|
HC DRAIN ABSCESS CYST HEM VISTIB
|
Facility
OP
|
$728.00
|
|
|
Service Code
|
CPT 40800
|
| Hospital Charge Code |
900501236
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$131.77 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$145.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$276.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$500.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,318.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$966.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$879.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cash Price |
$327.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$473.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,318.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$966.98
|
| Rate for Payer: Dignity Health Senior |
$879.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$879.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$492.86
|
| Rate for Payer: Heritage Provider Network Senior |
$492.86
|
| Rate for Payer: Humana Medicare |
$879.07
|
| Rate for Payer: IEHP Medi-Cal |
$936.00
|
| Rate for Payer: IEHP Medicare Advantage |
$879.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$350.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$131.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,037.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$182.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,107.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,107.63
|
| Rate for Payer: Multiplan Commercial |
$546.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$264.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$243.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,318.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$966.98
|
| Rate for Payer: Vantage Medical Group Senior |
$879.07
|
|
|
HC DRAIN ABSCESS/HEMATOMA,NASAL
|
Facility
OP
|
$691.00
|
|
|
Service Code
|
CPT 30020
|
| Hospital Charge Code |
900501594
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$125.07 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$138.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$474.72
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,031.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$756.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$687.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$310.95
|
| Rate for Payer: Cash Price |
$310.95
|
| Rate for Payer: Cash Price |
$310.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$449.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,031.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$756.18
|
| Rate for Payer: Dignity Health Senior |
$687.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$687.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$467.81
|
| Rate for Payer: Heritage Provider Network Senior |
$467.81
|
| Rate for Payer: Humana Medicare |
$687.44
|
| Rate for Payer: IEHP Medi-Cal |
$936.00
|
| Rate for Payer: IEHP Medicare Advantage |
$687.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$333.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$125.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$811.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$172.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$866.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$866.17
|
| Rate for Payer: Multiplan Commercial |
$518.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$250.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$230.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,031.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$756.18
|
| Rate for Payer: Vantage Medical Group Senior |
$687.44
|
|
|
HC DRAIN ABSCESS/HEMATOMA,NASAL
|
Facility
IP
|
$691.00
|
|
|
Service Code
|
CPT 30020
|
| Hospital Charge Code |
900501594
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$125.07 |
| Max. Negotiated Rate |
$518.25 |
| Rate for Payer: Adventist Health Commercial |
$138.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$474.72
|
| Rate for Payer: Cash Price |
$310.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$467.81
|
| Rate for Payer: Heritage Provider Network Senior |
$467.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$125.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$172.75
|
| Rate for Payer: Multiplan Commercial |
$518.25
|
|
|
HC DRAIN ABSCESS PALATE UVULA
|
Facility
OP
|
$679.00
|
|
|
Service Code
|
CPT 42000
|
| Hospital Charge Code |
900501466
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$122.90 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$135.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$466.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$457.78
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$335.71
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$305.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Cash Price |
$305.55
|
| Rate for Payer: Cash Price |
$305.55
|
| Rate for Payer: Cash Price |
$305.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$441.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$457.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$335.71
|
| Rate for Payer: Dignity Health Senior |
$305.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$305.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$459.68
|
| Rate for Payer: Heritage Provider Network Senior |
$459.68
|
| Rate for Payer: Humana Medicare |
$305.19
|
| Rate for Payer: IEHP Medi-Cal |
$936.00
|
| Rate for Payer: IEHP Medicare Advantage |
