|
HC SOM SACCHAROMY CEREVI AB, IGA
|
Facility
|
IP
|
$169.30
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
900913805
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$30.64 |
| Max. Negotiated Rate |
$126.97 |
| Rate for Payer: Adventist Health Commercial |
$33.86
|
| Rate for Payer: Cash Price |
$169.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$114.62
|
| Rate for Payer: Heritage Provider Network Senior |
$114.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.33
|
| Rate for Payer: Multiplan Commercial |
$126.97
|
|
|
HC SOM SACCHAROMY CEREVI AB, IGA
|
Facility
|
OP
|
$18.54
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
900913806
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.36 |
| Max. Negotiated Rate |
$117.64 |
| Rate for Payer: Adventist Health Commercial |
$3.71
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$117.64
|
| Rate for Payer: Blue Shield of California Commercial |
$98.67
|
| Rate for Payer: Blue Shield of California EPN |
$79.14
|
| Rate for Payer: Cash Price |
$18.54
|
| Rate for Payer: Cash Price |
$18.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.47
|
| Rate for Payer: Dignity Health Senior |
$12.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.05
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.48
|
| Rate for Payer: Heritage Provider Network Senior |
$11.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$17.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.44
|
| Rate for Payer: Multiplan Commercial |
$13.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.25
|
| Rate for Payer: TriValley Medical Group Senior |
$12.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.47
|
| Rate for Payer: Vantage Medical Group Senior |
$12.25
|
|
|
HC SOM SAL 86606
|
Facility
|
IP
|
$21.57
|
|
|
Service Code
|
CPT 86606
|
| Hospital Charge Code |
900914751
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.90 |
| Max. Negotiated Rate |
$16.18 |
| Rate for Payer: Adventist Health Commercial |
$4.31
|
| Rate for Payer: Cash Price |
$21.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.60
|
| Rate for Payer: Heritage Provider Network Senior |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.39
|
| Rate for Payer: Multiplan Commercial |
$16.18
|
|
|
HC SOM SAL 86606
|
Facility
|
OP
|
$21.57
|
|
|
Service Code
|
CPT 86606
|
| Hospital Charge Code |
900914751
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.90 |
| Max. Negotiated Rate |
$137.43 |
| Rate for Payer: Adventist Health Commercial |
$4.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$137.43
|
| Rate for Payer: Blue Shield of California Commercial |
$121.13
|
| Rate for Payer: Blue Shield of California EPN |
$97.16
|
| Rate for Payer: Cash Price |
$21.57
|
| Rate for Payer: Cash Price |
$21.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.55
|
| Rate for Payer: Dignity Health Senior |
$15.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.02
|
| Rate for Payer: EPIC Health Plan Medicare |
$15.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.35
|
| Rate for Payer: Heritage Provider Network Senior |
$13.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.96
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.96
|
| Rate for Payer: Multiplan Commercial |
$16.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.05
|
| Rate for Payer: TriValley Medical Group Senior |
$15.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.55
|
| Rate for Payer: Vantage Medical Group Senior |
$15.05
|
|
|
HC SOM SAL 86671A
|
Facility
|
IP
|
$17.55
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
900914749
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.18 |
| Max. Negotiated Rate |
$13.16 |
| Rate for Payer: Adventist Health Commercial |
$3.51
|
| Rate for Payer: Cash Price |
$17.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.88
|
| Rate for Payer: Heritage Provider Network Senior |
$11.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.39
|
| Rate for Payer: Multiplan Commercial |
$13.16
|
|
|
HC SOM SAL 86671A
|
Facility
|
OP
|
$17.55
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
900914749
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.18 |
| Max. Negotiated Rate |
$117.64 |
| Rate for Payer: Adventist Health Commercial |
$3.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$117.64
|
| Rate for Payer: Blue Shield of California Commercial |
$98.67
|
| Rate for Payer: Blue Shield of California EPN |
$79.14
|
| Rate for Payer: Cash Price |
$17.55
|
| Rate for Payer: Cash Price |
$17.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.47
|
| Rate for Payer: Dignity Health Senior |
$12.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.41
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.86
|
| Rate for Payer: Heritage Provider Network Senior |
$10.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$17.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.18
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.44
|
| Rate for Payer: Multiplan Commercial |
$13.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.25
|
| Rate for Payer: TriValley Medical Group Senior |
$12.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.47
|
| Rate for Payer: Vantage Medical Group Senior |
$12.25
|
|
|
HC SOM SAL 86671B
|
Facility
|
IP
|
$17.56
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
900914750
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.18 |
| Max. Negotiated Rate |
$13.17 |
| Rate for Payer: Adventist Health Commercial |
$3.51
|
| Rate for Payer: Cash Price |
$17.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.89
|
| Rate for Payer: Heritage Provider Network Senior |
$11.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.39
|
| Rate for Payer: Multiplan Commercial |
$13.17
|
|
|
