|
HC CULTURE MRSA SURVELLIANCE
|
Facility
OP
|
$32.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
900912438
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$72.02 |
| Rate for Payer: Adventist Health Commercial |
$6.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$72.02
|
| Rate for Payer: Blue Shield of California Commercial |
$67.25
|
| Rate for Payer: Blue Shield of California EPN |
$52.57
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.48
|
| Rate for Payer: Dignity Health Senior |
$8.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.81
|
| Rate for Payer: Heritage Provider Network Senior |
$19.81
|
| Rate for Payer: Humana Medicare |
$8.62
|
| Rate for Payer: IEHP Medi-Cal |
$11.72
|
| Rate for Payer: IEHP Medicare Advantage |
$8.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.86
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.62
|
| Rate for Payer: TriValley Medical Group Senior |
$8.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.48
|
| Rate for Payer: Vantage Medical Group Senior |
$8.62
|
|
|
HC CULTURE MRSA SURVELLIANCE
|
Facility
IP
|
$339.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
900912438
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$61.36 |
| Max. Negotiated Rate |
$254.25 |
| Rate for Payer: Adventist Health Commercial |
$67.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$232.89
|
| Rate for Payer: Cash Price |
$152.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$229.50
|
| Rate for Payer: Heritage Provider Network Senior |
$229.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.75
|
| Rate for Payer: Multiplan Commercial |
$254.25
|
|
|
HC CULTURE NEISS/HAEM RAPID ID
|
Facility
IP
|
$204.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
900912428
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$36.92 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Adventist Health Commercial |
$40.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$140.15
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$138.11
|
| Rate for Payer: Heritage Provider Network Senior |
$138.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.00
|
| Rate for Payer: Multiplan Commercial |
$153.00
|
|
|
HC CULTURE NEISS/HAEM RAPID ID
|
Facility
OP
|
$31.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
900912428
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$67.56 |
| Rate for Payer: Adventist Health Commercial |
$6.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$23.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$67.56
|
| Rate for Payer: Blue Shield of California Commercial |
$63.11
|
| Rate for Payer: Blue Shield of California EPN |
$49.34
|
| Rate for Payer: Cash Price |
$13.95
|
| Rate for Payer: Cash Price |
$13.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.89
|
| Rate for Payer: Dignity Health Senior |
$8.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.19
|
| Rate for Payer: Heritage Provider Network Senior |
$19.19
|
| Rate for Payer: Humana Medicare |
$8.08
|
| Rate for Payer: IEHP Medi-Cal |
$10.37
|
| Rate for Payer: IEHP Medicare Advantage |
$8.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.18
|
| Rate for Payer: Multiplan Commercial |
$23.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.08
|
| Rate for Payer: TriValley Medical Group Senior |
$8.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.89
|
| Rate for Payer: Vantage Medical Group Senior |
$8.08
|
|
|
HC CULTURE NON-FERMENT ID
|
Facility
IP
|
$204.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
900912426
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$36.92 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Adventist Health Commercial |
$40.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$140.15
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$138.11
|
| Rate for Payer: Heritage Provider Network Senior |
$138.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.00
|
| Rate for Payer: Multiplan Commercial |
$153.00
|
|
|
HC CULTURE NON-FERMENT ID
|
Facility
OP
|
$31.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
900912426
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$67.56 |
| Rate for Payer: Adventist Health Commercial |
$6.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$23.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$67.56
|
| Rate for Payer: Blue Shield of California Commercial |
$63.11
|
| Rate for Payer: Blue Shield of California EPN |
$49.34
|
| Rate for Payer: Cash Price |
$13.95
|
| Rate for Payer: Cash Price |
$13.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.89
|
| Rate for Payer: Dignity Health Senior |
$8.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.19
|
| Rate for Payer: Heritage Provider Network Senior |
$19.19
|
| Rate for Payer: Humana Medicare |
$8.08
|
| Rate for Payer: IEHP Medi-Cal |
$10.37
|
| Rate for Payer: IEHP Medicare Advantage |
$8.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.18
|
| Rate for Payer: Multiplan Commercial |
$23.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.08
|
| Rate for Payer: TriValley Medical Group Senior |
$8.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.89
|
| Rate for Payer: Vantage Medical Group Senior |
$8.08
|
|
|
HC CULTURE OPTIC
|
Facility
IP
|
$399.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
900911510
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$72.22 |
| Max. Negotiated Rate |
$299.25 |
| Rate for Payer: Adventist Health Commercial |
