|
E/M PROLONGED SVCS; EA 15 MINS
|
Facility
|
OP
|
$103.48
|
|
|
Service Code
|
CPT 99417
|
| Hospital Charge Code |
20399417
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$98.31 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$62.09
|
| Rate for Payer: Cash Price |
$62.09
|
| Rate for Payer: Cigna Commercial |
$87.96
|
| Rate for Payer: First Health Commercial |
$93.13
|
| Rate for Payer: First Health Workers Compensation |
$39.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$93.13
|
| Rate for Payer: GEHA Commercial |
$82.78
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$93.13
|
| Rate for Payer: Humana ChoiceCare |
$26.90
|
| Rate for Payer: Multiplan All |
$94.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$62.09
|
| Rate for Payer: OMNI Networks Commercial |
$72.44
|
| Rate for Payer: One Health Plan PPO/POS |
$93.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$98.31
|
| Rate for Payer: Three Rivers Provider Network All |
$77.61
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$91.06
|
| Rate for Payer: United Healthcare Managed Medicaid |
$25.87
|
| Rate for Payer: United Payors & United Providers UP&UP |
$96.24
|
| Rate for Payer: Zelis Auto |
$41.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$51.74
|
| Rate for Payer: Zelis Worker's Compensation |
$28.25
|
|
|
E/M PROLONGED SVCS; EA 15 MINS - FACILIT
|
Facility
|
OP
|
$122.19
|
|
|
Service Code
|
CPT 99417
|
| Hospital Charge Code |
1991001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.55 |
| Max. Negotiated Rate |
$116.08 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$73.31
|
| Rate for Payer: Cash Price |
$73.31
|
| Rate for Payer: Cigna Commercial |
$103.86
|
| Rate for Payer: First Health Commercial |
$109.97
|
| Rate for Payer: First Health Workers Compensation |
$47.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$109.97
|
| Rate for Payer: GEHA Commercial |
$97.75
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$109.97
|
| Rate for Payer: Humana ChoiceCare |
$31.77
|
| Rate for Payer: Multiplan All |
$111.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$73.31
|
| Rate for Payer: OMNI Networks Commercial |
$85.53
|
| Rate for Payer: One Health Plan PPO/POS |
$109.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$116.08
|
| Rate for Payer: Three Rivers Provider Network All |
$91.64
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$107.53
|
| Rate for Payer: United Healthcare Managed Medicaid |
$30.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$113.64
|
| Rate for Payer: Zelis Auto |
$48.88
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$61.09
|
| Rate for Payer: Zelis Worker's Compensation |
$33.36
|
|
|
E/M PROLONGED SVCS; EA 15 MINS - FACILIT
|
Facility
|
IP
|
$122.19
|
|
|
Service Code
|
CPT 99417
|
| Hospital Charge Code |
1991001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$33.36 |
| Max. Negotiated Rate |
$116.08 |
| Rate for Payer: Cash Price |
$73.31
|
| Rate for Payer: Cigna Commercial |
$103.86
|
| Rate for Payer: First Health Commercial |
$109.97
|
| Rate for Payer: First Health Workers Compensation |
$47.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$109.97
|
| Rate for Payer: GEHA Commercial |
$85.53
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$109.97
|
| Rate for Payer: Multiplan All |
$111.19
|
| Rate for Payer: OMNI Networks Commercial |
$85.53
|
| Rate for Payer: One Health Plan PPO/POS |
$109.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$116.08
|
| Rate for Payer: Three Rivers Provider Network All |
$91.64
|
| Rate for Payer: United Payors & United Providers UP&UP |
$113.64
|
| Rate for Payer: Zelis Auto |
$48.88
|
| Rate for Payer: Zelis Worker's Compensation |
$33.36
|
|
|
E/M PROLONGED SVCS; EA 15 MINS - PROFEE
|
Facility
|
OP
|
$63.33
|
|
|
Service Code
|
CPT 99417
|
| Hospital Charge Code |
1991012
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$15.83 |
| Max. Negotiated Rate |
$60.16 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$38.00
|
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Cigna Commercial |
$53.83
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: First Health Workers Compensation |
$24.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$57.00
|
| Rate for Payer: GEHA Commercial |
$50.66
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$57.00
|
| Rate for Payer: Humana ChoiceCare |
$16.47
|
| Rate for Payer: Multiplan All |
$57.63
|
| Rate for Payer: New Mexico Health Connections Medicare |
$38.00
|
| Rate for Payer: OMNI Networks Commercial |
$44.33
|
