|
HC PLASTIC REPAIR OF CANALICULI
|
Facility
IP
|
$4,818.00
|
|
|
Service Code
|
CPT 68700
|
| Hospital Charge Code |
900501395
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$872.06 |
| Max. Negotiated Rate |
$3,613.50 |
| Rate for Payer: Adventist Health Commercial |
$963.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,309.97
|
| Rate for Payer: Cash Price |
$2,168.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,261.79
|
| Rate for Payer: Heritage Provider Network Senior |
$3,261.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$872.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,204.50
|
| Rate for Payer: Multiplan Commercial |
$3,613.50
|
|
|
HC PLASTY BALLOON/ACCENT
|
Facility
IP
|
$300.00
|
|
|
Service Code
|
CPT C1725
|
| Hospital Charge Code |
909081210
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$60.00 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$60.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$144.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$206.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$138.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$162.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$203.10
|
| Rate for Payer: Heritage Provider Network Senior |
$203.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$150.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$150.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$150.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.00
|
| Rate for Payer: Multiplan Commercial |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$109.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$100.23
|
|
|
HC PLASTY BALLOON/ACCENT
|
Facility
OP
|
$300.00
|
|
|
Service Code
|
CPT C1725
|
| Hospital Charge Code |
909081210
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$60.00 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$60.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$144.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$206.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$255.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$165.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$225.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$186.30
|
| Rate for Payer: Blue Shield of California EPN |
$176.10
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$138.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$255.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$255.00
|
| Rate for Payer: Dignity Health Senior |
$255.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$192.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$138.90
|
| Rate for Payer: Heritage Provider Network Senior |
$138.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$150.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$150.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$150.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.00
|
| Rate for Payer: Multiplan Commercial |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$109.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$100.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$255.00
|
| Rate for Payer: Vantage Medical Group Senior |
$255.00
|
|
|
HC PLASTY BALLOON/LP/PF+ CORDIS
|
Facility
IP
|
$720.00
|
|
|
Service Code
|
CPT C1725
|
| Hospital Charge Code |
909081212
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$144.00 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$144.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$345.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$494.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$331.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$388.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$487.44
|
| Rate for Payer: Heritage Provider Network Senior |
$487.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$360.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$360.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$360.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$180.00
|
| Rate for Payer: Multiplan Commercial |
$540.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$262.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$240.55
|
|
|
HC PLASTY BALLOON/LP/PF+ CORDIS
|
Facility
OP
|
$720.00
|
|
|
Service Code
|
CPT C1725
|
| Hospital Charge Code |
909081212
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$144.00 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$144.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$345.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$494.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$612.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$396.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$540.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$447.12
|
| Rate for Payer: Blue Shield of California EPN |
$422.64
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$331.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$612.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$612.00
|
| Rate for Payer: Dignity Health Senior |
$612.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$460.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$333.36
|
| Rate for Payer: Heritage Provider Network Senior |
$333.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$360.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$360.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$360.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$180.00
|
| Rate for Payer: Multiplan Commercial |
$540.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$262.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$240.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$612.00
|
| Rate for Payer: Vantage Medical Group Senior |
$612.00
|
|
|
HC PLASTY BALLOON/XXL/MAXI