$79.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$274.11
|
| Rate for Payer: Cash Price |
$179.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$270.12
|
| Rate for Payer: Heritage Provider Network Senior |
$270.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.75
|
| Rate for Payer: Multiplan Commercial |
$299.25
|
|
|
HC CULTURE OPTIC
|
Facility
OP
|
$32.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
900911510
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$67.56 |
| Rate for Payer: Adventist Health Commercial |
$6.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$23.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$67.56
|
| Rate for Payer: Blue Shield of California Commercial |
$63.11
|
| Rate for Payer: Blue Shield of California EPN |
$49.34
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.89
|
| Rate for Payer: Dignity Health Senior |
$8.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.81
|
| Rate for Payer: Heritage Provider Network Senior |
$19.81
|
| Rate for Payer: Humana Medicare |
$8.08
|
| Rate for Payer: IEHP Medi-Cal |
$10.37
|
| Rate for Payer: IEHP Medicare Advantage |
$8.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.18
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.08
|
| Rate for Payer: TriValley Medical Group Senior |
$8.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.89
|
| Rate for Payer: Vantage Medical Group Senior |
$8.08
|
|
|
HC CULTURE OTIC
|
Facility
OP
|
$32.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
900911512
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$72.02 |
| Rate for Payer: Adventist Health Commercial |
$6.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$72.02
|
| Rate for Payer: Blue Shield of California Commercial |
$67.25
|
| Rate for Payer: Blue Shield of California EPN |
$52.57
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.48
|
| Rate for Payer: Dignity Health Senior |
$8.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.81
|
| Rate for Payer: Heritage Provider Network Senior |
$19.81
|
| Rate for Payer: Humana Medicare |
$8.62
|
| Rate for Payer: IEHP Medi-Cal |
$11.72
|
| Rate for Payer: IEHP Medicare Advantage |
$8.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.86
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.62
|
| Rate for Payer: TriValley Medical Group Senior |
$8.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.48
|
| Rate for Payer: Vantage Medical Group Senior |
$8.62
|
|
|
HC CULTURE OTIC
|
Facility
IP
|
$399.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
900911512
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$72.22 |
| Max. Negotiated Rate |
$299.25 |
| Rate for Payer: Adventist Health Commercial |
$79.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$274.11
|
| Rate for Payer: Cash Price |
$179.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$270.12
|
| Rate for Payer: Heritage Provider Network Senior |
$270.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.75
|
| Rate for Payer: Multiplan Commercial |
$299.25
|
|
|
HC CULTURE PBP2 LATEX AGGLUTINATION
|
Facility
IP
|
$136.00
|
|
|
Service Code
|
CPT 87147
|
| Hospital Charge Code |
900912417
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$24.62 |
| Max. Negotiated Rate |
$102.00 |
| Rate for Payer: Adventist Health Commercial |
$27.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$93.43
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$92.07
|
| Rate for Payer: Heritage Provider Network Senior |
$92.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.00
|
| Rate for Payer: Multiplan Commercial |
$102.00
|
|
|
HC CULTURE PBP2 LATEX AGGLUTINATION
|
Facility
OP
|
$44.00
|
|
|
Service Code
|
CPT 87147
|
| Hospital Charge Code |
900912417
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$40.42 |
| Rate for Payer: Adventist Health Commercial |
$8.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$39.16
|
| Rate for Payer: Blue Shield of California Commercial |
$40.42
|
| Rate for Payer: Blue Shield of California EPN |
$31.60
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.70
|
| Rate for Payer: Dignity Health Senior |
$5.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$5.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.24
|
| Rate for Payer: Heritage Provider Network Senior |
$27.24
|
| Rate for Payer: Humana Medicare |
$5.18
|
| Rate for Payer: IEHP Medi-Cal |
$5.66
|
| Rate for Payer: IEHP Medicare Advantage |
$5.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.53
|
| Rate for Payer: Multiplan Commercial |
$33.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.18
|
| Rate for Payer: TriValley Medical Group Senior |
$5.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.70
|
| Rate for Payer: Vantage Medical Group Senior |
$5.18
|
|
|
HC CULTURE PHARMACY COMPOUNDING
|
Facility
IP
|
$376.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
900912401
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$68.06 |
| Max. Negotiated Rate |
$282.00 |
| Rate for Payer: Adventist Health Commercial |
$75.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$258.31
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$254.55
|
| Rate for Payer: Heritage Provider Network Senior |
$254.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$94.00
|
| Rate for Payer: Multiplan Commercial |
$282.00
|
|
|
HC CULTURE PHARMACY COMPOUNDING
|
Facility
OP
|
$32.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
900912401
