|
HC TRYPSIN STOOL
|
Facility
OP
|
$28.00
|
|
|
Service Code
|
CPT 84488
|
| Hospital Charge Code |
900910231
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.07 |
| Max. Negotiated Rate |
$61.08 |
| Rate for Payer: Adventist Health Commercial |
$5.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$21.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.08
|
| Rate for Payer: Blue Shield of California Commercial |
$57.02
|
| Rate for Payer: Blue Shield of California EPN |
$44.57
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.03
|
| Rate for Payer: Dignity Health Senior |
$7.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$7.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.33
|
| Rate for Payer: Heritage Provider Network Senior |
$17.33
|
| Rate for Payer: Humana Medicare |
$7.30
|
| Rate for Payer: IEHP Medi-Cal |
$10.12
|
| Rate for Payer: IEHP Medicare Advantage |
$7.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.20
|
| Rate for Payer: Multiplan Commercial |
$21.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.30
|
| Rate for Payer: TriValley Medical Group Senior |
$7.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.03
|
| Rate for Payer: Vantage Medical Group Senior |
$7.30
|
|
|
HC TSH (THYROTROPIN)
|
Facility
IP
|
$276.00
|
|
|
Service Code
|
CPT 84443
|
| Hospital Charge Code |
900910829
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.96 |
| Max. Negotiated Rate |
$207.00 |
| Rate for Payer: Adventist Health Commercial |
$55.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$189.61
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$186.85
|
| Rate for Payer: Heritage Provider Network Senior |
$186.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.00
|
| Rate for Payer: Multiplan Commercial |
$207.00
|
|
|
HC TSH (THYROTROPIN)
|
Facility
OP
|
$28.00
|
|
|
Service Code
|
CPT 84443
|
| Hospital Charge Code |
900910829
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.07 |
| Max. Negotiated Rate |
$140.65 |
| Rate for Payer: Adventist Health Commercial |
$5.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$48.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$25.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$140.65
|
| Rate for Payer: Blue Shield of California Commercial |
$131.20
|
| Rate for Payer: Blue Shield of California EPN |
$102.56
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.48
|
| Rate for Payer: Dignity Health Senior |
$16.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.33
|
| Rate for Payer: Heritage Provider Network Senior |
$17.33
|
| Rate for Payer: Humana Medicare |
$16.80
|
| Rate for Payer: IEHP Medi-Cal |
$23.03
|
| Rate for Payer: IEHP Medicare Advantage |
$16.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$31.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.17
|
| Rate for Payer: Multiplan Commercial |
$21.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.80
|
| Rate for Payer: TriValley Medical Group Senior |
$16.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.48
|
| Rate for Payer: Vantage Medical Group Senior |
$16.80
|
|
|
HC TTE W OR W/O FOL W/CON,DOPPLER
|
Facility
OP
|
$1,621.00
|
|
|
Service Code
|
CPT C8929
|
| Hospital Charge Code |
900200256
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$251.00 |
| Max. Negotiated Rate |
$3,841.36 |
| Rate for Payer: Adventist Health Commercial |
$324.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,841.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,113.63
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,500.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,100.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,000.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1,006.64
|
| Rate for Payer: Blue Shield of California EPN |
$951.53
|
| Rate for Payer: Cash Price |
$729.45
|
| Rate for Payer: Cash Price |
$729.45
|
| Rate for Payer: Cash Price |
$729.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,053.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,500.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,100.44
|
| Rate for Payer: Dignity Health Senior |
$1,000.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,053.65
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,000.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,003.40
|
| Rate for Payer: Heritage Provider Network Senior |
$1,003.40
|
| Rate for Payer: Humana Medicare |
$1,000.40
|
| Rate for Payer: IEHP Medicare Advantage |
$1,000.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,900.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$293.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,180.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$405.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,260.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,260.50
|
| Rate for Payer: Multiplan Commercial |
$1,215.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,100.44
|
| Rate for Payer: TriValley Medical Group Senior |
$1,000.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$298.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$251.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,500.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,100.44
|
| Rate for Payer: Vantage Medical Group Senior |
$1,000.40
|
|
|
HC TTE W OR W/O FOL W/CON,DOPPLER
|
Facility
IP
|
$1,621.00
|
|
|
Service Code
|
CPT C8929
|
| Hospital Charge Code |
900200256
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$293.40 |
| Max. Negotiated Rate |
$1,215.75 |
| Rate for Payer: Adventist Health Commercial |
$324.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,113.63
|
| Rate for Payer: Cash Price |
$729.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,097.42
|
| Rate for Payer: Heritage Provider Network Senior |
$1,097.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$293.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$405.25