|
Facility
OP
|
$1,150.00
|
|
|
Service Code
|
CPT C1725
|
| Hospital Charge Code |
909081287
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$230.00 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$230.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$552.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$790.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$977.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$632.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$862.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$714.15
|
| Rate for Payer: Blue Shield of California EPN |
$675.05
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$529.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$977.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$977.50
|
| Rate for Payer: Dignity Health Senior |
$977.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$736.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$532.45
|
| Rate for Payer: Heritage Provider Network Senior |
$532.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$575.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$575.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$575.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$287.50
|
| Rate for Payer: Multiplan Commercial |
$862.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$419.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$384.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$977.50
|
| Rate for Payer: Vantage Medical Group Senior |
$977.50
|
|
|
HC PLASTY BALLOON/XXL/MAXI
|
Facility
IP
|
$1,150.00
|
|
|
Service Code
|
CPT C1725
|
| Hospital Charge Code |
909081287
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$230.00 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$230.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$552.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$790.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$529.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$621.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$778.55
|
| Rate for Payer: Heritage Provider Network Senior |
$778.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$575.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$575.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$575.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$287.50
|
| Rate for Payer: Multiplan Commercial |
$862.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$419.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$384.22
|
|
|
HC PLATELET COUNT
|
Facility
IP
|
$125.00
|
|
|
Service Code
|
CPT 85049
|
| Hospital Charge Code |
900910101
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$22.62 |
| Max. Negotiated Rate |
$93.75 |
| Rate for Payer: Adventist Health Commercial |
$25.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$85.88
|
| Rate for Payer: Cash Price |
$56.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$84.62
|
| Rate for Payer: Heritage Provider Network Senior |
$84.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.25
|
| Rate for Payer: Multiplan Commercial |
$93.75
|
|
|
HC PLATELET COUNT
|
Facility
OP
|
$17.00
|
|
|
Service Code
|
CPT 85049
|
| Hospital Charge Code |
900910101
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$37.47 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.93
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.47
|
| Rate for Payer: Blue Shield of California Commercial |
$34.94
|
| Rate for Payer: Blue Shield of California EPN |
$27.31
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.93
|
| Rate for Payer: Dignity Health Senior |
$4.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.05
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Senior |
$10.52
|
| Rate for Payer: Humana Medicare |
$4.48
|
| Rate for Payer: IEHP Medi-Cal |
$5.88
|
| Rate for Payer: IEHP Medicare Advantage |
$4.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.64
|
| Rate for Payer: Multiplan Commercial |
$12.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.48
|
| Rate for Payer: TriValley Medical Group Senior |
$4.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.93
|
| Rate for Payer: Vantage Medical Group Senior |
$4.48
|
|
|
HC PLATELET COUNT CITRATED
|
Facility
OP
|
$17.00
|
|
|
Service Code
|
CPT 85049
|
| Hospital Charge Code |
900912026
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$37.47 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.93
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.47
|
| Rate for Payer: Blue Shield of California Commercial |
$34.94
|
| Rate for Payer: Blue Shield of California EPN |
$27.31
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.93
|
| Rate for Payer: Dignity Health Senior |
$4.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.05
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Senior |
$10.52
|
| Rate for Payer: Humana Medicare |
$4.48
|
| Rate for Payer: IEHP Medi-Cal |
$5.88
|
| Rate for Payer: IEHP Medicare Advantage |
$4.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.64
|
| Rate for Payer: Multiplan Commercial |
$12.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.48
|
| Rate for Payer: TriValley Medical Group Senior |
$4.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.93
|
| Rate for Payer: Vantage Medical Group Senior |
$4.48
|
|
|
HC PLATELET COUNT CITRATED
|
Facility
IP
|
$125.00
|
|
|
Service Code
|
CPT 85049
|
| Hospital Charge Code |
900912026
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$22.62 |
| Max. Negotiated Rate |
$93.75 |
| Rate for Payer: Adventist Health Commercial |
$25.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$85.88
|
| Rate for Payer: Cash Price |
$56.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$84.62
|