| Rate for Payer: One Health Plan PPO/POS |
$57.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$60.16
|
| Rate for Payer: Three Rivers Provider Network All |
$47.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$55.73
|
| Rate for Payer: United Healthcare Managed Medicaid |
$15.83
|
| Rate for Payer: United Payors & United Providers UP&UP |
$58.90
|
| Rate for Payer: Zelis Auto |
$25.33
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$31.66
|
| Rate for Payer: Zelis Worker's Compensation |
$17.29
|
|
|
E/M PROLONGED SVCS; EA 15 MINS - PROFEE
|
Facility
|
IP
|
$63.33
|
|
|
Service Code
|
CPT 99417
|
| Hospital Charge Code |
1991012
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$17.29 |
| Max. Negotiated Rate |
$60.16 |
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Cigna Commercial |
$53.83
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: First Health Workers Compensation |
$24.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$57.00
|
| Rate for Payer: GEHA Commercial |
$44.33
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$57.00
|
| Rate for Payer: Multiplan All |
$57.63
|
| Rate for Payer: OMNI Networks Commercial |
$44.33
|
| Rate for Payer: One Health Plan PPO/POS |
$57.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$60.16
|
| Rate for Payer: Three Rivers Provider Network All |
$47.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$58.90
|
| Rate for Payer: Zelis Auto |
$25.33
|
| Rate for Payer: Zelis Worker's Compensation |
$17.29
|
|
|
EM TX ULCERS NOT HEALING 30 DA CARE
|
Facility
|
IP
|
$28.98
|
|
|
Service Code
|
CPT G0329
|
| Hospital Charge Code |
8500329
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$7.91 |
| Max. Negotiated Rate |
$27.53 |
| Rate for Payer: Cash Price |
$17.39
|
| Rate for Payer: Cigna Commercial |
$24.63
|
| Rate for Payer: First Health Commercial |
$26.08
|
| Rate for Payer: First Health Workers Compensation |
$11.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$26.08
|
| Rate for Payer: GEHA Commercial |
$20.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$26.08
|
| Rate for Payer: Multiplan All |
$26.37
|
| Rate for Payer: OMNI Networks Commercial |
$20.29
|
| Rate for Payer: One Health Plan PPO/POS |
$26.08
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$27.53
|
| Rate for Payer: Three Rivers Provider Network All |
$21.73
|
| Rate for Payer: United Payors & United Providers UP&UP |
$26.95
|
| Rate for Payer: Zelis Auto |
$11.59
|
| Rate for Payer: Zelis Worker's Compensation |
$7.91
|
|
|
EM TX ULCERS NOT HEALING 30 DA CARE
|
Facility
|
OP
|
$28.98
|
|
|
Service Code
|
CPT G0329
|
| Hospital Charge Code |
8500329
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$7.25 |
| Max. Negotiated Rate |
$27.53 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$17.39
|
| Rate for Payer: Cash Price |
$17.39
|
| Rate for Payer: Cigna Commercial |
$24.63
|
| Rate for Payer: First Health Commercial |
$26.08
|
| Rate for Payer: First Health Workers Compensation |
$11.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$26.08
|
| Rate for Payer: GEHA Commercial |
$23.18
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$26.08
|
| Rate for Payer: Humana ChoiceCare |
$7.53
|
| Rate for Payer: Multiplan All |
$26.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$17.39
|
| Rate for Payer: OMNI Networks Commercial |
$20.29
|
| Rate for Payer: One Health Plan PPO/POS |
$26.08
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$27.53
|
| Rate for Payer: Three Rivers Provider Network All |
$21.73
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$25.50
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$26.95
|
| Rate for Payer: Zelis Auto |
$11.59
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$14.49
|
| Rate for Payer: Zelis Worker's Compensation |
$7.91
|
|
|
ENALAPRILAT IV INJ 1.25MG/ML
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 00143978710
|
| Hospital Charge Code |
3300291
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$26.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$23.80
|
| Rate for Payer: First Health Commercial |
$25.20
|
| Rate for Payer: First Health Workers Compensation |
$10.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$25.20
|
| Rate for Payer: GEHA Commercial |
$22.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$25.20
|
| Rate for Payer: Humana ChoiceCare |
$7.28
|
| Rate for Payer: Multiplan All |
$25.48
|
| Rate for Payer: New Mexico Health Connections Medicare |
$16.80
|
| Rate for Payer: OMNI Networks Commercial |
$19.60
|
| Rate for Payer: One Health Plan PPO/POS |
