|
HC VENOGRAM EXTRM UNILATERAL
|
Facility
|
IP
|
$2,146.00
|
|
|
Service Code
|
CPT 75820
|
| Hospital Charge Code |
906820126
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$388.43 |
| Max. Negotiated Rate |
$1,609.50 |
| Rate for Payer: Adventist Health Commercial |
$429.20
|
| Rate for Payer: Cash Price |
$1,180.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,452.84
|
| Rate for Payer: Heritage Provider Network Senior |
$1,452.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$388.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$536.50
|
| Rate for Payer: Multiplan Commercial |
$1,609.50
|
|
|
HC VENOGRAM INFERIOR VENACAVA
|
Facility
|
OP
|
$6,058.00
|
|
|
Service Code
|
CPT 75825
|
| Hospital Charge Code |
909081633
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$167.70 |
| Max. Negotiated Rate |
$5,998.81 |
| Rate for Payer: Adventist Health Commercial |
$1,211.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,238.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,161.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,399.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,999.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,273.21
|
| Rate for Payer: Blue Shield of California Commercial |
$2,647.15
|
| Rate for Payer: Blue Shield of California EPN |
$2,128.75
|
| Rate for Payer: Cash Price |
$3,331.90
|
| Rate for Payer: Cash Price |
$3,331.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,937.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,399.13
|
| Rate for Payer: Dignity Health Senior |
$3,999.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,937.70
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,999.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,749.90
|
| Rate for Payer: Heritage Provider Network Senior |
$3,749.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$167.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,999.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,889.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,096.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,599.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,514.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,039.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,039.00
|
| Rate for Payer: Multiplan Commercial |
$4,543.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,999.21
|
| Rate for Payer: TriValley Medical Group Senior |
$3,999.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,338.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,338.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,399.13
|
| Rate for Payer: Vantage Medical Group Senior |
$3,999.21
|
|
|
HC VENOGRAM INFERIOR VENACAVA
|
Facility
|
IP
|
$6,058.00
|
|
|
Service Code
|
CPT 75825
|
| Hospital Charge Code |
909081633
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,096.50 |
| Max. Negotiated Rate |
$4,543.50 |
| Rate for Payer: Adventist Health Commercial |
$1,211.60
|
| Rate for Payer: Cash Price |
$3,331.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,101.27
|
| Rate for Payer: Heritage Provider Network Senior |
$4,101.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,096.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,514.50
|
| Rate for Payer: Multiplan Commercial |
$4,543.50
|
|
|
HC VENOGRAM INFERIOR VENACAVA
|
Facility
|
OP
|
$12,431.00
|
|
|
Service Code
|
CPT 75825
|
| Hospital Charge Code |
906820195
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$167.70 |
| Max. Negotiated Rate |
$9,323.25 |
| Rate for Payer: Adventist Health Commercial |
$2,486.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6,644.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8,540.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,399.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,999.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,273.21
|
| Rate for Payer: Blue Shield of California Commercial |
$2,647.15
|
| Rate for Payer: Blue Shield of California EPN |
$2,128.75
|
| Rate for Payer: Cash Price |
$6,837.05
|
| Rate for Payer: Cash Price |
$6,837.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8,080.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,399.13
|
| Rate for Payer: Dignity Health Senior |
$3,999.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,080.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,999.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,694.79
|
| Rate for Payer: Heritage Provider Network Senior |
$7,694.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$167.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,999.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,929.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,250.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,599.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,107.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,039.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,039.00
|
| Rate for Payer: Multiplan Commercial |
$9,323.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,999.21
|
| Rate for Payer: TriValley Medical Group Senior |
$3,999.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,338.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,338.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,399.13
|
| Rate for Payer: Vantage Medical Group Senior |
$3,999.21
|
|
|
HC VENOGRAM INFERIOR VENACAVA
|
Facility
|
IP
|
$12,431.00
|
|
|
Service Code
|
CPT 75825
|
| Hospital Charge Code |
906820195
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$2,250.01 |
| Max. Negotiated Rate |
$9,323.25 |
| Rate for Payer: Adventist Health Commercial |
$2,486.20
|
| Rate for Payer: Cash Price |
$6,837.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$8,415.79
|
| Rate for Payer: Heritage Provider Network Senior |
$8,415.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,250.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,107.75
|
| Rate for Payer: Multiplan Commercial |
$9,323.25
|
|
|
HC VENOGRAM JUGULAR OR SINUS
|
Facility
|
IP
|
$2,037.00
|
|
|
Service Code
|
CPT 75860
|
| Hospital Charge Code |
909081580
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$368.70 |
| Max. Negotiated Rate |
$1,527.75 |
| Rate for Payer: Adventist Health Commercial |
$407.40
|
| Rate for Payer: Cash Price |