| Rate for Payer: Heritage Provider Network Senior |
$84.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.25
|
| Rate for Payer: Multiplan Commercial |
$93.75
|
|
|
HC PLATELET NEUTRALIZATION
|
Facility
OP
|
$55.00
|
|
|
Service Code
|
CPT 85597
|
| Hospital Charge Code |
900912007
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$9.96 |
| Max. Negotiated Rate |
$140.42 |
| Rate for Payer: Adventist Health Commercial |
$11.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$52.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.78
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$26.97
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$19.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$17.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$127.80
|
| Rate for Payer: Blue Shield of California Commercial |
$140.42
|
| Rate for Payer: Blue Shield of California EPN |
$109.77
|
| Rate for Payer: Cash Price |
$24.75
|
| Rate for Payer: Cash Price |
$24.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$35.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.78
|
| Rate for Payer: Dignity Health Senior |
$17.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.04
|
| Rate for Payer: Heritage Provider Network Senior |
$34.04
|
| Rate for Payer: Humana Medicare |
$17.98
|
| Rate for Payer: IEHP Medi-Cal |
$24.93
|
| Rate for Payer: IEHP Medicare Advantage |
$17.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$34.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.65
|
| Rate for Payer: Multiplan Commercial |
$41.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.98
|
| Rate for Payer: TriValley Medical Group Senior |
$17.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.78
|
| Rate for Payer: Vantage Medical Group Senior |
$17.98
|
|
|
HC PLATELET NEUTRALIZATION
|
Facility
IP
|
$382.00
|
|
|
Service Code
|
CPT 85597
|
| Hospital Charge Code |
900912007
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$69.14 |
| Max. Negotiated Rate |
$286.50 |
| Rate for Payer: Adventist Health Commercial |
$76.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$262.43
|
| Rate for Payer: Cash Price |
$171.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$258.61
|
| Rate for Payer: Heritage Provider Network Senior |
$258.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.50
|
| Rate for Payer: Multiplan Commercial |
$286.50
|
|
|
HC PLATELET PED PAK ALIQUOT
|
Facility
OP
|
$1,151.00
|
|
|
Service Code
|
CPT P9011
|
| Hospital Charge Code |
900904532
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$134.02 |
| Max. Negotiated Rate |
$863.25 |
| Rate for Payer: Adventist Health Commercial |
$230.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$134.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$790.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$293.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$215.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$195.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$660.10
|
| Rate for Payer: Blue Shield of California Commercial |
$714.77
|
| Rate for Payer: Blue Shield of California EPN |
$675.64
|
| Rate for Payer: Cash Price |
$517.95
|
| Rate for Payer: Cash Price |
$517.95
|
| Rate for Payer: Cash Price |
$517.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$748.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$293.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$215.03
|
| Rate for Payer: Dignity Health Senior |
$195.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$748.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$195.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$712.47
|
| Rate for Payer: Heritage Provider Network Senior |
$712.47
|
| Rate for Payer: Humana Medicare |
$195.48
|
| Rate for Payer: IEHP Medi-Cal |
$232.75
|
| Rate for Payer: IEHP Medicare Advantage |
$195.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$371.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$208.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$230.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$287.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$246.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$246.30
|
| Rate for Payer: Multiplan Commercial |
$863.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$215.03
|
| Rate for Payer: TriValley Medical Group Senior |
$195.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$596.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$501.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$293.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$215.03
|
| Rate for Payer: Vantage Medical Group Senior |
$195.48
|
|
|
HC PLATELET PED PAK ALIQUOT
|
Facility
IP
|
$1,151.00
|
|
|
Service Code
|
CPT P9011
|
| Hospital Charge Code |
900904532
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$208.33 |
| Max. Negotiated Rate |
$863.25 |
| Rate for Payer: Adventist Health Commercial |
$230.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$790.74
|
| Rate for Payer: Cash Price |
$517.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$779.23
|
| Rate for Payer: Heritage Provider Network Senior |
$779.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$208.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$287.75
|
| Rate for Payer: Multiplan Commercial |
$863.25
|
|
|
HC PLATELET SURVIVAL
|
Facility
OP
|
$1,378.00
|
|
|
Service Code
|
CPT 78191
|
| Hospital Charge Code |
909301642
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$179.96 |
| Max. Negotiated Rate |
$1,495.21 |
| Rate for Payer: Adventist Health Commercial |
$275.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$325.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$946.69
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$772.98