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$72.02 |
| Rate for Payer: Adventist Health Commercial |
$6.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$72.02
|
| Rate for Payer: Blue Shield of California Commercial |
$67.25
|
| Rate for Payer: Blue Shield of California EPN |
$52.57
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.48
|
| Rate for Payer: Dignity Health Senior |
$8.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.81
|
| Rate for Payer: Heritage Provider Network Senior |
$19.81
|
| Rate for Payer: Humana Medicare |
$8.62
|
| Rate for Payer: IEHP Medi-Cal |
$11.72
|
| Rate for Payer: IEHP Medicare Advantage |
$8.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.86
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.62
|
| Rate for Payer: TriValley Medical Group Senior |
$8.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.48
|
| Rate for Payer: Vantage Medical Group Senior |
$8.62
|
|
|
HC CULTURE QUANT AEROBIC
|
Facility
OP
|
$75.00
|
|
|
Service Code
|
CPT 87071
|
| Hospital Charge Code |
900912433
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$73.68 |
| Rate for Payer: Adventist Health Commercial |
$15.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$27.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.88
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$39.45
|
| Rate for Payer: Blue Shield of California Commercial |
$73.68
|
| Rate for Payer: Blue Shield of California EPN |
$57.60
|
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.88
|
| Rate for Payer: Dignity Health Senior |
$9.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$9.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.42
|
| Rate for Payer: Heritage Provider Network Senior |
$46.42
|
| Rate for Payer: Humana Medicare |
$9.89
|
| Rate for Payer: IEHP Medi-Cal |
$8.14
|
| Rate for Payer: IEHP Medicare Advantage |
$9.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$18.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.46
|
| Rate for Payer: Multiplan Commercial |
$56.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.89
|
| Rate for Payer: TriValley Medical Group Senior |
$9.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.88
|
| Rate for Payer: Vantage Medical Group Senior |
$9.89
|
|
|
HC CULTURE QUANT AEROBIC
|
Facility
IP
|
$399.00
|
|
|
Service Code
|
CPT 87071
|
| Hospital Charge Code |
900912433
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$72.22 |
| Max. Negotiated Rate |
$299.25 |
| Rate for Payer: Adventist Health Commercial |
$79.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$274.11
|
| Rate for Payer: Cash Price |
$179.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$270.12
|
| Rate for Payer: Heritage Provider Network Senior |
$270.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.75
|
| Rate for Payer: Multiplan Commercial |
$299.25
|
|
|
HC CULTURE QUANT ANAEROBIC
|
Facility
OP
|
$130.00
|
|
|
Service Code
|
CPT 87073
|
| Hospital Charge Code |
900912434
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$97.50 |
| Rate for Payer: Adventist Health Commercial |
$26.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$27.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$89.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$39.45
|
| Rate for Payer: Blue Shield of California Commercial |
$73.68
|
| Rate for Payer: Blue Shield of California EPN |
$57.60
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$84.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.63
|
| Rate for Payer: Dignity Health Senior |
$9.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$9.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$80.47
|
| Rate for Payer: Heritage Provider Network Senior |
$80.47
|
| Rate for Payer: Humana Medicare |
$9.66
|
| Rate for Payer: IEHP Medi-Cal |
$8.14
|
| Rate for Payer: IEHP Medicare Advantage |
$9.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$18.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.17
|
| Rate for Payer: Multiplan Commercial |
$97.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.66
|
| Rate for Payer: TriValley Medical Group Senior |
$9.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.63
|
| Rate for Payer: Vantage Medical Group Senior |
$9.66
|
|
|
HC CULTURE QUANT ANAEROBIC
|
Facility
IP
|
$439.00
|
|
|
Service Code
|
CPT 87073
|
| Hospital Charge Code |
900912434
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$79.46 |
| Max. Negotiated Rate |
$329.25 |
| Rate for Payer: Adventist Health Commercial |
$87.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$301.59
|
| Rate for Payer: Cash Price |
$197.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$297.20
|
| Rate for Payer: Heritage Provider Network Senior |
$297.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$79.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.75
|
| Rate for Payer: Multiplan Commercial |
$329.25
|
|
|
HC CULTURE QUANTITATIVE
|
Facility
IP
|
$399.00
|
|
|
Service Code
|
CPT 87071
|
| Hospital Charge Code |
900912409
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$72.22 |
| Max. Negotiated Rate |
$299.25 |
| Rate for Payer: Adventist Health Commercial |
$79.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$274.11
|
| Rate for Payer: Cash Price |
$179.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$270.12
|
| Rate for Payer: Heritage Provider Network Senior |
$270.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.75
|