|
| Rate for Payer: Multiplan Commercial |
$1,215.75
|
|
|
HC TTE W WO CONTR ECG
|
Facility
IP
|
$1,621.00
|
|
|
Service Code
|
CPT C8930
|
| Hospital Charge Code |
900200257
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$293.40 |
| Max. Negotiated Rate |
$1,215.75 |
| Rate for Payer: Adventist Health Commercial |
$324.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,113.63
|
| Rate for Payer: Cash Price |
$729.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,097.42
|
| Rate for Payer: Heritage Provider Network Senior |
$1,097.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$293.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$405.25
|
| Rate for Payer: Multiplan Commercial |
$1,215.75
|
|
|
HC TTE W WO CONTR ECG
|
Facility
OP
|
$1,621.00
|
|
|
Service Code
|
CPT C8930
|
| Hospital Charge Code |
900200257
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$251.00 |
| Max. Negotiated Rate |
$6,039.45 |
| Rate for Payer: Adventist Health Commercial |
$324.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6,039.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,113.63
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,500.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,100.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,000.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1,006.64
|
| Rate for Payer: Blue Shield of California EPN |
$951.53
|
| Rate for Payer: Cash Price |
$729.45
|
| Rate for Payer: Cash Price |
$729.45
|
| Rate for Payer: Cash Price |
$729.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,053.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,500.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,100.44
|
| Rate for Payer: Dignity Health Senior |
$1,000.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,053.65
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,000.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,003.40
|
| Rate for Payer: Heritage Provider Network Senior |
$1,003.40
|
| Rate for Payer: Humana Medicare |
$1,000.40
|
| Rate for Payer: IEHP Medicare Advantage |
$1,000.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,900.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$293.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,180.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$405.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,260.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,260.50
|
| Rate for Payer: Multiplan Commercial |
$1,215.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,100.44
|
| Rate for Payer: TriValley Medical Group Senior |
$1,000.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$298.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$251.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,500.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,100.44
|
| Rate for Payer: Vantage Medical Group Senior |
$1,000.40
|
|
|
HC TTG IGA
|
Facility
IP
|
$58.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
900913669
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$43.50 |
| Rate for Payer: Adventist Health Commercial |
$11.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$39.85
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$39.27
|
| Rate for Payer: Heritage Provider Network Senior |
$39.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.50
|
| Rate for Payer: Multiplan Commercial |
$43.50
|
|
|
HC TTG IGA
|
Facility
OP
|
$39.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
900913669
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$195.82 |
| Rate for Payer: Adventist Health Commercial |
$7.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$27.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$195.82
|
| Rate for Payer: Blue Shield of California Commercial |
$72.56
|
| Rate for Payer: Blue Shield of California EPN |
$56.72
|
| Rate for Payer: Cash Price |
$17.55
|
| Rate for Payer: Cash Price |
$17.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.68
|
| Rate for Payer: Dignity Health Senior |
$11.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$11.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.14
|
| Rate for Payer: Heritage Provider Network Senior |
$24.14
|
| Rate for Payer: Humana Medicare |
$11.53
|
| Rate for Payer: IEHP Medi-Cal |
$13.42
|
| Rate for Payer: IEHP Medicare Advantage |
$11.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.53
|
| Rate for Payer: Multiplan Commercial |
$29.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.53
|
| Rate for Payer: TriValley Medical Group Senior |
$11.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.68
|
| Rate for Payer: Vantage Medical Group Senior |
$11.53
|
|
|
HC TTG IGG
|
Facility
IP
|
$58.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
900913670
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$43.50 |
| Rate for Payer: Adventist Health Commercial |
$11.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$39.85
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$39.27
|
| Rate for Payer: Heritage Provider Network Senior |
$39.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.50
|
| Rate for Payer: Multiplan Commercial |
$43.50
|
|
|
HC TTG IGG
|
Facility
OP
|
$39.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
900913670
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$195.82 |
| Rate for Payer: Adventist Health Commercial |
$7.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$27.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$195.82
|
| Rate for Payer: Blue Shield of California Commercial |
$72.56
|
| Rate for Payer: Blue Shield of California EPN |
$56.72
|
| Rate for Payer: Cash Price |
$17.55
|
| Rate for Payer: Cash Price |
$17.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.68
|
| Rate for Payer: Dignity Health Senior |