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$566.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$515.32
|
| Rate for Payer: Blue Shield of California Commercial |
$1,495.21
|
| Rate for Payer: Blue Shield of California EPN |
$850.28
|
| Rate for Payer: Cash Price |
$620.10
|
| Rate for Payer: Cash Price |
$620.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$895.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$772.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$566.85
|
| Rate for Payer: Dignity Health Senior |
$515.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$895.70
|
| Rate for Payer: EPIC Health Plan Medicare |
$515.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$852.98
|
| Rate for Payer: Heritage Provider Network Senior |
$852.98
|
| Rate for Payer: Humana Medicare |
$515.32
|
| Rate for Payer: IEHP Medi-Cal |
$179.96
|
| Rate for Payer: IEHP Medicare Advantage |
$515.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$979.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$249.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$608.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$344.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$649.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$649.30
|
| Rate for Payer: Multiplan Commercial |
$1,033.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$566.85
|
| Rate for Payer: TriValley Medical Group Senior |
$515.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$772.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$566.85
|
| Rate for Payer: Vantage Medical Group Senior |
$515.32
|
|
|
HC PLATELET SURVIVAL
|
Facility
IP
|
$1,378.00
|
|
|
Service Code
|
CPT 78191
|
| Hospital Charge Code |
909301642
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$249.42 |
| Max. Negotiated Rate |
$1,033.50 |
| Rate for Payer: Adventist Health Commercial |
$275.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$946.69
|
| Rate for Payer: Cash Price |
$620.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$932.91
|
| Rate for Payer: Heritage Provider Network Senior |
$932.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$249.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$344.50
|
| Rate for Payer: Multiplan Commercial |
$1,033.50
|
|
|
HC PLCMNT ACC BILIARY TREE PERCU
|
Facility
OP
|
$11,134.00
|
|
|
Service Code
|
CPT 47541
|
| Hospital Charge Code |
909047541
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,687.19 |
| Max. Negotiated Rate |
$17,960.09 |
| Rate for Payer: Adventist Health Commercial |
$2,226.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,649.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14,179.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10,397.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9,452.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$5,379.37
|
| Rate for Payer: Blue Shield of California EPN |
$4,623.32
|
| Rate for Payer: Cash Price |
$5,010.30
|
| Rate for Payer: Cash Price |
$5,010.30
|
| Rate for Payer: Cash Price |
$5,010.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,237.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14,179.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$10,397.95
|
| Rate for Payer: Dignity Health Senior |
$9,452.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$9,452.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,891.95
|
| Rate for Payer: Heritage Provider Network Senior |
$11,626.80
|
| Rate for Payer: Humana Medicare |
$9,452.68
|
| Rate for Payer: IEHP Medi-Cal |
$1,687.19
|
| Rate for Payer: IEHP Medicare Advantage |
$9,452.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17,960.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,015.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11,154.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,783.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11,910.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11,910.38
|
| Rate for Payer: Multiplan Commercial |
$8,350.50
|
| Rate for Payer: Multiplan WC |
$12,923.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$10,397.95
|
| Rate for Payer: TriValley Medical Group Senior |
$10,397.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9,520.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,039.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14,179.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10,397.95
|
| Rate for Payer: Vantage Medical Group Senior |
$9,452.68
|
|
|
HC PLCMNT ACC BILIARY TREE PERCU
|
Facility
IP
|
$11,134.00
|
|
|
Service Code
|
CPT 47541
|
| Hospital Charge Code |
909047541
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,015.25 |
| Max. Negotiated Rate |
$8,350.50 |
| Rate for Payer: Adventist Health Commercial |
$2,226.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,649.06
|
| Rate for Payer: Cash Price |
$5,010.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,537.72
|
| Rate for Payer: Heritage Provider Network Senior |
$7,537.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,015.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,783.50
|
| Rate for Payer: Multiplan Commercial |
$8,350.50
|
|
|
HC PLCMNT LCL DVC PERC 1ST LESION
|
Facility
IP
|
$1,281.00
|
|
|
Service Code
|
CPT 10035
|
| Hospital Charge Code |
909010035
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$231.86 |
| Max. Negotiated Rate |
$960.75 |
| Rate for Payer: Adventist Health Commercial |
$256.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$880.05
|
| Rate for Payer: Cash Price |
$576.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$867.24
|
| Rate for Payer: Heritage Provider Network Senior |
$867.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$231.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$320.25
|
| Rate for Payer: Multiplan Commercial |
$960.75