$1,120.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,379.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1,379.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$368.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$509.25
|
| Rate for Payer: Multiplan Commercial |
$1,527.75
|
|
|
HC VENOGRAM JUGULAR OR SINUS
|
Facility
|
OP
|
$11,351.00
|
|
|
Service Code
|
CPT 75860
|
| Hospital Charge Code |
906820187
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,055.15 |
| Max. Negotiated Rate |
$8,513.25 |
| Rate for Payer: Adventist Health Commercial |
$2,270.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6,067.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,798.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,399.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,999.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,291.28
|
| Rate for Payer: Blue Shield of California Commercial |
$2,647.15
|
| Rate for Payer: Blue Shield of California EPN |
$2,128.75
|
| Rate for Payer: Cash Price |
$6,243.05
|
| Rate for Payer: Cash Price |
$6,243.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,378.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,399.13
|
| Rate for Payer: Dignity Health Senior |
$3,999.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,378.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,999.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,026.27
|
| Rate for Payer: Heritage Provider Network Senior |
$7,026.27
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,999.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,414.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,054.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,599.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,837.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,039.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,039.00
|
| Rate for Payer: Multiplan Commercial |
$8,513.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,999.21
|
| Rate for Payer: TriValley Medical Group Senior |
$3,999.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,055.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,055.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,399.13
|
| Rate for Payer: Vantage Medical Group Senior |
$3,999.21
|
|
|
HC VENOGRAM JUGULAR OR SINUS
|
Facility
|
IP
|
$11,351.00
|
|
|
Service Code
|
CPT 75860
|
| Hospital Charge Code |
906820187
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$2,054.53 |
| Max. Negotiated Rate |
$8,513.25 |
| Rate for Payer: Adventist Health Commercial |
$2,270.20
|
| Rate for Payer: Cash Price |
$6,243.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,684.63
|
| Rate for Payer: Heritage Provider Network Senior |
$7,684.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,054.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,837.75
|
| Rate for Payer: Multiplan Commercial |
$8,513.25
|
|
|
HC VENOGRAM JUGULAR OR SINUS
|
Facility
|
OP
|
$2,037.00
|
|
|
Service Code
|
CPT 75860
|
| Hospital Charge Code |
909081580
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$368.70 |
| Max. Negotiated Rate |
$5,998.81 |
| Rate for Payer: Adventist Health Commercial |
$407.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,088.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,399.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,399.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,999.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,291.28
|
| Rate for Payer: Blue Shield of California Commercial |
$2,647.15
|
| Rate for Payer: Blue Shield of California EPN |
$2,128.75
|
| Rate for Payer: Cash Price |
$1,120.35
|
| Rate for Payer: Cash Price |
$1,120.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,324.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,399.13
|
| Rate for Payer: Dignity Health Senior |
$3,999.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,324.05
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,999.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,260.90
|
| Rate for Payer: Heritage Provider Network Senior |
$1,260.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,999.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$971.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$368.70
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,599.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$509.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,039.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,039.00
|
| Rate for Payer: Multiplan Commercial |
$1,527.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,999.21
|
| Rate for Payer: TriValley Medical Group Senior |
$3,999.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,055.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,055.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,399.13
|
| Rate for Payer: Vantage Medical Group Senior |
$3,999.21
|
|
|
HC VENOGRAM ORBITAL
|
Facility
|
IP
|
$4,521.00
|
|
|
Service Code
|
CPT 75880
|
| Hospital Charge Code |
909081659
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$818.30 |
| Max. Negotiated Rate |
$3,390.75 |
| Rate for Payer: Adventist Health Commercial |
$904.20
|
| Rate for Payer: Cash Price |
$2,486.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,060.72
|
| Rate for Payer: Heritage Provider Network Senior |
$3,060.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$818.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,130.25
|
| Rate for Payer: Multiplan Commercial |
$3,390.75
|
|
|
HC VENOGRAM ORBITAL
|
Facility
|
OP
|
$4,521.00
|
|
|
Service Code
|
CPT 75880
|
| Hospital Charge Code |
909081659
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$161.27 |
| Max. Negotiated Rate |
$3,390.75 |
| Rate for Payer: Adventist Health Commercial |
$904.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,416.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,105.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,178.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$864.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$785.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$246.10
|
| Rate for Payer: Blue Shield of California Commercial |
$200.54
|
| Rate for Payer: Blue Shield of California EPN |
$161.27
|
| Rate for Payer: Cash Price |
$2,486.55
|
| Rate for Payer: Cash Price |
$2,486.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,938.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,178.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$864.12