$11.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$11.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.14
|
| Rate for Payer: Heritage Provider Network Senior |
$24.14
|
| Rate for Payer: Humana Medicare |
$11.53
|
| Rate for Payer: IEHP Medi-Cal |
$13.42
|
| Rate for Payer: IEHP Medicare Advantage |
$11.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.53
|
| Rate for Payer: Multiplan Commercial |
$29.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.53
|
| Rate for Payer: TriValley Medical Group Senior |
$11.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.68
|
| Rate for Payer: Vantage Medical Group Senior |
$11.53
|
|
|
HC T-TUBE CHOLANGIOGRAM INJ
|
Facility
IP
|
$1,682.00
|
|
|
Service Code
|
CPT 47531
|
| Hospital Charge Code |
909000191
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$304.44 |
| Max. Negotiated Rate |
$1,261.50 |
| Rate for Payer: Adventist Health Commercial |
$336.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,155.53
|
| Rate for Payer: Cash Price |
$756.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,138.71
|
| Rate for Payer: Heritage Provider Network Senior |
$1,138.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$304.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$420.50
|
| Rate for Payer: Multiplan Commercial |
$1,261.50
|
|
|
HC T-TUBE CHOLANGIOGRAM INJ
|
Facility
OP
|
$1,682.00
|
|
|
Service Code
|
CPT 47531
|
| Hospital Charge Code |
909000191
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$304.44 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$336.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,155.53
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,483.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,754.88
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,322.62
|
| 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 |
$756.90
|
| Rate for Payer: Cash Price |
$756.90
|
| Rate for Payer: Cash Price |
$756.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,093.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,483.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,754.88
|
| Rate for Payer: Dignity Health Senior |
$4,322.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,322.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,041.16
|
| Rate for Payer: Heritage Provider Network Senior |
$5,316.82
|
| Rate for Payer: Humana Medicare |
$4,322.62
|
| Rate for Payer: IEHP Medi-Cal |
$532.01
|
| Rate for Payer: IEHP Medicare Advantage |
$4,322.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,212.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$304.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,100.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$420.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,446.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,446.50
|
| Rate for Payer: Multiplan Commercial |
$1,261.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,754.88
|
| Rate for Payer: TriValley Medical Group Senior |
$4,754.88
|
| 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 |
$6,483.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,754.88
|
| Rate for Payer: Vantage Medical Group Senior |
$4,322.62
|
|
|
HC TUBE BIVONA AIR CUFF PEDS
|
Facility
OP
|
$738.00
|
|
| Hospital Charge Code |
900800708
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$133.58 |
| Max. Negotiated Rate |
$627.30 |
| Rate for Payer: Adventist Health Commercial |
$147.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$394.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$507.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$627.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$405.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$553.50
|
| Rate for Payer: Blue Shield of California Commercial |
$458.30
|
| Rate for Payer: Blue Shield of California EPN |
$433.21
|
| Rate for Payer: Cash Price |
$332.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$479.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$627.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$627.30
|
| Rate for Payer: Dignity Health Senior |
$627.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$479.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$456.82
|
| Rate for Payer: Heritage Provider Network Senior |
$456.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$355.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$133.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$184.50
|
| Rate for Payer: Multiplan Commercial |
$553.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$627.30
|
| Rate for Payer: Vantage Medical Group Senior |
$627.30
|
|
|
HC TUBE BIVONA AIR CUFF PEDS
|
Facility
IP
|
$738.00
|
|
| Hospital Charge Code |
900800708
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$133.58 |
| Max. Negotiated Rate |
$553.50 |
| Rate for Payer: Adventist Health Commercial |
$147.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$507.01
|
| Rate for Payer: Cash Price |
$332.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$499.63
|
| Rate for Payer: Heritage Provider Network Senior |
$499.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$133.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$184.50
|
| Rate for Payer: Multiplan Commercial |
$553.50
|
|
|
HC TUBE CHECK (ABSCESS/CYST)
|
Facility
OP
|
$1,025.00
|
|
|
Service Code
|
CPT 49424
|
| Hospital Charge Code |
909000212
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$55.75 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$205.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$704.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$871.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$563.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$768.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,689.75
|
