|
HC UREA NITROGEN URINE RANDOM
|
Facility
|
IP
|
$215.00
|
|
|
Service Code
|
CPT 84540
|
| Hospital Charge Code |
900912195
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$38.91 |
| Max. Negotiated Rate |
$161.25 |
| Rate for Payer: Adventist Health Commercial |
$43.00
|
| Rate for Payer: Cash Price |
$118.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$145.56
|
| Rate for Payer: Heritage Provider Network Senior |
$145.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.75
|
| Rate for Payer: Multiplan Commercial |
$161.25
|
|
|
HC URE EMBOLIZATION OR OCCLUSION
|
Facility
|
IP
|
$6,462.00
|
|
|
Service Code
|
CPT 50705
|
| Hospital Charge Code |
909050705
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,169.62 |
| Max. Negotiated Rate |
$4,846.50 |
| Rate for Payer: Adventist Health Commercial |
$1,292.40
|
| Rate for Payer: Cash Price |
$3,554.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,374.77
|
| Rate for Payer: Heritage Provider Network Senior |
$4,374.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,169.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,615.50
|
| Rate for Payer: Multiplan Commercial |
$4,846.50
|
|
|
HC URE EMBOLIZATION OR OCCLUSION
|
Facility
|
OP
|
$6,462.00
|
|
|
Service Code
|
CPT 50705
|
| Hospital Charge Code |
909050705
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,292.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,439.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,492.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,554.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,846.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,959.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$3,554.10
|
| Rate for Payer: Cash Price |
$3,554.10
|
| Rate for Payer: Cash Price |
$3,554.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,200.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,492.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,492.70
|
| Rate for Payer: Dignity Health Senior |
$5,492.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,999.98
|
| Rate for Payer: Heritage Provider Network Senior |
$3,999.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2,556.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,082.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,169.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,615.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,523.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,523.40
|
| Rate for Payer: Multiplan Commercial |
$4,846.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,093.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,492.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,492.70
|
| Rate for Payer: Vantage Medical Group Senior |
$5,492.70
|
|
|
HC URE STNT PLCMNT W NEPH CATH
|
Facility
|
OP
|
$11,722.00
|
|
|
Service Code
|
CPT 50695
|
| Hospital Charge Code |
909050695
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$10,001.00 |
| Rate for Payer: Adventist Health Commercial |
$2,344.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8,053.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,573.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,820.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,382.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$6,447.10
|
| Rate for Payer: Cash Price |
$6,447.10
|
| Rate for Payer: Cash Price |
$6,447.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,619.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,573.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,820.49
|
| Rate for Payer: Dignity Health Senior |
$4,382.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,382.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,255.92
|
| Rate for Payer: Heritage Provider Network Senior |
$5,390.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2,109.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,382.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,326.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,121.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,039.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,930.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,521.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,521.65
|
| Rate for Payer: Multiplan Commercial |
$8,791.50
|
| Rate for Payer: Multiplan WC |
$6,982.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,820.49
|
| Rate for Payer: TriValley Medical Group Senior |
$4,820.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,001.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,445.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,573.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,820.49
|
| Rate for Payer: Vantage Medical Group Senior |
$4,382.26
|
|
|
HC URE STNT PLCMNT W NEPH CATH
|
Facility
|
IP
|
$11,722.00
|
|
|
Service Code
|
CPT 50695
|
| Hospital Charge Code |
909050695
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,121.68 |
| Max. Negotiated Rate |
$8,791.50 |
| Rate for Payer: Adventist Health Commercial |
$2,344.40
|
| Rate for Payer: Cash Price |
$6,447.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,935.79
|
| Rate for Payer: Heritage Provider Network Senior |
$7,935.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,121.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,930.50
|
| Rate for Payer: Multiplan Commercial |
$8,791.50
|
|
|
HC URETERAL BIOPSY
|
Facility
|
IP
|
$11,347.00
|
|
|
Service Code
|
CPT 50955
|
| Hospital Charge Code |
909000193
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,053.81 |
| Max. Negotiated Rate |
$8,510.25 |
| Rate for Payer: Adventist Health Commercial |
$2,269.40
|
| Rate for Payer: Cash Price |
$6,240.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,681.92
|
| Rate for Payer: Heritage Provider Network Senior |
$7,681.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,053.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,836.75
|
| Rate for Payer: Multiplan Commercial |
$8,510.25
|
|
|
HC URETERAL BIOPSY
|
Facility
|
OP
|
$11,347.00
|
|
|
Service Code
|
CPT 50955
|
| Hospital Charge Code |
909000193
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$12,272.58 |
| Rate for Payer: Adventist Health Commercial |
$2,269.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,795.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9,688.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7,105.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6,459.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$6,240.85
|
| Rate for Payer: Cash Price |
$6,240.85
|
| Rate for Payer: Cash Price |
$6,240.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,375.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,688.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,105.18
|
| Rate for Payer: Dignity Health Senior |
$6,459.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,459.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,023.79
|
| Rate for Payer: Heritage Provider Network Senior |
