|
GANGLIOSIDE GM1 AB IGM REF
|
Facility
|
IP
|
$249.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
2300005
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.31 |
| Max. Negotiated Rate |
$236.55 |
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$211.65
|
| Rate for Payer: First Health Commercial |
$224.10
|
| Rate for Payer: First Health Workers Compensation |
$20.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$224.10
|
| Rate for Payer: GEHA Commercial |
$174.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$224.10
|
| Rate for Payer: Multiplan All |
$226.59
|
| Rate for Payer: OMNI Networks Commercial |
$174.30
|
| Rate for Payer: One Health Plan PPO/POS |
$224.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$236.55
|
| Rate for Payer: Three Rivers Provider Network All |
$186.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$231.57
|
| Rate for Payer: Zelis Auto |
$99.60
|
| Rate for Payer: Zelis Worker's Compensation |
$14.31
|
|
|
GARMENT BELT SLEEVE OTH ELASTIC EA
|
Facility
|
OP
|
$69.00
|
|
| Hospital Charge Code |
8230048
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.25 |
| Max. Negotiated Rate |
$65.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$58.65
|
| Rate for Payer: First Health Commercial |
$62.10
|
| Rate for Payer: First Health Workers Compensation |
$26.64
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$62.10
|
| Rate for Payer: GEHA Commercial |
$55.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$62.10
|
| Rate for Payer: Humana ChoiceCare |
$17.94
|
| Rate for Payer: Multiplan All |
$62.79
|
| Rate for Payer: New Mexico Health Connections Medicare |
$41.40
|
| Rate for Payer: OMNI Networks Commercial |
$48.30
|
| Rate for Payer: One Health Plan PPO/POS |
$62.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$65.55
|
| Rate for Payer: Three Rivers Provider Network All |
$51.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$60.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$17.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$64.17
|
| Rate for Payer: Zelis Auto |
$27.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$34.50
|
| Rate for Payer: Zelis Worker's Compensation |
$18.84
|
|
|
GARMENT BELT SLEEVE OTH ELASTIC EA
|
Facility
|
IP
|
$69.00
|
|
| Hospital Charge Code |
8230048
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.84 |
| Max. Negotiated Rate |
$65.55 |
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$58.65
|
| Rate for Payer: First Health Commercial |
$62.10
|
| Rate for Payer: First Health Workers Compensation |
$26.64
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$62.10
|
| Rate for Payer: GEHA Commercial |
$48.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$62.10
|
| Rate for Payer: Multiplan All |
$62.79
|
| Rate for Payer: OMNI Networks Commercial |
$48.30
|
| Rate for Payer: One Health Plan PPO/POS |
$62.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$65.55
|
| Rate for Payer: Three Rivers Provider Network All |
$51.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$64.17
|
| Rate for Payer: Zelis Auto |
$27.60
|
| Rate for Payer: Zelis Worker's Compensation |
$18.84
|
|
|
GAS DILUTION OR WASHOUT
|
Facility
|
IP
|
$528.00
|
|
|
Service Code
|
CPT 94727
|
| Hospital Charge Code |
4094727
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$144.14 |
| Max. Negotiated Rate |
$501.60 |
| Rate for Payer: Cash Price |
$316.80
|
| Rate for Payer: Cigna Commercial |
$448.80
|
| Rate for Payer: First Health Commercial |
$475.20
|
| Rate for Payer: First Health Workers Compensation |
$203.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$475.20
|
| Rate for Payer: GEHA Commercial |
$369.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$475.20
|
| Rate for Payer: Multiplan All |
$480.48
|
| Rate for Payer: OMNI Networks Commercial |
$369.60
|
| Rate for Payer: One Health Plan PPO/POS |
$475.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$501.60
|
| Rate for Payer: Three Rivers Provider Network All |
$396.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$491.04
|
| Rate for Payer: Zelis Auto |
$211.20
|
| Rate for Payer: Zelis Worker's Compensation |
$144.14
|
|
|
GAS DILUTION OR WASHOUT
|
Facility
|
OP
|
$528.00
|
|
|
Service Code
|
CPT 94727
|
| Hospital Charge Code |
4094727
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$126.28 |
| Max. Negotiated Rate |
$501.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$241.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$316.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$241.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$191.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$148.57
|
| Rate for Payer: Cash Price |
$316.80
|
| Rate for Payer: Cash Price |
$316.80
|
| Rate for Payer: Cigna Commercial |
$448.80
|
| Rate for Payer: First Health Commercial |
$475.20
|
| Rate for Payer: First Health Workers Compensation |
$203.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$475.20
|
| Rate for Payer: GEHA Commercial |
$422.40
|
| Rate for Payer: GEHA Medicare |
$148.57
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$475.20
|
| Rate for Payer: Humana ChoiceCare |
$163.43
|
| Rate for Payer: Humana Medicare Advantage |
$148.57
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$249.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$195.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$148.57
|
| Rate for Payer: Multiplan All |
$480.48
|
| Rate for Payer: New Mexico Health Connections Medicare |
$252.57
|
| Rate for Payer: OMNI Networks Commercial |
$369.60
|
| Rate for Payer: One Health Plan PPO/POS |
$475.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$225.71
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$195.48
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$148.57