|
| Rate for Payer: Dignity Health Senior |
$785.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,938.65
|
| Rate for Payer: EPIC Health Plan Medicare |
$785.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,798.50
|
| Rate for Payer: Heritage Provider Network Senior |
$2,798.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$785.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,156.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$818.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$903.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,130.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$989.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$989.81
|
| Rate for Payer: Multiplan Commercial |
$3,390.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$785.56
|
| Rate for Payer: TriValley Medical Group Senior |
$785.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,055.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,055.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,178.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$864.12
|
| Rate for Payer: Vantage Medical Group Senior |
$785.56
|
|
|
HC VENOGRAM RENAL BILAT
|
Facility
|
IP
|
$855.00
|
|
|
Service Code
|
CPT 75833
|
| Hospital Charge Code |
909081636
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$154.75 |
| Max. Negotiated Rate |
$641.25 |
| Rate for Payer: Adventist Health Commercial |
$171.00
|
| Rate for Payer: Cash Price |
$470.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$578.84
|
| Rate for Payer: Heritage Provider Network Senior |
$578.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$154.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.75
|
| Rate for Payer: Multiplan Commercial |
$641.25
|
|
|
HC VENOGRAM RENAL BILAT
|
Facility
|
OP
|
$855.00
|
|
|
Service Code
|
CPT 75833
|
| Hospital Charge Code |
909081636
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$154.75 |
| Max. Negotiated Rate |
$5,998.81 |
| Rate for Payer: Adventist Health Commercial |
$171.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$457.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$587.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,399.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,999.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,291.28
|
| Rate for Payer: Blue Shield of California Commercial |
$2,647.15
|
| Rate for Payer: Blue Shield of California EPN |
$2,128.75
|
| Rate for Payer: Cash Price |
$470.25
|
| Rate for Payer: Cash Price |
$470.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$555.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,399.13
|
| Rate for Payer: Dignity Health Senior |
$3,999.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$555.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,999.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$529.25
|
| Rate for Payer: Heritage Provider Network Senior |
$529.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,999.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$407.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$154.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,599.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,039.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,039.00
|
| Rate for Payer: Multiplan Commercial |
$641.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,999.21
|
| Rate for Payer: TriValley Medical Group Senior |
$3,999.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,338.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,338.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,399.13
|
| Rate for Payer: Vantage Medical Group Senior |
$3,999.21
|
|
|
HC VENOGRAM RENAL UNILAT
|
Facility
|
OP
|
$5,707.00
|
|
|
Service Code
|
CPT 75831
|
| Hospital Charge Code |
909081578
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,032.97 |
| Max. Negotiated Rate |
$5,998.81 |
| Rate for Payer: Adventist Health Commercial |
$1,141.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,050.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,920.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,399.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,999.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,289.75
|
| Rate for Payer: Blue Shield of California Commercial |
$2,647.15
|
| Rate for Payer: Blue Shield of California EPN |
$2,128.75
|
| Rate for Payer: Cash Price |
$3,138.85
|
| Rate for Payer: Cash Price |
$3,138.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,709.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,399.13
|
| Rate for Payer: Dignity Health Senior |
$3,999.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,709.55
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,999.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,532.63
|
| Rate for Payer: Heritage Provider Network Senior |
$3,532.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,999.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,722.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,032.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,599.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,426.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,039.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,039.00
|
| Rate for Payer: Multiplan Commercial |
$4,280.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,999.21
|
| Rate for Payer: TriValley Medical Group Senior |
$3,999.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,338.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,338.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,399.13
|
| Rate for Payer: Vantage Medical Group Senior |
$3,999.21
|
|
|
HC VENOGRAM RENAL UNILAT
|
Facility
|
IP
|
$5,707.00
|
|
|
Service Code
|
CPT 75831
|
| Hospital Charge Code |
909081578
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,032.97 |
| Max. Negotiated Rate |
$4,280.25 |
| Rate for Payer: Adventist Health Commercial |
$1,141.40
|
| Rate for Payer: Cash Price |
$3,138.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,863.64
|
| Rate for Payer: Heritage Provider Network Senior |
$3,863.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,032.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,426.75
|
| Rate for Payer: Multiplan Commercial |
$4,280.25
|
|
|
HC VENOGRAM SUPERIOR VENACAVA
|
Facility
|
IP
|
$6,168.00
|
|
|