$25.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$26.60
|
| Rate for Payer: Three Rivers Provider Network All |
$21.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$24.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$26.04
|
| Rate for Payer: Zelis Auto |
$11.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$14.00
|
| Rate for Payer: Zelis Worker's Compensation |
$7.64
|
|
|
ENALAPRILAT IV INJ 1.25MG/ML
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 00143978710
|
| Hospital Charge Code |
3300291
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.64 |
| Max. Negotiated Rate |
$26.60 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$23.80
|
| Rate for Payer: First Health Commercial |
$25.20
|
| Rate for Payer: First Health Workers Compensation |
$10.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$25.20
|
| Rate for Payer: GEHA Commercial |
$19.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$25.20
|
| Rate for Payer: Multiplan All |
$25.48
|
| Rate for Payer: OMNI Networks Commercial |
$19.60
|
| Rate for Payer: One Health Plan PPO/POS |
$25.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$26.60
|
| Rate for Payer: Three Rivers Provider Network All |
$21.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$26.04
|
| Rate for Payer: Zelis Auto |
$11.20
|
| Rate for Payer: Zelis Worker's Compensation |
$7.64
|
|
|
ENALAPRIL MALEATE TAB 10MG
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 00904561061
|
| Hospital Charge Code |
3300290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$8.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
ENALAPRIL MALEATE TAB 10MG
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 00904561061
|
| Hospital Charge Code |
3300290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$9.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Humana ChoiceCare |
$3.12
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.20
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
ENDOCAPSULE STUDY
|
Facility
|
OP
|
$2,551.00
|
|
|
Service Code
|
CPT 91110
|
| Hospital Charge Code |
6180010
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$696.42 |
| Max. Negotiated Rate |
$2,423.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$995.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,530.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$995.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$789.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$890.25
|
| Rate for Payer: Cash Price |
$1,530.60
|
| Rate for Payer: Cash Price |
$1,530.60
|
| Rate for Payer: Cigna Commercial |
$2,168.35
|
| Rate for Payer: First Health Commercial |
$2,295.90
|
| Rate for Payer: First Health Workers Compensation |
$984.94
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,295.90
|
| Rate for Payer: GEHA Commercial |
$2,040.80
|
| Rate for Payer: GEHA Medicare |
$890.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,295.90
|
| Rate for Payer: Humana ChoiceCare |
$979.27
|
| Rate for Payer: Humana Medicare Advantage |
$890.25
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,495.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$805.06
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$890.25
|
| Rate for Payer: Multiplan All |
$2,321.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,513.42
|
| Rate for Payer: OMNI Networks Commercial |
$1,785.70
|
| Rate for Payer: One Health Plan PPO/POS |
$2,295.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$929.56
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$805.06
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$890.25
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,423.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,780.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,913.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$872.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$805.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$890.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,372.43
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$890.25
|
| Rate for Payer: Zelis Auto |
$1,020.40
|
| Rate for Payer: Zelis Medicare |
$756.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,068.30
|
| Rate for Payer: Zelis Worker's Compensation |
$696.42
|
|
|
ENDOCAPSULE STUDY
|
Facility
|
IP
|
$2,551.00
|
|
|
Service Code
|
CPT 91110
|
| Hospital Charge Code |
6180010
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$696.42 |
| Max. Negotiated Rate |
$2,423.45 |
| Rate for Payer: Cash Price |
$1,530.60
|