$305.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$327.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$122.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$360.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$169.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$384.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$384.54
|
| Rate for Payer: Multiplan Commercial |
$509.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$246.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$226.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$457.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$335.71
|
| Rate for Payer: Vantage Medical Group Senior |
$305.19
|
|
|
HC DRAIN ABSCESS PALATE UVULA
|
Facility
IP
|
$679.00
|
|
|
Service Code
|
CPT 42000
|
| Hospital Charge Code |
900501466
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$122.90 |
| Max. Negotiated Rate |
$509.25 |
| Rate for Payer: Adventist Health Commercial |
$135.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$466.47
|
| Rate for Payer: Cash Price |
$305.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$459.68
|
| Rate for Payer: Heritage Provider Network Senior |
$459.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$122.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$169.75
|
| Rate for Payer: Multiplan Commercial |
$509.25
|
|
|
HC DRAINAGE OF EYE
|
Facility
OP
|
$7,667.00
|
|
|
Service Code
|
CPT 65800
|
| Hospital Charge Code |
900501746
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$936.00 |
| Max. Negotiated Rate |
$5,750.25 |
| Rate for Payer: Adventist Health Commercial |
$1,533.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,267.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4,367.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,202.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,911.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$3,450.15
|
| Rate for Payer: Cash Price |
$3,450.15
|
| Rate for Payer: Cash Price |
$3,450.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,983.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,367.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,202.79
|
| Rate for Payer: Dignity Health Senior |
$2,911.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,983.55
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,911.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,190.56
|
| Rate for Payer: Heritage Provider Network Senior |
$5,190.56
|
| Rate for Payer: Humana Medicare |
$2,911.63
|
| Rate for Payer: IEHP Medi-Cal |
$936.00
|
| Rate for Payer: IEHP Medicare Advantage |
$2,911.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,695.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,387.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,435.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,916.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,668.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,668.65
|
| Rate for Payer: Multiplan Commercial |
$5,750.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,783.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,561.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,367.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,202.79
|
| Rate for Payer: Vantage Medical Group Senior |
$2,911.63
|
|
|
HC DRAINAGE OF EYE
|
Facility
IP
|
$7,667.00
|
|
|
Service Code
|
CPT 65800
|
| Hospital Charge Code |
900501746
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,387.73 |
| Max. Negotiated Rate |
$5,750.25 |
| Rate for Payer: Adventist Health Commercial |
$1,533.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,267.23
|
| Rate for Payer: Cash Price |
$3,450.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,190.56
|
| Rate for Payer: Heritage Provider Network Senior |
$5,190.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,387.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,916.75
|
| Rate for Payer: Multiplan Commercial |
$5,750.25
|
|
|
HC DRAINAGE OF SALIVARY GLAND
|
Facility
IP
|
$673.00
|
|
|
Service Code
|
CPT 42320
|
| Hospital Charge Code |
900501363
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$121.81 |
| Max. Negotiated Rate |
$504.75 |
| Rate for Payer: Adventist Health Commercial |
$134.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$462.35
|
| Rate for Payer: Cash Price |
$302.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$455.62
|
| Rate for Payer: Heritage Provider Network Senior |
$455.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$121.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$168.25
|
| Rate for Payer: Multiplan Commercial |
$504.75
|
|
|
HC DRAINAGE OF SALIVARY GLAND
|
Facility
OP
|
$673.00
|
|
|
Service Code
|
CPT 42320
|
| Hospital Charge Code |
900501363
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$121.81 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$134.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$462.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,031.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$756.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$687.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$302.85
|
| Rate for Payer: Cash Price |
$302.85
|
| Rate for Payer: Cash Price |
$302.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$437.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,031.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$756.18
|
| Rate for Payer: Dignity Health Senior |
$687.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$687.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$455.62
|
| Rate for Payer: Heritage Provider Network Senior |
$455.62
|
| Rate for Payer: Humana Medicare |
$687.44
|
| Rate for Payer: IEHP Medi-Cal |
$936.00
|
| Rate for Payer: IEHP Medicare Advantage |