HC SOM SAL 86671B
|
Facility
|
OP
|
$17.56
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
900914750
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.18 |
| Max. Negotiated Rate |
$117.64 |
| Rate for Payer: Adventist Health Commercial |
$3.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$117.64
|
| Rate for Payer: Blue Shield of California Commercial |
$98.67
|
| Rate for Payer: Blue Shield of California EPN |
$79.14
|
| Rate for Payer: Cash Price |
$17.56
|
| Rate for Payer: Cash Price |
$17.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.47
|
| Rate for Payer: Dignity Health Senior |
$12.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.41
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.87
|
| Rate for Payer: Heritage Provider Network Senior |
$10.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$17.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.18
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.44
|
| Rate for Payer: Multiplan Commercial |
$13.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.25
|
| Rate for Payer: TriValley Medical Group Senior |
$12.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.47
|
| Rate for Payer: Vantage Medical Group Senior |
$12.25
|
|
|
HC SOM SARS COV2
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
CPT U0003
|
| Hospital Charge Code |
900915348
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$13.57 |
| Max. Negotiated Rate |
$56.25 |
| Rate for Payer: Adventist Health Commercial |
$15.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.77
|
| Rate for Payer: Heritage Provider Network Senior |
$50.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.75
|
| Rate for Payer: Multiplan Commercial |
$56.25
|
|
|
HC SOM SARS COV2
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
CPT U0003
|
| Hospital Charge Code |
900915348
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$13.57 |
| Max. Negotiated Rate |
$460.97 |
| Rate for Payer: Adventist Health Commercial |
$15.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$108.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$108.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$63.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$41.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$56.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$460.97
|
| Rate for Payer: Blue Shield of California Commercial |
$45.75
|
| Rate for Payer: Blue Shield of California EPN |
$36.60
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$63.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$63.75
|
| Rate for Payer: Dignity Health Senior |
$63.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.42
|
| Rate for Payer: Heritage Provider Network Senior |
$46.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$35.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$52.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$56.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$37.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$63.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$63.75
|
| Rate for Payer: Vantage Medical Group Senior |
$63.75
|
|
|
HC SOM SARS-COV-2 IGG
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
CPT 86769
|
| Hospital Charge Code |
900915349
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.78 |
| Max. Negotiated Rate |
$32.25 |
| Rate for Payer: Adventist Health Commercial |
$8.60
|
| Rate for Payer: Cash Price |
$43.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.11
|
| Rate for Payer: Heritage Provider Network Senior |
$29.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.75
|
| Rate for Payer: Multiplan Commercial |
$32.25
|
|
|
HC SOM SARS-COV-2 IGG
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
CPT 86769
|
| Hospital Charge Code |
900915349
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.78 |
| Max. Negotiated Rate |
$270.44 |
| Rate for Payer: Adventist Health Commercial |
$8.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$63.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$46.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$42.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$270.44
|
| Rate for Payer: Blue Shield of California Commercial |
$26.23
|
| Rate for Payer: Blue Shield of California EPN |
$20.98
|
| Rate for Payer: Cash Price |
$43.00
|
| Rate for Payer: Cash Price |
$43.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$63.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$46.34
|
| Rate for Payer: Dignity Health Senior |
$42.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.95
|
| Rate for Payer: EPIC Health Plan Medicare |
$42.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.62
|
| Rate for Payer: Heritage Provider Network Senior |
$26.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$68.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$42.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$20.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$48.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$53.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$53.08
|
| Rate for Payer: Multiplan Commercial |
$32.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$42.13
|
| Rate for Payer: TriValley Medical Group Senior |
$42.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$45.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$63.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$46.34
|
| Rate for Payer: Vantage Medical Group Senior |
$42.13
|
|
|
HC SOM SCHISTOSOMIASIS AB IGG
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT 86682
|
| Hospital Charge Code |
900911335
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$119.85 |
| Rate for Payer: Adventist Health Commercial |