| Rate for Payer: Cigna Commercial |
$2,168.35
|
| Rate for Payer: First Health Commercial |
$2,295.90
|
| Rate for Payer: First Health Workers Compensation |
$984.94
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,295.90
|
| Rate for Payer: GEHA Commercial |
$1,785.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,295.90
|
| Rate for Payer: Multiplan All |
$2,321.41
|
| Rate for Payer: OMNI Networks Commercial |
$1,785.70
|
| Rate for Payer: One Health Plan PPO/POS |
$2,295.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,423.45
|
| Rate for Payer: Three Rivers Provider Network All |
$1,913.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,372.43
|
| Rate for Payer: Zelis Auto |
$1,020.40
|
| Rate for Payer: Zelis Worker's Compensation |
$696.42
|
|
|
ENDOCERVICAL CURETTAGE
|
Facility
|
OP
|
$441.48
|
|
|
Service Code
|
CPT 57505
|
| Hospital Charge Code |
23557505
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$120.52 |
| Max. Negotiated Rate |
$1,653.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$687.03
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$264.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$687.03
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$544.27
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$826.80
|
| Rate for Payer: Cash Price |
$264.89
|
| Rate for Payer: Cash Price |
$264.89
|
| Rate for Payer: Cigna Commercial |
$375.26
|
| Rate for Payer: First Health Commercial |
$397.33
|
| Rate for Payer: First Health Workers Compensation |
$170.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$397.33
|
| Rate for Payer: GEHA Commercial |
$353.18
|
| Rate for Payer: GEHA Medicare |
$826.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$397.33
|
| Rate for Payer: Humana ChoiceCare |
$909.48
|
| Rate for Payer: Humana Medicare Advantage |
$826.80
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,389.02
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$555.35
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$826.80
|
| Rate for Payer: Multiplan All |
$401.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,405.56
|
| Rate for Payer: OMNI Networks Commercial |
$309.04
|
| Rate for Payer: One Health Plan PPO/POS |
$397.33
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$641.23
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$555.35
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$826.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$419.41
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,653.60
|
| Rate for Payer: Three Rivers Provider Network All |
$331.11
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$810.26
|
| Rate for Payer: United Healthcare Managed Medicaid |
$555.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$826.80
|
| Rate for Payer: United Payors & United Providers UP&UP |
$410.58
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$826.80
|
| Rate for Payer: Zelis Auto |
$176.59
|
| Rate for Payer: Zelis Medicare |
$702.78
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$992.16
|
| Rate for Payer: Zelis Worker's Compensation |
$120.52
|
|
|
ENDOCERVICAL CURETTAGE
|
Facility
|
OP
|
$441.48
|
|
|
Service Code
|
CPT 57505
|
| Hospital Charge Code |
6157505
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$120.52 |
| Max. Negotiated Rate |
$1,653.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$687.03
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$264.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$687.03
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$544.27
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$826.80
|
| Rate for Payer: Cash Price |
$264.89
|
| Rate for Payer: Cash Price |
$264.89
|
| Rate for Payer: Cigna Commercial |
$375.26
|
| Rate for Payer: First Health Commercial |
$397.33
|
| Rate for Payer: First Health Workers Compensation |
$170.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$397.33
|
| Rate for Payer: GEHA Commercial |
$353.18
|
| Rate for Payer: GEHA Medicare |
$826.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$397.33
|
| Rate for Payer: Humana ChoiceCare |
$909.48
|
| Rate for Payer: Humana Medicare Advantage |
$826.80
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,389.02
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$555.35
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$826.80
|
| Rate for Payer: Multiplan All |
$401.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,405.56
|
| Rate for Payer: OMNI Networks Commercial |
$309.04
|
| Rate for Payer: One Health Plan PPO/POS |
$397.33