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$501.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$297.14
|
| Rate for Payer: Three Rivers Provider Network All |
$396.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$145.60
|
| Rate for Payer: United Healthcare Commercial |
$448.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$148.57
|
| Rate for Payer: United Payors & United Providers UP&UP |
$491.04
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$148.57
|
| Rate for Payer: Zelis Auto |
$211.20
|
| Rate for Payer: Zelis Medicare |
$126.28
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$178.28
|
| Rate for Payer: Zelis Worker's Compensation |
$144.14
|
|
|
GASTRIC BYPASS FOR OBESITY
|
Facility
|
OP
|
$3,401.00
|
|
|
Service Code
|
CPT 43846
|
| Hospital Charge Code |
6143846
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$850.25 |
| Max. Negotiated Rate |
$3,230.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,040.60
|
| Rate for Payer: Cash Price |
$2,040.60
|
| Rate for Payer: Cigna Commercial |
$2,890.85
|
| Rate for Payer: First Health Commercial |
$3,060.90
|
| Rate for Payer: First Health Workers Compensation |
$1,313.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,060.90
|
| Rate for Payer: GEHA Commercial |
$2,720.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,060.90
|
| Rate for Payer: Humana ChoiceCare |
$884.26
|
| Rate for Payer: Multiplan All |
$3,094.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,040.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,380.70
|
| Rate for Payer: One Health Plan PPO/POS |
$3,060.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,230.95
|
| Rate for Payer: Three Rivers Provider Network All |
$2,550.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,992.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$850.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,162.93
|
| Rate for Payer: Zelis Auto |
$1,360.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,700.50
|
| Rate for Payer: Zelis Worker's Compensation |
$928.47
|
|
|
GASTRIC BYPASS FOR OBESITY
|
Facility
|
IP
|
$3,401.00
|
|
|
Service Code
|
CPT 43846
|
| Hospital Charge Code |
6143846
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$928.47 |
| Max. Negotiated Rate |
$3,230.95 |
| Rate for Payer: Cash Price |
$2,040.60
|
| Rate for Payer: Cigna Commercial |
$2,890.85
|
| Rate for Payer: First Health Commercial |
$3,060.90
|
| Rate for Payer: First Health Workers Compensation |
$1,313.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,060.90
|
| Rate for Payer: GEHA Commercial |
$2,380.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,060.90
|
| Rate for Payer: Multiplan All |
$3,094.91
|
| Rate for Payer: OMNI Networks Commercial |
$2,380.70
|
| Rate for Payer: One Health Plan PPO/POS |
$3,060.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,230.95
|
| Rate for Payer: Three Rivers Provider Network All |
$2,550.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,162.93
|
| Rate for Payer: Zelis Auto |
$1,360.40
|
| Rate for Payer: Zelis Worker's Compensation |
$928.47
|
|
|
GASTRIC BYPASS INCL SMALL I
|
Facility
|
OP
|
$3,736.00
|
|
|
Service Code
|
CPT 43847
|
| Hospital Charge Code |
6143847
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$934.00 |
| Max. Negotiated Rate |
$3,549.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,241.60
|
| Rate for Payer: Cash Price |
$2,241.60
|
| Rate for Payer: Cigna Commercial |
$3,175.60
|
| Rate for Payer: First Health Commercial |
$3,362.40
|
| Rate for Payer: First Health Workers Compensation |
$1,442.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,362.40
|
| Rate for Payer: GEHA Commercial |
$2,988.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,362.40
|
| Rate for Payer: Humana ChoiceCare |
$971.36
|
| Rate for Payer: Multiplan All |
$3,399.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,241.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,615.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,362.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,549.20
|
| Rate for Payer: Three Rivers Provider Network All |
$2,802.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,287.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$934.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,474.48
|
| Rate for Payer: Zelis Auto |
$1,494.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,868.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,019.93
|
|
|
GASTRIC BYPASS INCL SMALL I
|
Facility
|
IP
|
$3,736.00
|
|
|
Service Code
|
CPT 43847
|
| Hospital Charge Code |
6143847
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,019.93 |
| Max. Negotiated Rate |
$3,549.20 |
| Rate for Payer: Cash Price |
$2,241.60
|
| Rate for Payer: Cigna Commercial |
$3,175.60
|
| Rate for Payer: First Health Commercial |
$3,362.40
|
| Rate for Payer: First Health Workers Compensation |
$1,442.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,362.40
|
| Rate for Payer: GEHA Commercial |
$2,615.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,362.40
|
| Rate for Payer: Multiplan All |
$3,399.76
|
| Rate for Payer: OMNI Networks Commercial |
$2,615.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,362.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,549.20
|
| Rate for Payer: Three Rivers Provider Network All |
$2,802.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,474.48
|
| Rate for Payer: Zelis Auto |
$1,494.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1,019.93
|
|
|
GASTRIC INTUBAT & ASPIRA W/PHY SKL/LAVAG
|
Facility
|
IP
|
$577.00
|
|
|
Service Code
|
CPT 43753
|
| Hospital Charge Code |
1000035
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$157.52 |
| Max. Negotiated Rate |
$548.15 |
| Rate for Payer: Cash Price |
