|
HC CL TRT FEM FX W/O MANIP PE NCK
|
Facility
OP
|
$987.00
|
|
|
Service Code
|
CPT 27230
|
| Hospital Charge Code |
900501368
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$178.65 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$197.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$678.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$441.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$324.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$294.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$444.15
|
| Rate for Payer: Cash Price |
$444.15
|
| Rate for Payer: Cash Price |
$444.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$641.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$441.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$324.10
|
| Rate for Payer: Dignity Health Senior |
$294.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$294.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$668.20
|
| Rate for Payer: Heritage Provider Network Senior |
$668.20
|
| Rate for Payer: Humana Medicare |
$294.64
|
| Rate for Payer: IEHP Medi-Cal |
$936.00
|
| Rate for Payer: IEHP Medicare Advantage |
$294.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$475.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$178.65
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$347.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$246.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$371.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$371.25
|
| Rate for Payer: Multiplan Commercial |
$740.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$358.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$329.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$441.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$324.10
|
| Rate for Payer: Vantage Medical Group Senior |
$294.64
|
|
|
HC CL TRT FX GREAT TOE,W/MANIPUL
|
Facility
OP
|
$609.00
|
|
|
Service Code
|
CPT 28495
|
| Hospital Charge Code |
900501249
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$110.23 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$121.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$418.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$441.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$324.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$294.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$274.05
|
| Rate for Payer: Cash Price |
$274.05
|
| Rate for Payer: Cash Price |
$274.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$395.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$441.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$324.10
|
| Rate for Payer: Dignity Health Senior |
$294.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$294.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$412.29
|
| Rate for Payer: Heritage Provider Network Senior |
$412.29
|
| Rate for Payer: Humana Medicare |
$294.64
|
| Rate for Payer: IEHP Medi-Cal |
$936.00
|
| Rate for Payer: IEHP Medicare Advantage |
$294.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$293.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$110.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$347.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$152.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$371.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$371.25
|
| Rate for Payer: Multiplan Commercial |
$456.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$221.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$203.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$441.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$324.10
|
| Rate for Payer: Vantage Medical Group Senior |
$294.64
|
|
|
HC CL TRT FX GREAT TOE,W/MANIPUL
|
Facility
IP
|
$609.00
|
|
|
Service Code
|
CPT 28495
|
| Hospital Charge Code |
900501249
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$110.23 |
| Max. Negotiated Rate |
$456.75 |
| Rate for Payer: Adventist Health Commercial |
$121.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$418.38
|
| Rate for Payer: Cash Price |
$274.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$412.29
|
| Rate for Payer: Heritage Provider Network Senior |
$412.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$110.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$152.25
|
| Rate for Payer: Multiplan Commercial |
$456.75
|
|
|
HC CL TRT MET FX W MANIPULATION EA
|
Facility
IP
|
$1,436.00
|
|
|
Service Code
|
CPT 28475
|
| Hospital Charge Code |
900501248
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$259.92 |
| Max. Negotiated Rate |
$1,077.00 |
| Rate for Payer: Adventist Health Commercial |
$287.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$986.53
|
| Rate for Payer: Cash Price |
$646.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$972.17
|
| Rate for Payer: Heritage Provider Network Senior |
$972.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$259.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$359.00
|
| Rate for Payer: Multiplan Commercial |
$1,077.00
|
|
|
HC CL TRT MET FX W MANIPULATION EA
|
Facility
OP
|
$1,436.00
|
|
|
Service Code
|
CPT 28475
|
| Hospital Charge Code |
900501248
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$259.92 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$287.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$986.53
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$441.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$324.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$294.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$646.20
|
| Rate for Payer: Cash Price |
$646.20
|
| Rate for Payer: Cash Price |
$646.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$933.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$441.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$324.10
|
| Rate for Payer: Dignity Health Senior |