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$641.23
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$555.35
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$826.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$419.41
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,653.60
|
| Rate for Payer: Three Rivers Provider Network All |
$331.11
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$810.26
|
| Rate for Payer: United Healthcare Managed Medicaid |
$555.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$826.80
|
| Rate for Payer: United Payors & United Providers UP&UP |
$410.58
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$826.80
|
| Rate for Payer: Zelis Auto |
$176.59
|
| Rate for Payer: Zelis Medicare |
$702.78
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$992.16
|
| Rate for Payer: Zelis Worker's Compensation |
$120.52
|
|
|
ENDOCERVICAL CURETTAGE
|
Facility
|
IP
|
$441.48
|
|
|
Service Code
|
CPT 57505
|
| Hospital Charge Code |
23557505
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$120.52 |
| Max. Negotiated Rate |
$419.41 |
| Rate for Payer: Cash Price |
$264.89
|
| Rate for Payer: Cigna Commercial |
$375.26
|
| Rate for Payer: First Health Commercial |
$397.33
|
| Rate for Payer: First Health Workers Compensation |
$170.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$397.33
|
| Rate for Payer: GEHA Commercial |
$309.04
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$397.33
|
| Rate for Payer: Multiplan All |
$401.75
|
| Rate for Payer: OMNI Networks Commercial |
$309.04
|
| Rate for Payer: One Health Plan PPO/POS |
$397.33
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$419.41
|
| Rate for Payer: Three Rivers Provider Network All |
$331.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$410.58
|
| Rate for Payer: Zelis Auto |
$176.59
|
| Rate for Payer: Zelis Worker's Compensation |
$120.52
|
|
|
ENDOCERVICAL CURETTAGE
|
Facility
|
IP
|
$441.48
|
|
|
Service Code
|
CPT 57505
|
| Hospital Charge Code |
6157505
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$120.52 |
| Max. Negotiated Rate |
$419.41 |
| Rate for Payer: Cash Price |
$264.89
|
| Rate for Payer: Cigna Commercial |
$375.26
|
| Rate for Payer: First Health Commercial |
$397.33
|
| Rate for Payer: First Health Workers Compensation |
$170.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$397.33
|
| Rate for Payer: GEHA Commercial |
$309.04
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$397.33
|
| Rate for Payer: Multiplan All |
$401.75
|
| Rate for Payer: OMNI Networks Commercial |
$309.04
|
| Rate for Payer: One Health Plan PPO/POS |
$397.33
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$419.41
|
| Rate for Payer: Three Rivers Provider Network All |
$331.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$410.58
|
| Rate for Payer: Zelis Auto |
$176.59
|
| Rate for Payer: Zelis Worker's Compensation |
$120.52
|
|
|
ENDO CHOLANGIOPANCREATOGRAPH
|
Facility
|
OP
|
$957.00
|
|
|
Service Code
|
CPT 43262
|
| Hospital Charge Code |
6143262
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$261.26 |
| Max. Negotiated Rate |
$7,225.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,286.18
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$574.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,286.18
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,811.11
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,612.55
|
| Rate for Payer: Cash Price |
$574.20
|
| Rate for Payer: Cash Price |
$574.20
|
| Rate for Payer: Cigna Commercial |
$813.45
|
| Rate for Payer: First Health Commercial |
$861.30
|
| Rate for Payer: First Health Workers Compensation |
$369.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$861.30
|
| Rate for Payer: GEHA Commercial |
$765.60
|
| Rate for Payer: GEHA Medicare |
$3,612.55
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$861.30
|
| Rate for Payer: Humana ChoiceCare |
$3,973.80
|
| Rate for Payer: Humana Medicare Advantage |
$3,612.55
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$6,069.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,848.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,612.55
|
| Rate for Payer: Multiplan All |
$870.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,141.34
|
| Rate for Payer: OMNI Networks Commercial |
$669.90
|
| Rate for Payer: One Health Plan PPO/POS |
$861.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,133.77
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,848.00
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,612.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$909.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$7,225.10