Service Code
|
CPT 75827
|
| Hospital Charge Code |
906820196
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,116.41 |
| Max. Negotiated Rate |
$4,626.00 |
| Rate for Payer: Adventist Health Commercial |
$1,233.60
|
| Rate for Payer: Cash Price |
$3,392.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,175.74
|
| Rate for Payer: Heritage Provider Network Senior |
$4,175.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,116.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,542.00
|
| Rate for Payer: Multiplan Commercial |
$4,626.00
|
|
|
HC VENOGRAM SUPERIOR VENACAVA
|
Facility
|
OP
|
$3,819.00
|
|
|
Service Code
|
CPT 75827
|
| Hospital Charge Code |
909081634
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$176.99 |
| Max. Negotiated Rate |
$3,273.21 |
| Rate for Payer: Adventist Health Commercial |
$763.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,041.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,623.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,960.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,171.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,973.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,273.21
|
| Rate for Payer: Blue Shield of California Commercial |
$2,647.15
|
| Rate for Payer: Blue Shield of California EPN |
$2,128.75
|
| Rate for Payer: Cash Price |
$2,100.45
|
| Rate for Payer: Cash Price |
$2,100.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,482.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,960.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,171.18
|
| Rate for Payer: Dignity Health Senior |
$1,973.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,482.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,973.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,363.96
|
| Rate for Payer: Heritage Provider Network Senior |
$2,363.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$176.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,973.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,821.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$691.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,269.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$954.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,486.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,486.99
|
| Rate for Payer: Multiplan Commercial |
$2,864.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,973.80
|
| Rate for Payer: TriValley Medical Group Senior |
$1,973.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,055.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,055.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,960.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,171.18
|
| Rate for Payer: Vantage Medical Group Senior |
$1,973.80
|
|
|
HC VENOGRAM SUPERIOR VENACAVA
|
Facility
|
OP
|
$6,168.00
|
|
|
Service Code
|
CPT 75827
|
| Hospital Charge Code |
906820196
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$176.99 |
| Max. Negotiated Rate |
$4,626.00 |
| Rate for Payer: Adventist Health Commercial |
$1,233.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,296.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,237.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,960.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,171.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,973.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,273.21
|
| Rate for Payer: Blue Shield of California Commercial |
$2,647.15
|
| Rate for Payer: Blue Shield of California EPN |
$2,128.75
|
| Rate for Payer: Cash Price |
$3,392.40
|
| Rate for Payer: Cash Price |
$3,392.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,009.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,960.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,171.18
|
| Rate for Payer: Dignity Health Senior |
$1,973.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,009.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,973.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,817.99
|
| Rate for Payer: Heritage Provider Network Senior |
$3,817.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$176.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,973.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,942.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,116.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,269.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,542.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,486.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,486.99
|
| Rate for Payer: Multiplan Commercial |
$4,626.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,973.80
|
| Rate for Payer: TriValley Medical Group Senior |
$1,973.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,055.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,055.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,960.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,171.18
|
| Rate for Payer: Vantage Medical Group Senior |
$1,973.80
|
|
|
HC VENOGRAM SUPERIOR VENACAVA
|
Facility
|
IP
|
$3,819.00
|
|
|
Service Code
|
CPT 75827
|
| Hospital Charge Code |
909081634
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$691.24 |
| Max. Negotiated Rate |
$2,864.25 |
| Rate for Payer: Adventist Health Commercial |
$763.80
|
| Rate for Payer: Cash Price |
$2,100.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,585.46
|
| Rate for Payer: Heritage Provider Network Senior |
$2,585.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$691.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$954.75
|
| Rate for Payer: Multiplan Commercial |
$2,864.25
|
|
|
HC VENOGRAM SUP SAG SINUS
|
Facility
|
OP
|
$3,109.00
|
|
|
Service Code
|
CPT 75870
|
| Hospital Charge Code |
909081641
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$216.53 |
| Max. Negotiated Rate |
$5,998.81 |
| Rate for Payer: Adventist Health Commercial |
$621.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,661.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,135.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,399.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,999.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,291.28
|
| Rate for Payer: Blue Shield of California Commercial |
$2,647.15
|
| Rate for Payer: Blue Shield of California EPN |
$2,128.75
|
| Rate for Payer: Cash Price |
$1,709.95
|
| Rate for Payer: Cash Price |