| Rate for Payer: Blue Shield of California EPN |
$7,468.44
|
| Rate for Payer: Cash Price |
$461.25
|
| Rate for Payer: Cash Price |
$461.25
|
| Rate for Payer: Cash Price |
$461.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$666.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$871.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$871.25
|
| Rate for Payer: Dignity Health Senior |
$871.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$634.48
|
| Rate for Payer: Heritage Provider Network Senior |
$634.48
|
| Rate for Payer: IEHP Medi-Cal |
$55.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$494.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$185.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$256.25
|
| Rate for Payer: Multiplan Commercial |
$768.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,040.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$874.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$871.25
|
| Rate for Payer: Vantage Medical Group Senior |
$871.25
|
|
|
HC TUBE CHECK (ABSCESS/CYST)
|
Facility
IP
|
$1,025.00
|
|
|
Service Code
|
CPT 49424
|
| Hospital Charge Code |
909000212
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$185.52 |
| Max. Negotiated Rate |
$768.75 |
| Rate for Payer: Adventist Health Commercial |
$205.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$704.18
|
| Rate for Payer: Cash Price |
$461.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$693.92
|
| Rate for Payer: Heritage Provider Network Senior |
$693.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$185.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$256.25
|
| Rate for Payer: Multiplan Commercial |
$768.75
|
|
|
HC TUBE PLACEMENT/GASTROINTESTINA
|
Facility
OP
|
$1,439.00
|
|
|
Service Code
|
CPT 74340
|
| Hospital Charge Code |
909001835
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$98.56 |
| Max. Negotiated Rate |
$1,223.15 |
| Rate for Payer: Adventist Health Commercial |
$287.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$179.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$988.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,223.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$791.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,079.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$627.52
|
| Rate for Payer: Blue Shield of California Commercial |
$533.43
|
| Rate for Payer: Blue Shield of California EPN |
$303.35
|
| Rate for Payer: Cash Price |
$647.55
|
| Rate for Payer: Cash Price |
$647.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$935.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,223.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,223.15
|
| Rate for Payer: Dignity Health Senior |
$1,223.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$935.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$890.74
|
| Rate for Payer: Heritage Provider Network Senior |
$890.74
|
| Rate for Payer: IEHP Medi-Cal |
$98.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$693.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$260.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$359.75
|
| Rate for Payer: Multiplan Commercial |
$1,079.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,223.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1,223.15
|
|
|
HC TUBE PLACEMENT/GASTROINTESTINA
|
Facility
IP
|
$1,439.00
|
|
|
Service Code
|
CPT 74340
|
| Hospital Charge Code |
909001835
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$260.46 |
| Max. Negotiated Rate |
$1,079.25 |
| Rate for Payer: Adventist Health Commercial |
$287.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$988.59
|
| Rate for Payer: Cash Price |
$647.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$974.20
|
| Rate for Payer: Heritage Provider Network Senior |
$974.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$260.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$359.75
|
| Rate for Payer: Multiplan Commercial |
$1,079.25
|
|
|
HC TUBE THORACOSTOMY
|
Facility
IP
|
$1,442.00
|
|
|
Service Code
|
CPT 32551
|
| Hospital Charge Code |
900800116
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$261.00 |
| Max. Negotiated Rate |
$1,081.50 |
| Rate for Payer: Adventist Health Commercial |
$288.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$990.65
|
| Rate for Payer: Cash Price |
$648.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$976.23
|
| Rate for Payer: Heritage Provider Network Senior |
$976.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$261.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$360.50
|
| Rate for Payer: Multiplan Commercial |
$1,081.50
|
|
|
HC TUBE THORACOSTOMY
|
Facility
OP
|
$1,442.00
|
|
|
Service Code
|
CPT 32551
|
| Hospital Charge Code |
900800116
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$100.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$288.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$990.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,001.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,201.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,001.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Blue Shield of California Commercial |
$343.00
|
| Rate for Payer: Blue Shield of California EPN |
$295.00
|
| Rate for Payer: Cash Price |
$648.90
|
| Rate for Payer: Cash Price |
$648.90
|
| Rate for Payer: Cash Price |
$648.90
|
| Rate for Payer: Cash Price |
$648.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$937.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,001.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,201.11
|
| Rate for Payer: Dignity Health Senior |
$2,001.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,001.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$892.60
|
| Rate for Payer: Heritage Provider Network Senior |
$892.60
|
| Rate for Payer: Humana Medicare |