$7,944.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$546.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6,459.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12,272.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,053.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,428.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,836.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,138.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,138.65
|
| Rate for Payer: Multiplan Commercial |
$8,510.25
|
| Rate for Payer: Multiplan WC |
$10,291.67
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,105.18
|
| Rate for Payer: TriValley Medical Group Senior |
$7,105.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,454.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,273.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,688.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,105.18
|
| Rate for Payer: Vantage Medical Group Senior |
$6,459.25
|
|
|
HC URETERAL BRUSH BIOPSY
|
Facility
|
OP
|
$11,347.00
|
|
|
Service Code
|
CPT 52007
|
| Hospital Charge Code |
909000173
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$2,269.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,795.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,573.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,820.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,382.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,959.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$6,240.85
|
| Rate for Payer: Cash Price |
$6,240.85
|
| Rate for Payer: Cash Price |
$6,240.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,375.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,573.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,820.49
|
| Rate for Payer: Dignity Health Senior |
$4,382.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,382.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,023.79
|
| Rate for Payer: Heritage Provider Network Senior |
$5,390.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$800.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,382.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,326.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,053.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,039.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,836.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,521.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,521.65
|
| Rate for Payer: Multiplan Commercial |
$8,510.25
|
| Rate for Payer: Multiplan WC |
$6,982.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,820.49
|
| Rate for Payer: TriValley Medical Group Senior |
$4,820.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,454.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,273.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,573.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,820.49
|
| Rate for Payer: Vantage Medical Group Senior |
$4,382.26
|
|
|
HC URETERAL BRUSH BIOPSY
|
Facility
|
IP
|
$11,347.00
|
|
|
Service Code
|
CPT 52007
|
| Hospital Charge Code |
909000173
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,053.81 |
| Max. Negotiated Rate |
$8,510.25 |
| Rate for Payer: Adventist Health Commercial |
$2,269.40
|
| Rate for Payer: Cash Price |
$6,240.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,681.92
|
| Rate for Payer: Heritage Provider Network Senior |
$7,681.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,053.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,836.75
|
| Rate for Payer: Multiplan Commercial |
$8,510.25
|
|
|
HC URETERAL DILATION
|
Facility
|
IP
|
$10,278.00
|
|
|
Service Code
|
CPT 53899
|
| Hospital Charge Code |
909000174
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,860.32 |
| Max. Negotiated Rate |
$7,708.50 |
| Rate for Payer: Adventist Health Commercial |
$2,055.60
|
| Rate for Payer: Cash Price |
$5,652.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,958.21
|
| Rate for Payer: Heritage Provider Network Senior |
$6,958.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,860.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,569.50
|
| Rate for Payer: Multiplan Commercial |
$7,708.50
|
|
|
HC URETERAL DILATION
|
Facility
|
IP
|
$10,278.00
|
|
|
Service Code
|
CPT 53899
|
| Hospital Charge Code |
909000174
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,860.32 |
| Max. Negotiated Rate |
$7,708.50 |
| Rate for Payer: Adventist Health Commercial |
$2,055.60
|
| Rate for Payer: Cash Price |
$5,652.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,958.21
|
| Rate for Payer: Heritage Provider Network Senior |
$6,958.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,860.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,569.50
|
| Rate for Payer: Multiplan Commercial |
$7,708.50
|
|
|
HC URETERAL DILATION
|
Facility
|
OP
|
$10,278.00
|
|
|
Service Code
|
CPT 53899
|
| Hospital Charge Code |
909000174
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$2,055.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,060.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$463.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$339.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$309.02
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$5,652.90
|
| Rate for Payer: Cash Price |
$5,652.90
|
| Rate for Payer: Cash Price |
$5,652.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6,680.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$463.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$339.92
|
| Rate for Payer: Dignity Health Senior |
$309.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$309.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,362.08
|
| Rate for Payer: Heritage Provider Network Senior |
$380.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$309.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$587.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,860.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$355.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,569.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$389.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$389.37
|
| Rate for Payer: Multiplan Commercial |
$7,708.50
|
| Rate for Payer: Multiplan WC |
$492.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$339.92
|
| Rate for Payer: TriValley Medical Group Senior |
$339.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,093.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$463.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$339.92
|
| Rate for Payer: Vantage Medical Group Senior |
$309.02
|
|
|
HC URETERAL DILATION
|
Facility
|
OP
|
$10,278.00
|
|
|
Service Code
|
CPT 53899
|
| Hospital Charge Code |
909000174
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$2,055.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,060.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$463.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$339.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$309.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,915.00
|
| Rate for Payer: Cash Price |
$5,652.90
|
| Rate for Payer: Cash Price |
$5,652.90
|
| Rate for Payer: Cash Price |
$5,652.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6,680.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$463.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$339.92