$687.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$324.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$121.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$811.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$168.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$866.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$866.17
|
| Rate for Payer: Multiplan Commercial |
$504.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$244.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$224.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,031.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$756.18
|
| Rate for Payer: Vantage Medical Group Senior |
$687.44
|
|
|
HC DRAINAGE/ SCROTAL WALL ABSCESS
|
Facility
IP
|
$4,319.00
|
|
|
Service Code
|
CPT 55100
|
| Hospital Charge Code |
900501614
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$781.74 |
| Max. Negotiated Rate |
$3,239.25 |
| Rate for Payer: Adventist Health Commercial |
$863.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,967.15
|
| Rate for Payer: Cash Price |
$1,943.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,923.96
|
| Rate for Payer: Heritage Provider Network Senior |
$2,923.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$781.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,079.75
|
| Rate for Payer: Multiplan Commercial |
$3,239.25
|
|
|
HC DRAINAGE/ SCROTAL WALL ABSCESS
|
Facility
OP
|
$4,319.00
|
|
|
Service Code
|
CPT 55100
|
| Hospital Charge Code |
900501614
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$781.74 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$863.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,967.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: AlphaCare 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: Cash Price |
$1,943.55
|
| Rate for Payer: Cash Price |
$1,943.55
|
| Rate for Payer: Cash Price |
$1,943.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,807.35
|
| 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 |
$2,923.96
|
| Rate for Payer: Heritage Provider Network Senior |
$2,923.96
|
| Rate for Payer: Humana Medicare |
$2,025.69
|
| Rate for Payer: IEHP Medi-Cal |
$936.00
|
| Rate for Payer: IEHP Medicare Advantage |
$2,025.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,081.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$781.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,390.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,079.75
|
| 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 |
$3,239.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,568.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,442.98
|
| 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 DRAIN CATH PLCMT HEMATOMA/SEROMA/CYST
|
Facility
OP
|
$751.00
|
|
|
Service Code
|
CPT 10030
|
| Hospital Charge Code |
909020024
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$135.93 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$150.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$515.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,318.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$966.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$879.07
|
| 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 |
$337.95
|
| Rate for Payer: Cash Price |
$337.95
|
| Rate for Payer: Cash Price |
$337.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$488.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,318.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$966.98
|
| Rate for Payer: Dignity Health Senior |
$879.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$879.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$464.87
|
| Rate for Payer: Heritage Provider Network Senior |
$1,081.26
|
| Rate for Payer: Humana Medicare |
$879.07
|
| Rate for Payer: IEHP Medi-Cal |
$207.92
|
| Rate for Payer: IEHP Medicare Advantage |
$879.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,670.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$135.93
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,037.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$187.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,107.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,107.63
|
| Rate for Payer: Multiplan Commercial |
$563.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$966.98
|
| Rate for Payer: TriValley Medical Group Senior |
$966.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,600.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,188.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,318.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$966.98
|
| Rate for Payer: Vantage Medical Group Senior |
$879.07
|
|
|
HC DRAIN CATH PLCMT HEMATOMA/SEROMA/CYST
|
Facility
IP
|
$751.00
|
|
|
Service Code
|
CPT 10030
|
| Hospital Charge Code |
909020024
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$135.93 |
| Max. Negotiated Rate |
$563.25 |
| Rate for Payer: Adventist Health Commercial |
$150.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$515.94
|
| Rate for Payer: Cash Price |
$337.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$508.43
|
| Rate for Payer: Heritage Provider Network Senior |
$508.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$135.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$187.75
|
| Rate for Payer: Multiplan Commercial |
$563.25
|
|
|
HC DRAIN EXT EAR ABSC SIMPLE
|
Facility
OP
|
$609.00
|
|
|
Service Code
|
CPT 69000
|
| Hospital Charge Code |
900501184
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$110.23 |
| Max. Negotiated Rate |
$3,237.00 |
| 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 |