$294.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$294.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$972.17
|
| Rate for Payer: Heritage Provider Network Senior |
$972.17
|
| Rate for Payer: Humana Medicare |
$294.64
|
| Rate for Payer: IEHP Medi-Cal |
$936.00
|
| Rate for Payer: IEHP Medicare Advantage |
$294.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$692.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$259.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$347.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$359.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$371.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$371.25
|
| Rate for Payer: Multiplan Commercial |
$1,077.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$521.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$479.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$441.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$324.10
|
| Rate for Payer: Vantage Medical Group Senior |
$294.64
|
|
|
HC CL TRT OF KNEE DISC W/O ANESTH
|
Facility
IP
|
$1,182.00
|
|
|
Service Code
|
CPT 27550
|
| Hospital Charge Code |
900501246
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$213.94 |
| Max. Negotiated Rate |
$886.50 |
| Rate for Payer: Adventist Health Commercial |
$236.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$812.03
|
| Rate for Payer: Blue Shield of California Commercial |
$498.80
|
| Rate for Payer: Blue Shield of California EPN |
$475.16
|
| Rate for Payer: Cash Price |
$531.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$800.21
|
| Rate for Payer: Heritage Provider Network Senior |
$800.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$213.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$295.50
|
| Rate for Payer: Multiplan Commercial |
$886.50
|
|
|
HC CL TRT OF KNEE DISC W/O ANESTH
|
Facility
OP
|
$1,182.00
|
|
|
Service Code
|
CPT 27550
|
| Hospital Charge Code |
900501246
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$213.94 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$236.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$812.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$441.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$324.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$294.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$531.90
|
| Rate for Payer: Cash Price |
$531.90
|
| Rate for Payer: Cash Price |
$531.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$768.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$441.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$324.10
|
| Rate for Payer: Dignity Health Senior |
$294.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$294.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$800.21
|
| Rate for Payer: Heritage Provider Network Senior |
$800.21
|
| Rate for Payer: Humana Medicare |
$294.64
|
| Rate for Payer: IEHP Medi-Cal |
$936.00
|
| Rate for Payer: IEHP Medicare Advantage |
$294.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$569.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$213.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$347.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$295.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$371.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$371.25
|
| Rate for Payer: Multiplan Commercial |
$886.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$429.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$394.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$441.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$324.10
|
| Rate for Payer: Vantage Medical Group Senior |
$294.64
|
|
|
HC CMRI MORPH/FUNCT W/O CONTRAST
|
Facility
OP
|
$3,956.00
|
|
|
Service Code
|
CPT 75557
|
| Hospital Charge Code |
908801260
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$306.16 |
| Max. Negotiated Rate |
$2,967.00 |
| Rate for Payer: Adventist Health Commercial |
$791.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$814.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,717.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$459.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$336.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$306.16
|
| Rate for Payer: Blue Shield of California Commercial |
$2,147.79
|
| Rate for Payer: Blue Shield of California EPN |
$1,221.38
|
| Rate for Payer: Cash Price |
$1,780.20
|
| Rate for Payer: Cash Price |
$1,780.20
|
| Rate for Payer: Cash Price |
$1,780.20
|
| Rate for Payer: Cash Price |
$1,780.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$459.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$336.78
|
| Rate for Payer: Dignity Health Senior |
$306.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$306.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Humana Medicare |
$306.16
|
| Rate for Payer: IEHP Medicare Advantage |
$306.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$581.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$716.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$361.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$989.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$385.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$385.76
|
| Rate for Payer: Multiplan Commercial |
$2,967.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$541.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$541.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$459.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$336.78
|
| Rate for Payer: Vantage Medical Group Senior |
$306.16
|
|
|
HC CMRI MORPH/FUNCT W/O CONTRAST
|
Facility
IP
|
$10,089.00
|
|
|
Service Code
|
CPT 75557
|
| Hospital Charge Code |
908801260
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$929.00 |
| Max. Negotiated Rate |
$7,566.75 |
| Rate for Payer: Adventist Health Commercial |