$9.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$119.85
|
| Rate for Payer: Blue Shield of California Commercial |
$104.66
|
| Rate for Payer: Blue Shield of California EPN |
$83.95
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.31
|
| Rate for Payer: Dignity Health Senior |
$13.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.86
|
| Rate for Payer: Heritage Provider Network Senior |
$27.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.39
|
| Rate for Payer: Multiplan Commercial |
$33.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.01
|
| Rate for Payer: TriValley Medical Group Senior |
$13.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.31
|
| Rate for Payer: Vantage Medical Group Senior |
$13.01
|
|
|
HC SOM SCHISTOSOMIASIS AB IGG
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT 86682
|
| Hospital Charge Code |
900911335
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$33.75 |
| Rate for Payer: Adventist Health Commercial |
$9.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.46
|
| Rate for Payer: Heritage Provider Network Senior |
$30.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.25
|
| Rate for Payer: Multiplan Commercial |
$33.75
|
|
|
HC SOM SEBV EBNA
|
Facility
|
IP
|
$9.48
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
900915457
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$7.11 |
| Rate for Payer: Adventist Health Commercial |
$1.90
|
| Rate for Payer: Cash Price |
$9.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.42
|
| Rate for Payer: Heritage Provider Network Senior |
$6.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.37
|
| Rate for Payer: Multiplan Commercial |
$7.11
|
|
|
HC SOM SEBV EBNA
|
Facility
|
OP
|
$9.48
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
900915457
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$141.73 |
| Rate for Payer: Adventist Health Commercial |
$1.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$141.73
|
| Rate for Payer: Blue Shield of California Commercial |
$123.15
|
| Rate for Payer: Blue Shield of California EPN |
$98.78
|
| Rate for Payer: Cash Price |
$9.48
|
| Rate for Payer: Cash Price |
$9.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.82
|
| Rate for Payer: Dignity Health Senior |
$15.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.16
|
| Rate for Payer: EPIC Health Plan Medicare |
$15.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.87
|
| Rate for Payer: Heritage Provider Network Senior |
$5.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$19.27
|
| Rate for Payer: Multiplan Commercial |
$7.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.29
|
| Rate for Payer: TriValley Medical Group Senior |
$15.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.82
|
| Rate for Payer: Vantage Medical Group Senior |
$15.29
|
|
|
HC SOM SEBV IGG
|
Facility
|
OP
|
$11.26
|
|
|
Service Code
|
CPT 86665
|
| Hospital Charge Code |
900915456
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$147.20 |
| Rate for Payer: Adventist Health Commercial |
$2.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$147.20
|
| Rate for Payer: Blue Shield of California Commercial |
$140.26
|
| Rate for Payer: Blue Shield of California EPN |
$112.50
|
| Rate for Payer: Cash Price |
$11.26
|
| Rate for Payer: Cash Price |
$11.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.95
|
| Rate for Payer: Dignity Health Senior |
$18.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.32
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.97
|
| Rate for Payer: Heritage Provider Network Senior |
$6.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$20.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.86
|
| Rate for Payer: Multiplan Commercial |
$8.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.14
|
| Rate for Payer: TriValley Medical Group Senior |
$18.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.95
|
| Rate for Payer: Vantage Medical Group Senior |
$18.14
|
|
|
HC SOM SEBV IGG
|
Facility
|
IP
|
$11.26
|
|
|
Service Code
|
CPT 86665
|
| Hospital Charge Code |
900915456
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$8.45 |
| Rate for Payer: Adventist Health Commercial |
$2.25
|
| Rate for Payer: Cash Price |
$11.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.62
|
| Rate for Payer: Heritage Provider Network Senior |
$7.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.81
|
| Rate for Payer: Multiplan Commercial |
$8.45
|
|
|
HC SOM SEBV IGM
|
Facility
|
OP
|
$11.26
|
|
|
Service Code
|
CPT 86665
|
| Hospital Charge Code |
900915455
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$147.20 |
| Rate for Payer: Adventist Health Commercial |
$2.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$147.20
|
| Rate for Payer: Blue Shield of California Commercial |
$140.26
|
| Rate for Payer: Blue Shield of California EPN |
$112.50
|
| Rate for Payer: Cash Price |
$11.26
|
| Rate for Payer: Cash Price |
$11.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.95
|
| Rate for Payer: Dignity Health Senior |
$18.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.32
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.97
|
| Rate for Payer: Heritage Provider Network Senior |
$6.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$20.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.86
|
| Rate for Payer: Multiplan Commercial |
$8.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.14
|
| Rate for Payer: TriValley Medical Group Senior |
$18.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.95
|
| Rate for Payer: Vantage Medical Group Senior |
$18.14
|
|
|
HC SOM SEBV IGM
|
Facility
|
IP
|
$11.26
|
|
|
Service Code
|
CPT 86665
|
| Hospital Charge Code |
900915455
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$8.45 |