|
| Rate for Payer: Dignity Health Senior |
$309.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$309.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,958.21
|
| Rate for Payer: Heritage Provider Network Senior |
$6,958.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$973.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$309.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,902.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,860.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$355.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,569.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$389.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$389.37
|
| Rate for Payer: Multiplan Commercial |
$7,708.50
|
| Rate for Payer: Multiplan WC |
$492.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,698.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,403.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$463.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$339.92
|
| Rate for Payer: Vantage Medical Group Senior |
$309.02
|
|
|
HC URETERAL STENT KIT
|
Facility
|
IP
|
$759.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
909001064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$151.80 |
| Max. Negotiated Rate |
$13,277.00 |
| Rate for Payer: Adventist Health Commercial |
$151.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$364.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,277.00
|
| Rate for Payer: Blue Shield of California Commercial |
$305.12
|
| Rate for Payer: Blue Shield of California EPN |
$305.12
|
| Rate for Payer: Cash Price |
$417.45
|
| Rate for Payer: Cash Price |
$417.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$349.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$409.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$351.42
|
| Rate for Payer: Heritage Provider Network Senior |
$351.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$379.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$379.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$379.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.75
|
| Rate for Payer: Multiplan Commercial |
$569.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$274.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$251.30
|
|
|
HC URETERAL STENT KIT
|
Facility
|
OP
|
$759.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
909001064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$151.80 |
| Max. Negotiated Rate |
$13,240.00 |
| Rate for Payer: Adventist Health Commercial |
$151.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$364.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$521.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$645.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$417.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$569.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,240.00
|
| Rate for Payer: Blue Shield of California Commercial |
$305.12
|
| Rate for Payer: Blue Shield of California EPN |
$305.12
|
| Rate for Payer: Cash Price |
$417.45
|
| Rate for Payer: Cash Price |
$417.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$349.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$645.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$645.15
|
| Rate for Payer: Dignity Health Senior |
$645.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$485.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$351.42
|
| Rate for Payer: Heritage Provider Network Senior |
$351.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$379.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$379.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$379.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$531.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$531.30
|
| Rate for Payer: Multiplan Commercial |
$569.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$274.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$251.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$645.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$645.15
|
| Rate for Payer: Vantage Medical Group Senior |
$645.15
|
|
|
HC URETER DRAIN OR STENT PLCMNT
|
Facility
|
IP
|
$9,137.00
|
|
|
Service Code
|
CPT 50693
|
| Hospital Charge Code |
909000166
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,653.80 |
| Max. Negotiated Rate |
$6,852.75 |
| Rate for Payer: Adventist Health Commercial |
$1,827.40
|
| Rate for Payer: Cash Price |
$5,025.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,185.75
|
| Rate for Payer: Heritage Provider Network Senior |
$6,185.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,653.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,284.25
|
| Rate for Payer: Multiplan Commercial |
$6,852.75
|
|
|
HC URETER DRAIN OR STENT PLCMNT
|
Facility
|
OP
|
$9,137.00
|
|
|
Service Code
|
CPT 50693
|
| Hospital Charge Code |
909000166
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$10,001.00 |
| Rate for Payer: Adventist Health Commercial |
$1,827.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,277.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,573.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,820.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,382.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$5,025.35
|
| Rate for Payer: Cash Price |
$5,025.35
|
| Rate for Payer: Cash Price |
$5,025.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,939.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,573.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,820.49
|
| Rate for Payer: Dignity Health Senior |
$4,382.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,382.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,655.80
|
| Rate for Payer: Heritage Provider Network Senior |
$5,390.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,577.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,382.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,326.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,653.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,039.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,284.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,521.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,521.65
|
| Rate for Payer: Multiplan Commercial |
$6,852.75
|
| Rate for Payer: Multiplan WC |
$6,982.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,820.49
|
| Rate for Payer: TriValley Medical Group Senior |
$4,820.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,001.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,445.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,573.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,820.49
|
| Rate for Payer: Vantage Medical Group Senior |
$4,382.26
|
|
|
HC URET'GRAM THRU URET. CATH
|
Facility
|
IP
|
$346.00
|
|
|
Service Code
|
CPT 50684
|
| Hospital Charge Code |
909000208
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$62.63 |
| Max. Negotiated Rate |
$259.50 |
| Rate for Payer: Adventist Health Commercial |
$69.20
|
| Rate for Payer: Cash Price |
$190.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$234.24
|
| Rate for Payer: Heritage Provider Network Senior |