$2,017.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,931.14
|
| Rate for Payer: Cash Price |
$4,540.05
|
| Rate for Payer: Cash Price |
$4,540.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,830.25
|
| Rate for Payer: Heritage Provider Network Senior |
$6,830.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,826.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,522.25
|
| Rate for Payer: Multiplan Commercial |
$7,566.75
|
|
|
HC CMRI MORPH/FUNCT W+W/O CONT
|
Facility
IP
|
$7,113.00
|
|
|
Service Code
|
CPT 75561
|
| Hospital Charge Code |
908801270
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$929.00 |
| Max. Negotiated Rate |
$5,334.75 |
| Rate for Payer: Adventist Health Commercial |
$1,422.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,886.63
|
| Rate for Payer: Cash Price |
$3,200.85
|
| Rate for Payer: Cash Price |
$3,200.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,815.50
|
| Rate for Payer: Heritage Provider Network Senior |
$4,815.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,287.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,778.25
|
| Rate for Payer: Multiplan Commercial |
$5,334.75
|
|
|
HC CMRI MORPH/FUNCT W+W/O CONT
|
Facility
OP
|
$4,694.00
|
|
|
Service Code
|
CPT 75561
|
| Hospital Charge Code |
908801270
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$3,520.50 |
| Rate for Payer: Adventist Health Commercial |
$938.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$814.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,224.78
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$720.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$528.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$480.50
|
| Rate for Payer: Blue Shield of California Commercial |
$3,064.46
|
| Rate for Payer: Blue Shield of California EPN |
$1,742.67
|
| Rate for Payer: Cash Price |
$2,112.30
|
| Rate for Payer: Cash Price |
$2,112.30
|
| Rate for Payer: Cash Price |
$2,112.30
|
| Rate for Payer: Cash Price |
$2,112.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$720.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$528.55
|
| Rate for Payer: Dignity Health Senior |
$480.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$480.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Humana Medicare |
$480.50
|
| Rate for Payer: IEHP Medi-Cal |
$563.21
|
| Rate for Payer: IEHP Medicare Advantage |
$480.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$912.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$849.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$566.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,173.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$605.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$605.43
|
| Rate for Payer: Multiplan Commercial |
$3,520.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$854.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$854.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$720.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$528.55
|
| Rate for Payer: Vantage Medical Group Senior |
$480.50
|
|
|
HC CMRI W FLOW/VEL QUANT W/O CONT
|
Facility
IP
|
$1,057.00
|
|
| Hospital Charge Code |
908801261
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$191.32 |
| Max. Negotiated Rate |
$929.00 |
| Rate for Payer: Adventist Health Commercial |
$211.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$726.16
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$715.59
|
| Rate for Payer: Heritage Provider Network Senior |
$715.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$191.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$264.25
|
| Rate for Payer: Multiplan Commercial |
$792.75
|
|
|
HC CMRI W FLOW/VEL QUANT W/O CONT
|
Facility
OP
|
$1,057.00
|
|
| Hospital Charge Code |
908801261
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$191.32 |
| Max. Negotiated Rate |
$1,075.00 |
| Rate for Payer: Adventist Health Commercial |
$211.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$564.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$726.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$898.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$581.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$792.75
|
| Rate for Payer: Blue Shield of California Commercial |
$656.40
|
| Rate for Payer: Blue Shield of California EPN |
$620.46
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$898.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$898.45
|
| Rate for Payer: Dignity Health Senior |
$898.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$509.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$191.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$264.25
|
| Rate for Payer: Multiplan Commercial |
$792.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$898.45
|
| Rate for Payer: Vantage Medical Group Senior |
$898.45
|
|
|
HC CMRI W FLOW/VEL QUANT W+W/O CO
|
Facility
OP
|
$1,057.00
|
|
| Hospital Charge Code |
908801271
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$191.32 |
| Max. Negotiated Rate |
$1,075.00 |
| Rate for Payer: Adventist Health Commercial |
$211.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$564.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$726.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$898.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$581.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$792.75
|
| Rate for Payer: Blue Shield of California Commercial |
$656.40
|
| Rate for Payer: Blue Shield of California EPN |
$620.46
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$898.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$898.45
|
| Rate for Payer: Dignity Health Senior |
$898.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$509.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$191.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$264.25
|
| Rate for Payer: Multiplan Commercial |