$2,001.01
|
| Rate for Payer: IEHP Medi-Cal |
$205.02
|
| Rate for Payer: IEHP Medicare Advantage |
$2,001.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,801.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$261.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,361.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$360.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,521.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,521.27
|
| Rate for Payer: Multiplan Commercial |
$1,081.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$358.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$304.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,001.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,201.11
|
| Rate for Payer: Vantage Medical Group Senior |
$2,001.01
|
|
|
HC TUBE THORACOSTOMY
|
Facility
OP
|
$1,442.00
|
|
|
Service Code
|
CPT 32551
|
| Hospital Charge Code |
900800116
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$261.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$288.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$990.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,001.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,201.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,001.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$648.90
|
| Rate for Payer: Cash Price |
$648.90
|
| Rate for Payer: Cash Price |
$648.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$937.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,001.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,201.11
|
| Rate for Payer: Dignity Health Senior |
$2,001.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,001.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$976.23
|
| Rate for Payer: Heritage Provider Network Senior |
$976.23
|
| Rate for Payer: Humana Medicare |
$2,001.01
|
| Rate for Payer: IEHP Medi-Cal |
$936.00
|
| Rate for Payer: IEHP Medicare Advantage |
$2,001.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$695.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$261.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,361.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$360.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,521.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,521.27
|
| Rate for Payer: Multiplan Commercial |
$1,081.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$523.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$481.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,001.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,201.11
|
| Rate for Payer: Vantage Medical Group Senior |
$2,001.01
|
|
|
HC TUBE THORACOSTOMY
|
Facility
OP
|
$3,863.00
|
|
|
Service Code
|
CPT 32551
|
| Hospital Charge Code |
988132551
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$699.20 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$772.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,653.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,001.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,201.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,001.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Cash Price |
$1,738.35
|
| Rate for Payer: Cash Price |
$1,738.35
|
| Rate for Payer: Cash Price |
$1,738.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,510.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,001.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,201.11
|
| Rate for Payer: Dignity Health Senior |
$2,001.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,001.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,615.25
|
| Rate for Payer: Heritage Provider Network Senior |
$2,615.25
|
| Rate for Payer: Humana Medicare |
$2,001.01
|
| Rate for Payer: IEHP Medi-Cal |
$936.00
|
| Rate for Payer: IEHP Medicare Advantage |
$2,001.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,861.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$699.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,361.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$965.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,521.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,521.27
|
| Rate for Payer: Multiplan Commercial |
$2,897.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,402.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,290.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,001.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,201.11
|
| Rate for Payer: Vantage Medical Group Senior |
$2,001.01
|
|
|
HC TUBE THORACOSTOMY
|
Facility
IP
|
$1,442.00
|
|
|
Service Code
|
CPT 32551
|
| Hospital Charge Code |
900800116
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$261.00 |
| Max. Negotiated Rate |
$1,081.50 |
| Rate for Payer: Adventist Health Commercial |
$288.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$990.65
|
| Rate for Payer: Cash Price |
$648.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$976.23
|
| Rate for Payer: Heritage Provider Network Senior |
$976.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$261.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$360.50
|
| Rate for Payer: Multiplan Commercial |
$1,081.50
|
|
|
HC TUBE THORACOSTOMY
|
Facility
IP
|
$3,863.00
|
|
|
Service Code
|
CPT 32551
|
| Hospital Charge Code |
988132551
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$699.20 |
| Max. Negotiated Rate |
$2,897.25 |
| Rate for Payer: Adventist Health Commercial |
$772.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,653.88
|
| Rate for Payer: Cash Price |
$1,738.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,615.25
|
| Rate for Payer: Heritage Provider Network Senior |
$2,615.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$699.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$965.75
|
| Rate for Payer: Multiplan Commercial |
$2,897.25
|
|