|
| Rate for Payer: Three Rivers Provider Network All |
$717.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,540.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,848.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,612.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$890.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,612.55
|
| Rate for Payer: Zelis Auto |
$382.80
|
| Rate for Payer: Zelis Medicare |
$3,070.67
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,335.06
|
| Rate for Payer: Zelis Worker's Compensation |
$261.26
|
|
|
ENDO CHOLANGIOPANCREATOGRAPH
|
Facility
|
IP
|
$957.00
|
|
|
Service Code
|
CPT 43262
|
| Hospital Charge Code |
6143262
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$261.26 |
| Max. Negotiated Rate |
$909.15 |
| Rate for Payer: Cash Price |
$574.20
|
| Rate for Payer: Cigna Commercial |
$813.45
|
| Rate for Payer: First Health Commercial |
$861.30
|
| Rate for Payer: First Health Workers Compensation |
$369.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$861.30
|
| Rate for Payer: GEHA Commercial |
$669.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$861.30
|
| Rate for Payer: Multiplan All |
$870.87
|
| Rate for Payer: OMNI Networks Commercial |
$669.90
|
| Rate for Payer: One Health Plan PPO/POS |
$861.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$909.15
|
| Rate for Payer: Three Rivers Provider Network All |
$717.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$890.01
|
| Rate for Payer: Zelis Auto |
$382.80
|
| Rate for Payer: Zelis Worker's Compensation |
$261.26
|
|
|
ENDO CHOLANGIOPANCREATOGRAPH
|
Facility
|
IP
|
$908.00
|
|
|
Service Code
|
CPT 43261
|
| Hospital Charge Code |
6143261
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$247.88 |
| Max. Negotiated Rate |
$862.60 |
| Rate for Payer: Cash Price |
$544.80
|
| Rate for Payer: Cigna Commercial |
$771.80
|
| Rate for Payer: First Health Commercial |
$817.20
|
| Rate for Payer: First Health Workers Compensation |
$350.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$817.20
|
| Rate for Payer: GEHA Commercial |
$635.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$817.20
|
| Rate for Payer: Multiplan All |
$826.28
|
| Rate for Payer: OMNI Networks Commercial |
$635.60
|
| Rate for Payer: One Health Plan PPO/POS |
$817.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$862.60
|
| Rate for Payer: Three Rivers Provider Network All |
$681.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$844.44
|
| Rate for Payer: Zelis Auto |
$363.20
|
| Rate for Payer: Zelis Worker's Compensation |
$247.88
|
|
|
ENDO CHOLANGIOPANCREATOGRAPH
|
Facility
|
OP
|
$908.00
|
|
|
Service Code
|
CPT 43261
|
| Hospital Charge Code |
6143261
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$247.88 |
| Max. Negotiated Rate |
$7,225.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,286.18
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$544.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,286.18
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,811.11
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,612.55
|
| Rate for Payer: Cash Price |
$544.80
|
| Rate for Payer: Cash Price |
$544.80
|
| Rate for Payer: Cigna Commercial |
$771.80
|
| Rate for Payer: First Health Commercial |
$817.20
|
| Rate for Payer: First Health Workers Compensation |
$350.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$817.20
|
| Rate for Payer: GEHA Commercial |
$726.40
|
| Rate for Payer: GEHA Medicare |
$3,612.55
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$817.20
|
| Rate for Payer: Humana ChoiceCare |
$3,973.80
|
| Rate for Payer: Humana Medicare Advantage |
$3,612.55
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$6,069.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,848.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,612.55
|
| Rate for Payer: Multiplan All |
$826.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,141.34
|
| Rate for Payer: OMNI Networks Commercial |
$635.60
|
| Rate for Payer: One Health Plan PPO/POS |
$817.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,133.77
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,848.00
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,612.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$862.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$7,225.10
|
| Rate for Payer: Three Rivers Provider Network All |