$792.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$898.45
|
| Rate for Payer: Vantage Medical Group Senior |
$898.45
|
|
|
HC CMRI W FLOW/VEL QUANT W+W/O CO
|
Facility
IP
|
$1,057.00
|
|
| Hospital Charge Code |
908801271
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$191.32 |
| Max. Negotiated Rate |
$929.00 |
| Rate for Payer: Adventist Health Commercial |
$211.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$726.16
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$715.59
|
| Rate for Payer: Heritage Provider Network Senior |
$715.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$191.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$264.25
|
| Rate for Payer: Multiplan Commercial |
$792.75
|
|
|
HC CMRI W FLOW/VEL+STRESS W/O CON
|
Facility
IP
|
$1,057.00
|
|
| Hospital Charge Code |
908801263
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$191.32 |
| Max. Negotiated Rate |
$929.00 |
| Rate for Payer: Adventist Health Commercial |
$211.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$726.16
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$715.59
|
| Rate for Payer: Heritage Provider Network Senior |
$715.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$191.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$264.25
|
| Rate for Payer: Multiplan Commercial |
$792.75
|
|
|
HC CMRI W FLOW/VEL+STRESS W/O CON
|
Facility
OP
|
$1,057.00
|
|
| Hospital Charge Code |
908801263
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$191.32 |
| Max. Negotiated Rate |
$1,075.00 |
| Rate for Payer: Adventist Health Commercial |
$211.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$564.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$726.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$898.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$581.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$792.75
|
| Rate for Payer: Blue Shield of California Commercial |
$656.40
|
| Rate for Payer: Blue Shield of California EPN |
$620.46
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$898.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$898.45
|
| Rate for Payer: Dignity Health Senior |
$898.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$509.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$191.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$264.25
|
| Rate for Payer: Multiplan Commercial |
$792.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$898.45
|
| Rate for Payer: Vantage Medical Group Senior |
$898.45
|
|
|
HC CMRI W FLOW/VEL+STRESS W+W/O C
|
Facility
IP
|
$1,057.00
|
|
| Hospital Charge Code |
908801273
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$191.32 |
| Max. Negotiated Rate |
$929.00 |
| Rate for Payer: Adventist Health Commercial |
$211.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$726.16
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$715.59
|
| Rate for Payer: Heritage Provider Network Senior |
$715.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$191.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$264.25
|
| Rate for Payer: Multiplan Commercial |
$792.75
|
|
|
HC CMRI W FLOW/VEL+STRESS W+W/O C
|
Facility
OP
|
$1,057.00
|
|
| Hospital Charge Code |
908801273
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$191.32 |
| Max. Negotiated Rate |
$1,075.00 |
| Rate for Payer: Adventist Health Commercial |
$211.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$564.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$726.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$898.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$581.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$792.75
|
| Rate for Payer: Blue Shield of California Commercial |
$656.40
|
| Rate for Payer: Blue Shield of California EPN |
$620.46
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$898.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$898.45
|
| Rate for Payer: Dignity Health Senior |
$898.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$509.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$191.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$264.25
|
| Rate for Payer: Multiplan Commercial |
$792.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$898.45
|
| Rate for Payer: Vantage Medical Group Senior |
$898.45
|
|
|
HC CMRI W STRESS W/O CONT
|
Facility
OP
|
$4,332.00
|
|
|
Service Code
|
CPT 75559
|
| Hospital Charge Code |
908801262
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$3,257.71 |
| Rate for Payer: Adventist Health Commercial |
$866.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$814.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,976.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,033.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$758.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$689.28
|
| Rate for Payer: Blue Shield of California Commercial |
$3,257.71
|
| Rate for Payer: Blue Shield of California EPN |
$1,852.56
|
| Rate for Payer: Cash Price |
$1,949.40
|
| Rate for Payer: Cash Price |
$1,949.40
|
| Rate for Payer: Cash Price |
$1,949.40
|
| Rate for Payer: Cash Price |
$1,949.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,033.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$758.21
|
| Rate for Payer: Dignity Health Senior |
$689.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$689.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Humana Medicare |
$689.28
|
| Rate for Payer: IEHP Medicare Advantage |
$689.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,309.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$784.09
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$813.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,083.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$868.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$868.49
|
| Rate for Payer: Multiplan Commercial |