| Rate for Payer: Multiplan Commercial |
$299.25
|
|
|
HC CULTURE QUANTITATIVE
|
Facility
OP
|
$75.00
|
|
|
Service Code
|
CPT 87071
|
| Hospital Charge Code |
900912409
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$73.68 |
| Rate for Payer: Adventist Health Commercial |
$15.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$27.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.88
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$39.45
|
| Rate for Payer: Blue Shield of California Commercial |
$73.68
|
| Rate for Payer: Blue Shield of California EPN |
$57.60
|
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.88
|
| Rate for Payer: Dignity Health Senior |
$9.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$9.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.42
|
| Rate for Payer: Heritage Provider Network Senior |
$46.42
|
| Rate for Payer: Humana Medicare |
$9.89
|
| Rate for Payer: IEHP Medi-Cal |
$8.14
|
| Rate for Payer: IEHP Medicare Advantage |
$9.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$18.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.46
|
| Rate for Payer: Multiplan Commercial |
$56.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.89
|
| Rate for Payer: TriValley Medical Group Senior |
$9.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.88
|
| Rate for Payer: Vantage Medical Group Senior |
$9.89
|
|
|
HC CULTURE RAPID NEG ID3
|
Facility
OP
|
$31.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
900912415
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$67.56 |
| Rate for Payer: Adventist Health Commercial |
$6.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$23.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$67.56
|
| Rate for Payer: Blue Shield of California Commercial |
$63.11
|
| Rate for Payer: Blue Shield of California EPN |
$49.34
|
| Rate for Payer: Cash Price |
$13.95
|
| Rate for Payer: Cash Price |
$13.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.89
|
| Rate for Payer: Dignity Health Senior |
$8.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.19
|
| Rate for Payer: Heritage Provider Network Senior |
$19.19
|
| Rate for Payer: Humana Medicare |
$8.08
|
| Rate for Payer: IEHP Medi-Cal |
$10.37
|
| Rate for Payer: IEHP Medicare Advantage |
$8.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.18
|
| Rate for Payer: Multiplan Commercial |
$23.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.08
|
| Rate for Payer: TriValley Medical Group Senior |
$8.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.89
|
| Rate for Payer: Vantage Medical Group Senior |
$8.08
|
|
|
HC CULTURE RAPID NEG ID3
|
Facility
IP
|
$204.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
900912415
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$36.92 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Adventist Health Commercial |
$40.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$140.15
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$138.11
|
| Rate for Payer: Heritage Provider Network Senior |
$138.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.00
|
| Rate for Payer: Multiplan Commercial |
$153.00
|
|
|
HC CULTURE RESPIRATORY
|
Facility
OP
|
$52.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
900912435
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$72.02 |
| Rate for Payer: Adventist Health Commercial |
$10.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.72
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$72.02
|
| Rate for Payer: Blue Shield of California Commercial |
$67.25
|
| Rate for Payer: Blue Shield of California EPN |
$52.57
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.48
|
| Rate for Payer: Dignity Health Senior |
$8.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.19
|
| Rate for Payer: Heritage Provider Network Senior |
$32.19
|
| Rate for Payer: Humana Medicare |
$8.62
|
| Rate for Payer: IEHP Medi-Cal |
$11.72
|
| Rate for Payer: IEHP Medicare Advantage |
$8.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.86
|
| Rate for Payer: Multiplan Commercial |
$39.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.62
|
| Rate for Payer: TriValley Medical Group Senior |
$8.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.48
|
| Rate for Payer: Vantage Medical Group Senior |
$8.62
|
|
|
HC CULTURE RESPIRATORY
|
Facility
IP
|
$399.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
900912435
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$72.22 |
| Max. Negotiated Rate |
$299.25 |
| Rate for Payer: Adventist Health Commercial |
$79.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$274.11
|
| Rate for Payer: Cash Price |
$179.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$270.12
|
| Rate for Payer: Heritage Provider Network Senior |
$270.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.75
|
| Rate for Payer: Multiplan Commercial |
$299.25
|
|
|
HC CULTURE SPUTUM
|
Facility
IP
|
$399.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
900911513
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$72.22 |
| Max. Negotiated Rate |
$299.25 |
| Rate for Payer: Adventist Health Commercial |
$79.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$274.11
|
| Rate for Payer: Cash Price |
$179.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$270.12
|
| Rate for Payer: Heritage Provider Network Senior |
$270.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.75
|
| Rate for Payer: Multiplan Commercial |
$299.25
|
|