$234.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$62.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$86.50
|
| Rate for Payer: Multiplan Commercial |
$259.50
|
|
|
HC URET'GRAM THRU URET. CATH
|
Facility
|
OP
|
$346.00
|
|
|
Service Code
|
CPT 50684
|
| Hospital Charge Code |
909000208
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$69.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$237.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$294.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$190.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$259.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,531.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$190.30
|
| Rate for Payer: Cash Price |
$190.30
|
| Rate for Payer: Cash Price |
$190.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$224.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$294.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$294.10
|
| Rate for Payer: Dignity Health Senior |
$294.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$214.17
|
| Rate for Payer: Heritage Provider Network Senior |
$214.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$408.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$165.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$62.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$86.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$242.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$242.20
|
| Rate for Payer: Multiplan Commercial |
$259.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,093.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$294.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$294.10
|
| Rate for Payer: Vantage Medical Group Senior |
$294.10
|
|
|
HC URETHROCYSTOGRAM,RETROGRADE
|
Facility
|
OP
|
$450.00
|
|
|
Service Code
|
CPT 51610
|
| Hospital Charge Code |
909000172
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$81.45 |
| Max. Negotiated Rate |
$12,620.00 |
| Rate for Payer: Adventist Health Commercial |
$90.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12,620.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$309.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$382.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$247.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$337.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,959.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$292.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$382.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$382.50
|
| Rate for Payer: Dignity Health Senior |
$382.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$278.55
|
| Rate for Payer: Heritage Provider Network Senior |
$278.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$445.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$214.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$112.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.00
|
| Rate for Payer: Multiplan Commercial |
$337.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,093.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$382.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$382.50
|
| Rate for Payer: Vantage Medical Group Senior |
$382.50
|
|
|
HC URETHROCYSTOGRAM,RETROGRADE
|
Facility
|
IP
|
$450.00
|
|
|
Service Code
|
CPT 51610
|
| Hospital Charge Code |
909000172
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$81.45 |
| Max. Negotiated Rate |
$337.50 |
| Rate for Payer: Adventist Health Commercial |
$90.00
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$304.65
|
| Rate for Payer: Heritage Provider Network Senior |
$304.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$112.50
|
| Rate for Payer: Multiplan Commercial |
$337.50
|
|
|
HC URIC ACID
|
Facility
|
IP
|
$99.20
|
|
|
Service Code
|
CPT 84550
|
| Hospital Charge Code |
900910254
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$74.40 |
| Rate for Payer: Adventist Health Commercial |
$19.84
|
| Rate for Payer: Cash Price |
$54.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$67.16
|
| Rate for Payer: Heritage Provider Network Senior |
$67.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.80
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
|
|
HC URIC ACID
|
Facility
|
OP
|
$99.20
|
|
|
Service Code
|
CPT 84550
|
| Hospital Charge Code |
900910254
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$74.40 |
| Rate for Payer: Adventist Health Commercial |
$19.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$53.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$68.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$41.30
|
| Rate for Payer: Blue Shield of California Commercial |
$36.35
|
| Rate for Payer: Blue Shield of California EPN |
$29.15
|
| Rate for Payer: Cash Price |
$54.56
|
| Rate for Payer: Cash Price |
$54.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$64.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.97
|
| Rate for Payer: Dignity Health Senior |
$4.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.48
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$61.40
|
| Rate for Payer: Heritage Provider Network Senior |
$61.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$47.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.70
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.52
|
| Rate for Payer: TriValley Medical Group Senior |
$4.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.97
|
| Rate for Payer: Vantage Medical Group Senior |
$4.52
|
|
|
HC URIC ACID BODY FLUID
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
CPT 84560
|
| Hospital Charge Code |
900912248
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.07 |
| Max. Negotiated Rate |
$43.33 |
| Rate for Payer: Adventist Health Commercial |
$5.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$43.33
|
| Rate for Payer: Blue Shield of California Commercial |
$38.25
|
| Rate for Payer: Blue Shield of California EPN |
$30.68
|
| Rate for Payer: Cash Price |
$15.40
|
| Rate for Payer: Cash Price |
$15.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.59
|
| Rate for Payer: Dignity Health Senior |
$5.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$5.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.33
|
| Rate for Payer: Heritage Provider Network Senior |
$17.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.40
|
| Rate for Payer: Multiplan Commercial |
$21.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.08
|
| Rate for Payer: TriValley Medical Group Senior |
$5.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.59
|
| Rate for Payer: Vantage Medical Group Senior |
$5.08
|
|
|
HC URIC ACID BODY FLUID
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
CPT 84560
|
| Hospital Charge Code |
900912248
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.07 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Adventist Health Commercial |
$5.60
|
| Rate for Payer: Cash Price |
$15.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.96
|
| Rate for Payer: Heritage Provider Network Senior |
$18.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.00
|
| Rate for Payer: Multiplan Commercial |
$21.00
|
|