$3,249.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$541.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$541.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,033.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$758.21
|
| Rate for Payer: Vantage Medical Group Senior |
$689.28
|
|
|
HC CMRI W STRESS W/O CONT
|
Facility
IP
|
$8,969.00
|
|
|
Service Code
|
CPT 75559
|
| Hospital Charge Code |
908801262
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$929.00 |
| Max. Negotiated Rate |
$6,726.75 |
| Rate for Payer: Adventist Health Commercial |
$1,793.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,161.70
|
| Rate for Payer: Cash Price |
$4,036.05
|
| Rate for Payer: Cash Price |
$4,036.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,072.01
|
| Rate for Payer: Heritage Provider Network Senior |
$6,072.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,623.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,242.25
|
| Rate for Payer: Multiplan Commercial |
$6,726.75
|
|
|
HC CMRI W STRESS W+W/O CONT
|
Facility
OP
|
$5,088.00
|
|
|
Service Code
|
CPT 75563
|
| Hospital Charge Code |
908801272
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$3,830.66 |
| Rate for Payer: Adventist Health Commercial |
$1,017.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$814.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,495.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,500.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,100.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,000.40
|
| Rate for Payer: Blue Shield of California Commercial |
$3,830.66
|
| Rate for Payer: Blue Shield of California EPN |
$2,178.38
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,075.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,500.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,100.44
|
| Rate for Payer: Dignity Health Senior |
$1,000.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,038.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,000.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$955.00
|
| Rate for Payer: Heritage Provider Network Senior |
$869.00
|
| Rate for Payer: Humana Medicare |
$1,000.40
|
| Rate for Payer: IEHP Medicare Advantage |
$1,000.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,900.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$920.93
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,180.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,272.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,260.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,260.50
|
| Rate for Payer: Multiplan Commercial |
$3,816.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$325.00
|
| Rate for Payer: TriValley Medical Group Senior |
$325.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$854.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$854.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,500.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,100.44
|
| Rate for Payer: Vantage Medical Group Senior |
$1,000.40
|
|
|
HC CMRI W STRESS W+W/O CONT
|
Facility
IP
|
$13,165.00
|
|
|
Service Code
|
CPT 75563
|
| Hospital Charge Code |
908801272
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$929.00 |
| Max. Negotiated Rate |
$9,873.75 |
| Rate for Payer: Adventist Health Commercial |
$2,633.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9,044.36
|
| Rate for Payer: Cash Price |
$5,924.25
|
| Rate for Payer: Cash Price |
$5,924.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$929.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$8,912.70
|
| Rate for Payer: Heritage Provider Network Senior |
$8,912.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,382.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,291.25
|
| Rate for Payer: Multiplan Commercial |
$9,873.75
|
|
|
HC CMV AB IGG
|
Facility
OP
|
$39.00
|
|
|
Service Code
|
CPT 86644
|
| Hospital Charge Code |
900910987
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$120.08 |
| Rate for Payer: Adventist Health Commercial |
$7.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$41.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$21.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$120.08
|
| Rate for Payer: Blue Shield of California Commercial |
$112.41
|
| Rate for Payer: Blue Shield of California EPN |
$87.88
|
| Rate for Payer: Cash Price |
$17.55
|
| Rate for Payer: Cash Price |
$17.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.83
|
| Rate for Payer: Dignity Health Senior |
$14.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$14.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.14
|
| Rate for Payer: Heritage Provider Network Senior |
$24.14
|
| Rate for Payer: Humana Medicare |
$14.39
|
| Rate for Payer: IEHP Medi-Cal |
$19.31
|
| Rate for Payer: IEHP Medicare Advantage |
$14.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$27.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$16.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.13
|
| Rate for Payer: Multiplan Commercial |
$29.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.39
|
| Rate for Payer: TriValley Medical Group Senior |
$14.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.83
|
| Rate for Payer: Vantage Medical Group Senior |
$14.39
|
|
|
HC CMV AB IGG
|
Facility
IP
|
$237.00
|
|
|
Service Code
|
CPT 86644
|
| Hospital Charge Code |
900910987
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$42.90 |
| Max. Negotiated Rate |
$177.75 |
| Rate for Payer: Adventist Health Commercial |
$47.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$162.82
|
| Rate for Payer: Cash Price |
$106.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$160.45
|
| Rate for Payer: Heritage Provider Network Senior |
$160.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.25
|
| Rate for Payer: Multiplan Commercial |
$177.75
|
|