| Rate for Payer: Adventist Health Commercial |
$2.25
|
| Rate for Payer: Cash Price |
$11.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.62
|
| Rate for Payer: Heritage Provider Network Senior |
$7.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.81
|
| Rate for Payer: Multiplan Commercial |
$8.45
|
|
|
HC SOM SECOBARBITAL
|
Facility
|
OP
|
$264.70
|
|
|
Service Code
|
CPT 80345
|
| Hospital Charge Code |
900910552
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.91 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Adventist Health Commercial |
$52.94
|
| Rate for Payer: Aetna of CA Gatekeeper |
$141.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$181.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$225.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$145.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$198.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$100.31
|
| Rate for Payer: Cash Price |
$264.70
|
| Rate for Payer: Cash Price |
$264.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$172.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$225.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$225.00
|
| Rate for Payer: Dignity Health Senior |
$225.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$172.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$163.85
|
| Rate for Payer: Heritage Provider Network Senior |
$163.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$126.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$185.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$185.29
|
| Rate for Payer: Multiplan Commercial |
$198.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$132.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$132.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$225.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$225.00
|
| Rate for Payer: Vantage Medical Group Senior |
$225.00
|
|
|
HC SOM SECOBARBITAL
|
Facility
|
IP
|
$264.70
|
|
|
Service Code
|
CPT 80345
|
| Hospital Charge Code |
900910552
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.91 |
| Max. Negotiated Rate |
$198.53 |
| Rate for Payer: Adventist Health Commercial |
$52.94
|
| Rate for Payer: Cash Price |
$264.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$179.20
|
| Rate for Payer: Heritage Provider Network Senior |
$179.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.17
|
| Rate for Payer: Multiplan Commercial |
$198.53
|
|
|
HC SOM SELENIUM URINE
|
Facility
|
IP
|
$25.62
|
|
|
Service Code
|
CPT 84255
|
| Hospital Charge Code |
900911019
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$19.21 |
| Rate for Payer: Adventist Health Commercial |
$5.12
|
| Rate for Payer: Cash Price |
$25.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.34
|
| Rate for Payer: Heritage Provider Network Senior |
$17.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.41
|
| Rate for Payer: Multiplan Commercial |
$19.21
|
|
|
HC SOM SELENIUM URINE
|
Facility
|
OP
|
$25.62
|
|
|
Service Code
|
CPT 84255
|
| Hospital Charge Code |
900911019
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$233.13 |
| Rate for Payer: Adventist Health Commercial |
$5.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$28.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$233.13
|
| Rate for Payer: Blue Shield of California Commercial |
$205.46
|
| Rate for Payer: Blue Shield of California EPN |
$164.80
|
| Rate for Payer: Cash Price |
$25.62
|
| Rate for Payer: Cash Price |
$25.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.08
|
| Rate for Payer: Dignity Health Senior |
$25.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.65
|
| Rate for Payer: EPIC Health Plan Medicare |
$25.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.86
|
| Rate for Payer: Heritage Provider Network Senior |
$15.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$36.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$25.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.17
|
| Rate for Payer: Multiplan Commercial |
$19.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$25.53
|
| Rate for Payer: TriValley Medical Group Senior |
$25.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.08
|
| Rate for Payer: Vantage Medical Group Senior |
$25.53
|
|
|
HC SOM SEROTONIN BLOOD
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 84260
|
| Hospital Charge Code |
900911033
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$282.79 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$46.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$34.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$30.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$282.79
|
| Rate for Payer: Blue Shield of California Commercial |
$249.29
|
| Rate for Payer: Blue Shield of California EPN |
$199.95
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$46.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$34.08
|
| Rate for Payer: Dignity Health Senior |
$30.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$30.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.57
|
| Rate for Payer: Heritage Provider Network Senior |
$18.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$44.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$30.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$35.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39.03
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$30.98
|
| Rate for Payer: TriValley Medical Group Senior |
$30.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$33.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$33.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$46.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$34.08
|
| Rate for Payer: Vantage Medical Group Senior |
$30.98
|
|