$1,318.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$966.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$879.07
|
| 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 |
$1,318.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$966.98
|
| Rate for Payer: Dignity Health Senior |
$879.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$395.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$879.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$412.29
|
| Rate for Payer: Heritage Provider Network Senior |
$412.29
|
| Rate for Payer: Humana Medicare |
$879.07
|
| Rate for Payer: IEHP Medi-Cal |
$936.00
|
| Rate for Payer: IEHP Medicare Advantage |
$879.07
|
| 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 |
$1,037.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$152.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,107.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,107.63
|
| 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 |
$1,318.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$966.98
|
| Rate for Payer: Vantage Medical Group Senior |
$879.07
|
|
|
HC DRAIN EXT EAR ABSC SIMPLE
|
Facility
IP
|
$609.00
|
|
|
Service Code
|
CPT 69000
|
| Hospital Charge Code |
900501184
|
|
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 DRAIN FINGER ABSCESS COMPL
|
Facility
OP
|
$2,118.00
|
|
|
Service Code
|
CPT 26011
|
| Hospital Charge Code |
900501073
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$221.29 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$423.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,455.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: AlphaCare 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 |
$1,315.28
|
| Rate for Payer: Blue Shield of California EPN |
$1,243.27
|
| Rate for Payer: Cash Price |
$953.10
|
| Rate for Payer: Cash Price |
$953.10
|
| Rate for Payer: Cash Price |
$953.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,376.70
|
| 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 |
$1,311.04
|
| Rate for Payer: Heritage Provider Network Senior |
$2,491.60
|
| Rate for Payer: Humana Medicare |
$2,025.69
|
| Rate for Payer: IEHP Medi-Cal |
$221.29
|
| Rate for Payer: 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 |
$383.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,390.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$529.50
|
| 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 |
$1,588.50
|
| 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 DRAIN FINGER ABSCESS COMPL
|
Facility
IP
|
$2,118.00
|
|
|
Service Code
|
CPT 26011
|
| Hospital Charge Code |
900501073
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$383.36 |
| Max. Negotiated Rate |
$1,588.50 |
| Rate for Payer: Adventist Health Commercial |
$423.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,455.07
|
| Rate for Payer: Cash Price |
$953.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,433.89
|
| Rate for Payer: Heritage Provider Network Senior |
$1,433.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$383.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$529.50
|
| Rate for Payer: Multiplan Commercial |
$1,588.50
|
|
|
HC DRAIN FINGER ABSCESS, SIMPLE
|
Facility
IP
|
$627.00
|
|
|
Service Code
|
CPT 26010
|
| Hospital Charge Code |
900501461
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$113.49 |
| Max. Negotiated Rate |
$470.25 |
| Rate for Payer: Adventist Health Commercial |
$125.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$430.75
|
| Rate for Payer: Cash Price |
$282.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$424.48
|
| Rate for Payer: Heritage Provider Network Senior |
$424.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$113.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$156.75
|
| Rate for Payer: Multiplan Commercial |
$470.25
|
|
|
HC DRAIN FINGER ABSCESS, SIMPLE
|
Facility
OP
|
$627.00
|
|
|
Service Code
|
CPT 26010
|
| Hospital Charge Code |
900501461
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$113.49 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$125.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$277.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$430.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$282.15
|
| Rate for Payer: Cash Price |
$282.15
|
| Rate for Payer: Cash Price |
$282.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$407.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: Dignity Health Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$250.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$424.48
|
| Rate for Payer: Heritage Provider Network Senior |
$424.48
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: IEHP Medi-Cal |
$936.00
|
| Rate for Payer: IEHP Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$302.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$113.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$295.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$156.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.18
|
| Rate for Payer: Multiplan Commercial |
$470.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$227.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$209.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Vantage Medical Group Senior |
$250.14
|
|
|
HC DRAIN JP
|
Facility
OP
|
$35.09
|
|
| Hospital Charge Code |
909020083
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.35 |
| Max. Negotiated Rate |
$29.83 |
| Rate for Payer: Adventist Health Commercial |
$7.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$18.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$29.83
