
| Max. Negotiated Rate |
$510.00 |
| Rate for Payer: Adventist Health Commercial |
$136.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$467.16
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$460.36
|
| Rate for Payer: Heritage Provider Network Senior |
$460.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$123.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$170.00
|
| Rate for Payer: Multiplan Commercial |
$510.00
|
|
|
HC ABD PARACENTESIS W IMAGE GUID
|
Facility
|
OP
|
$2,062.00
|
|
|
Service Code
|
CPT 49083
|
| Hospital Charge Code |
906749080
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$373.22 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$412.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,416.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,132.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,517.28
|
| Rate for Payer: Blue Shield of California EPN |
$3,022.94
|
| Rate for Payer: Cash Price |
$927.90
|
| Rate for Payer: Cash Price |
$927.90
|
| Rate for Payer: Cash Price |
$927.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,340.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,245.85
|
| Rate for Payer: Dignity Health Senior |
$1,132.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,132.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,276.38
|
| Rate for Payer: Heritage Provider Network Senior |
$1,393.09
|
| Rate for Payer: Humana Medicare |
$1,132.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$431.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,132.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,151.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$373.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,336.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$515.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,427.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,427.06
|
| Rate for Payer: Multiplan Commercial |
$1,546.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,245.85
|
| Rate for Payer: TriValley Medical Group Senior |
$1,245.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,374.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,841.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,698.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,245.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1,132.59
|
|
|
HC ABD PARACENTESIS W IMAGE GUID
|
Facility
|
IP
|
$2,062.00
|
|
|
Service Code
|
CPT 49083
|
| Hospital Charge Code |
906749080
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$373.22 |
| Max. Negotiated Rate |
$1,546.50 |
| Rate for Payer: Adventist Health Commercial |
$412.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,416.59
|
| Rate for Payer: Cash Price |
$927.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,395.97
|
| Rate for Payer: Heritage Provider Network Senior |
$1,395.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$373.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$515.50
|
| Rate for Payer: Multiplan Commercial |
$1,546.50
|
|