$681.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,540.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,848.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,612.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$844.44
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,612.55
|
| Rate for Payer: Zelis Auto |
$363.20
|
| Rate for Payer: Zelis Medicare |
$3,070.67
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,335.06
|
| Rate for Payer: Zelis Worker's Compensation |
$247.88
|
|
|
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
CPT 58110
|
| Hospital Charge Code |
6158110
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$34.40 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$107.10
|
| Rate for Payer: First Health Commercial |
$113.40
|
| Rate for Payer: First Health Workers Compensation |
$48.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$113.40
|
| Rate for Payer: GEHA Commercial |
$88.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$113.40
|
| Rate for Payer: Multiplan All |
$114.66
|
| Rate for Payer: OMNI Networks Commercial |
$88.20
|
| Rate for Payer: One Health Plan PPO/POS |
$113.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$119.70
|
| Rate for Payer: Three Rivers Provider Network All |
$94.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$117.18
|
| Rate for Payer: Zelis Auto |
$50.40
|
| Rate for Payer: Zelis Worker's Compensation |
$34.40
|
|
|
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
CPT 58110
|
| Hospital Charge Code |
6158110
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$75.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$107.10
|
| Rate for Payer: First Health Commercial |
$113.40
|
| Rate for Payer: First Health Workers Compensation |
$48.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$113.40
|
| Rate for Payer: GEHA Commercial |
$100.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$113.40
|
| Rate for Payer: Humana ChoiceCare |
$32.76
|
| Rate for Payer: Multiplan All |
$114.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$75.60
|
| Rate for Payer: OMNI Networks Commercial |
$88.20
|
| Rate for Payer: One Health Plan PPO/POS |
$113.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$119.70
|
| Rate for Payer: Three Rivers Provider Network All |
$94.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$110.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$117.18
|
| Rate for Payer: Zelis Auto |
$50.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$63.00
|
| Rate for Payer: Zelis Worker's Compensation |
$34.40
|
|
|
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
CPT 58110
|
| Hospital Charge Code |
23500057
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$34.40 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$107.10
|
| Rate for Payer: First Health Commercial |
$113.40
|
| Rate for Payer: First Health Workers Compensation |
$48.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$113.40
|
| Rate for Payer: GEHA Commercial |
$88.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$113.40
|
| Rate for Payer: Multiplan All |
$114.66
|
| Rate for Payer: OMNI Networks Commercial |
$88.20
|
| Rate for Payer: One Health Plan PPO/POS |
$113.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$119.70
|
| Rate for Payer: Three Rivers Provider Network All |
$94.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$117.18
|
| Rate for Payer: Zelis Auto |
$50.40
|
| Rate for Payer: Zelis Worker's Compensation |
$34.40
|
|
|
ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
CPT 58110
|
| Hospital Charge Code |
23500057
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$75.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$107.10
|
| Rate for Payer: First Health Commercial |
$113.40
|
| Rate for Payer: First Health Workers Compensation |
$48.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$113.40
|
| Rate for Payer: GEHA Commercial |
$100.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$113.40
|
| Rate for Payer: Humana ChoiceCare |
$32.76
|
| Rate for Payer: Multiplan All |
$114.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$75.60
|
| Rate for Payer: OMNI Networks Commercial |
$88.20
|
| Rate for Payer: One Health Plan PPO/POS |
$113.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$119.70
|
| Rate for Payer: Three Rivers Provider Network All |
$94.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$110.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$117.18
|
| Rate for Payer: Zelis Auto |
$50.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$63.00
|
| Rate for Payer: Zelis Worker's Compensation |
$34.40
|
|