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$19.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$26.32
|
| Rate for Payer: Blue Shield of California Commercial |
$21.79
|
| Rate for Payer: Blue Shield of California EPN |
$20.60
|
| Rate for Payer: Cash Price |
$15.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.83
|
| Rate for Payer: Dignity Health Senior |
$29.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.72
|
| Rate for Payer: Heritage Provider Network Senior |
$21.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.77
|
| Rate for Payer: Multiplan Commercial |
$26.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.83
|
| Rate for Payer: Vantage Medical Group Senior |
$29.83
|
|
|
HC DRAIN JP
|
Facility
IP
|
$35.09
|
|
| Hospital Charge Code |
909020083
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.35 |
| Max. Negotiated Rate |
$26.32 |
| Rate for Payer: Adventist Health Commercial |
$7.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.11
|
| Rate for Payer: Cash Price |
$15.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.76
|
| Rate for Payer: Heritage Provider Network Senior |
$23.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.77
|
| Rate for Payer: Multiplan Commercial |
$26.32
|
|
|
HC DRES & OR DEB OF BURN INT/SUB LG
|
Facility
IP
|
$1,188.00
|
|
|
Service Code
|
CPT 16030
|
| Hospital Charge Code |
900501048
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$215.03 |
| Max. Negotiated Rate |
$891.00 |
| Rate for Payer: Adventist Health Commercial |
$237.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$816.16
|
| Rate for Payer: Cash Price |
$534.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$804.28
|
| Rate for Payer: Heritage Provider Network Senior |
$804.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$215.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$297.00
|
| Rate for Payer: Multiplan Commercial |
$891.00
|
|
|
HC DRES & OR DEB OF BURN INT/SUB LG
|
Facility
OP
|
$1,188.00
|
|
|
Service Code
|
CPT 16030
|
| Hospital Charge Code |
900501048
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$215.03 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$237.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$816.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$498.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$534.60
|
| Rate for Payer: Cash Price |
$534.60
|
| Rate for Payer: Cash Price |
$534.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$772.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$747.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$548.02
|
| Rate for Payer: Dignity Health Senior |
$498.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$498.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$804.28
|
| Rate for Payer: Heritage Provider Network Senior |
$804.28
|
| Rate for Payer: Humana Medicare |
$498.20
|
| Rate for Payer: IEHP Medi-Cal |
$936.00
|
| Rate for Payer: IEHP Medicare Advantage |
$498.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$572.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$215.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$587.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$297.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$627.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$627.73
|
| Rate for Payer: Multiplan Commercial |
$891.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$431.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$396.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Vantage Medical Group Senior |
$498.20
|
|
|
HC DRES & OR DEB OF BURN INT/SUB MED
|
Facility
OP
|
$912.00
|
|
|
Service Code
|
CPT 16025
|
| Hospital Charge Code |
900501047
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.07 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$182.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$626.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$410.40
|
| Rate for Payer: Cash Price |
$410.40
|
| Rate for Payer: Cash Price |
$410.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$592.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: Dignity Health Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$250.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$617.42
|
| Rate for Payer: Heritage Provider Network Senior |
$617.42
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: IEHP Medi-Cal |
$936.00
|
| Rate for Payer: IEHP Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$439.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$165.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$295.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$228.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.18
|
| Rate for Payer: Multiplan Commercial |
$684.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$331.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$304.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Vantage Medical Group Senior |
$250.14
|
|
|
HC DRES & OR DEB OF BURN INT/SUB MED
|
Facility
IP
|
$912.00
|
|
|
Service Code
|
CPT 16025
|
| Hospital Charge Code |
900501047
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.07 |
| Max. Negotiated Rate |
$684.00 |
| Rate for Payer: Adventist Health Commercial |
$182.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$626.54
|
| Rate for Payer: Cash Price |
$410.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$617.42
|
| Rate for Payer: Heritage Provider Network Senior |
$617.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$165.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$228.00
|
| Rate for Payer: Multiplan Commercial |
$684.00
|
|