|
|
|
HC PLCMNT LCL DVC PERC 1ST LESION
|
Facility
OP
|
$1,281.00
|
|
|
Service Code
|
CPT 10035
|
| Hospital Charge Code |
909010035
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$231.86 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$256.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$880.05
|
| 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 |
$795.50
|
| Rate for Payer: Blue Shield of California EPN |
$751.95
|
| Rate for Payer: Cash Price |
$576.45
|
| Rate for Payer: Cash Price |
$576.45
|
| Rate for Payer: Cash Price |
$576.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$832.65
|
| 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 |
$792.94
|
| Rate for Payer: Heritage Provider Network Senior |
$792.94
|
| Rate for Payer: Humana Medicare |
$879.07
|
| Rate for Payer: IEHP Medi-Cal |
$768.38
|
| 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 |
$231.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,037.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$320.25
|
| 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 |
$960.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$879.07
|
| Rate for Payer: TriValley Medical Group Senior |
$879.07
|
| 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 PLCMNT LCL DVC PERC ADD LESION
|
Facility
IP
|
$898.00
|
|
|
Service Code
|
CPT 10036
|
| Hospital Charge Code |
909010036
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$162.54 |
| Max. Negotiated Rate |
$673.50 |
| Rate for Payer: Adventist Health Commercial |
$179.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$616.93
|
| Rate for Payer: Cash Price |
$404.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$607.95
|
| Rate for Payer: Heritage Provider Network Senior |
$607.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$162.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$224.50
|
| Rate for Payer: Multiplan Commercial |
$673.50
|
|
|
HC PLCMNT LCL DVC PERC ADD LESION
|
Facility
OP
|
$898.00
|
|
|
Service Code
|
CPT 10036
|
| Hospital Charge Code |
909010036
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$162.54 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$179.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$616.93
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$763.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$493.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$673.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$557.66
|
| Rate for Payer: Blue Shield of California EPN |
$527.13
|
| Rate for Payer: Cash Price |
$404.10
|
| Rate for Payer: Cash Price |
$404.10
|
| Rate for Payer: Cash Price |
$404.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$583.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$763.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$763.30
|
| Rate for Payer: Dignity Health Senior |
$763.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$555.86
|
| Rate for Payer: Heritage Provider Network Senior |
$555.86
|
| Rate for Payer: IEHP Medi-Cal |
$671.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$432.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$162.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$224.50
|
| Rate for Payer: Multiplan Commercial |
$673.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$763.30
|
| Rate for Payer: Vantage Medical Group Senior |
$763.30
|
|
|
HC PLCMNT NEPH CATH PERCU
|
Facility
IP
|
$6,822.00
|
|
|
Service Code
|
CPT 50432
|
| Hospital Charge Code |
909050432
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,234.78 |
| Max. Negotiated Rate |
$5,116.50 |
| Rate for Payer: Adventist Health Commercial |
$1,364.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,686.71
|
| Rate for Payer: Cash Price |
$3,069.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,618.49
|
| Rate for Payer: Heritage Provider Network Senior |
$4,618.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,234.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,705.50
|
| Rate for Payer: Multiplan Commercial |
$5,116.50
|
|
|
HC PLCMNT NEPH CATH PERCU
|
Facility
OP
|
$6,822.00
|
|
|
Service Code
|
CPT 50432
|
| Hospital Charge Code |
909050432
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,206.88 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,364.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,686.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,544.87
|
| 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 |
$3,069.90
|
| Rate for Payer: Cash Price |
$3,069.90
|
| Rate for Payer: Cash Price |
$3,069.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,434.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,799.36
|
| Rate for Payer: Dignity Health Senior |
$2,544.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,544.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,222.82
|
| Rate for Payer: Heritage Provider Network Senior |
$3,130.19
|
| Rate for Payer: Humana Medicare |
$2,544.87
|
| Rate for Payer: IEHP Medi-Cal |
$1,206.88
|
| Rate for Payer: IEHP Medicare Advantage |
$2,544.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,835.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,234.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,002.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,705.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,206.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,206.54
|
| Rate for Payer: Multiplan Commercial |
$5,116.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,799.36
|
| Rate for Payer: TriValley Medical Group Senior |
$2,799.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,096.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5,971.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Vantage Medical Group Senior |
$2,544.87
|
|