$1,709.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,020.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,399.13
|
| Rate for Payer: Dignity Health Senior |
$3,999.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,020.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,999.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,924.47
|
| Rate for Payer: Heritage Provider Network Senior |
$1,924.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$216.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,999.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,482.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$562.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,599.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$777.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,039.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,039.00
|
| Rate for Payer: Multiplan Commercial |
$2,331.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,999.21
|
| Rate for Payer: TriValley Medical Group Senior |
$3,999.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,055.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,055.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,998.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,399.13
|
| Rate for Payer: Vantage Medical Group Senior |
$3,999.21
|
|
|
HC VENOGRAM SUP SAG SINUS
|
Facility
|
IP
|
$3,109.00
|
|
|
Service Code
|
CPT 75870
|
| Hospital Charge Code |
909081641
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$562.73 |
| Max. Negotiated Rate |
$2,331.75 |
| Rate for Payer: Adventist Health Commercial |
$621.80
|
| Rate for Payer: Cash Price |
$1,709.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,104.79
|
| Rate for Payer: Heritage Provider Network Senior |
$2,104.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$562.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$777.25
|
| Rate for Payer: Multiplan Commercial |
$2,331.75
|
|
|
HC VENOUS 1ST ORDER CATH PLCMT
|
Facility
|
OP
|
$862.00
|
|
|
Service Code
|
CPT 36011
|
| Hospital Charge Code |
906820169
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$130.88 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$172.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6,699.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$592.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$732.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$474.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$646.50
|
| 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 |
$474.10
|
| Rate for Payer: Cash Price |
$474.10
|
| Rate for Payer: Cash Price |
$474.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$560.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$732.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$732.70
|
| Rate for Payer: Dignity Health Senior |
$732.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$533.58
|
| Rate for Payer: Heritage Provider Network Senior |
$533.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$130.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$411.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$156.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$215.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$603.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$603.40
|
| Rate for Payer: Multiplan Commercial |
$646.50
|
| 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 |
$732.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$732.70
|
| Rate for Payer: Vantage Medical Group Senior |
$732.70
|
|
|
HC VENOUS 1ST ORDER CATH PLCMT
|
Facility
|
IP
|
$862.00
|
|
|
Service Code
|
CPT 36011
|
| Hospital Charge Code |
906820169
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$156.02 |
| Max. Negotiated Rate |
$646.50 |
| Rate for Payer: Adventist Health Commercial |
$172.40
|
| Rate for Payer: Cash Price |
$474.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$583.57
|
| Rate for Payer: Heritage Provider Network Senior |
$583.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$156.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$215.50
|
| Rate for Payer: Multiplan Commercial |
$646.50
|
|
|
HC VENOUS 1ST ORDER CATH PLCMT
|
Facility
|
OP
|
$733.00
|
|
|
Service Code
|
CPT 36011
|
| Hospital Charge Code |
909081309
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$130.88 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$146.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6,699.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$503.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$623.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$403.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$549.75
|
| 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 |
$403.15
|
| Rate for Payer: Cash Price |
$403.15
|
| Rate for Payer: Cash Price |
$403.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$476.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$623.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$623.05
|
| Rate for Payer: Dignity Health Senior |
$623.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$453.73
|
| Rate for Payer: Heritage Provider Network Senior |
$453.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$130.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$349.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$132.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$183.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$513.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$513.10
|
| Rate for Payer: Multiplan Commercial |
$549.75
|
| 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 |
$623.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$623.05
|
| Rate for Payer: Vantage Medical Group Senior |
$623.05
|
|
|
HC VENOUS 1ST ORDER CATH PLCMT
|
Facility
|
IP
|
$733.00
|
|
|
Service Code
|
CPT 36011
|
| Hospital Charge Code |
909081309
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$132.67 |
| Max. Negotiated Rate |
$549.75 |
| Rate for Payer: Adventist Health Commercial |
$146.60
|
| Rate for Payer: Cash Price |
$403.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$496.24
|
| Rate for Payer: Heritage Provider Network Senior |
$496.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$132.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$183.25
|
| Rate for Payer: Multiplan Commercial |
$549.75
|
|