$346.20
|
| Rate for Payer: Cigna Commercial |
$490.45
|
| Rate for Payer: First Health Commercial |
$519.30
|
| Rate for Payer: First Health Workers Compensation |
$222.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$519.30
|
| Rate for Payer: GEHA Commercial |
$403.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$519.30
|
| Rate for Payer: Multiplan All |
$525.07
|
| Rate for Payer: OMNI Networks Commercial |
$403.90
|
| Rate for Payer: One Health Plan PPO/POS |
$519.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$548.15
|
| Rate for Payer: Three Rivers Provider Network All |
$432.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$536.61
|
| Rate for Payer: Zelis Auto |
$230.80
|
| Rate for Payer: Zelis Worker's Compensation |
$157.52
|
|
|
GASTRIC INTUBAT & ASPIRA W/PHY SKL/LAVAG
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
CPT 43753
|
| Hospital Charge Code |
6143753
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$18.84 |
| Max. Negotiated Rate |
$591.38 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$197.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$41.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$197.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$156.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$295.69
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$58.65
|
| Rate for Payer: First Health Commercial |
$62.10
|
| Rate for Payer: First Health Workers Compensation |
$26.64
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$62.10
|
| Rate for Payer: GEHA Commercial |
$55.20
|
| Rate for Payer: GEHA Medicare |
$295.69
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$62.10
|
| Rate for Payer: Humana ChoiceCare |
$325.26
|
| Rate for Payer: Humana Medicare Advantage |
$295.69
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$496.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$159.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$295.69
|
| Rate for Payer: Multiplan All |
$62.79
|
| Rate for Payer: New Mexico Health Connections Medicare |
$502.67
|
| Rate for Payer: OMNI Networks Commercial |
$48.30
|
| Rate for Payer: One Health Plan PPO/POS |
$62.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$184.37
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$159.67
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$295.69
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$65.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$591.38
|
| Rate for Payer: Three Rivers Provider Network All |
$51.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$289.78
|
| Rate for Payer: United Healthcare Managed Medicaid |
$159.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$295.69
|
| Rate for Payer: United Payors & United Providers UP&UP |
$64.17
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$295.69
|
| Rate for Payer: Zelis Auto |
$27.60
|
| Rate for Payer: Zelis Medicare |
$251.34
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$354.83
|
| Rate for Payer: Zelis Worker's Compensation |
$18.84
|
|
|
GASTRIC INTUBAT & ASPIRA W/PHY SKL/LAVAG
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
CPT 43753
|
| Hospital Charge Code |
6143753
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$18.84 |
| Max. Negotiated Rate |
$65.55 |
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$58.65
|
| Rate for Payer: First Health Commercial |
$62.10
|
| Rate for Payer: First Health Workers Compensation |
$26.64
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$62.10
|
| Rate for Payer: GEHA Commercial |
$48.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$62.10
|
| Rate for Payer: Multiplan All |
$62.79
|
| Rate for Payer: OMNI Networks Commercial |
$48.30
|
| Rate for Payer: One Health Plan PPO/POS |
$62.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$65.55
|
| Rate for Payer: Three Rivers Provider Network All |
$51.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$64.17
|
| Rate for Payer: Zelis Auto |
$27.60
|
| Rate for Payer: Zelis Worker's Compensation |
$18.84
|
|
|
gastrin REF004390
|
Facility
|
IP
|
$286.00
|
|
|
Service Code
|
CPT 82941
|
| Hospital Charge Code |
22990755
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.22 |
| Max. Negotiated Rate |
$271.70 |
| Rate for Payer: Cash Price |
$171.60
|
| Rate for Payer: Cash Price |
$171.60
|
| Rate for Payer: Cigna Commercial |
$243.10
|
| Rate for Payer: First Health Commercial |
$257.40
|
| Rate for Payer: First Health Workers Compensation |
$32.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$257.40
|
| Rate for Payer: GEHA Commercial |
$200.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$257.40
|
| Rate for Payer: Multiplan All |
$260.26
|
| Rate for Payer: OMNI Networks Commercial |
$200.20
|
| Rate for Payer: One Health Plan PPO/POS |
$257.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$271.70
|
| Rate for Payer: Three Rivers Provider Network All |
$214.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$265.98
|
| Rate for Payer: Zelis Auto |
$114.40
|
| Rate for Payer: Zelis Worker's Compensation |
$23.22
|
|
|
gastrin REF004390
|
Facility
|
OP
|
$286.00
|
|
|
Service Code
|
CPT 82941
|
| Hospital Charge Code |
22990755
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.99 |
| Max. Negotiated Rate |
$271.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$31.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$171.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$31.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$25.14
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$17.63
|
| Rate for Payer: Cash Price |
$171.60
|
| Rate for Payer: Cash Price |
$171.60
|
| Rate for Payer: Cigna Commercial |
$243.10
|
| Rate for Payer: First Health Commercial |
$257.40
|
| Rate for Payer: First Health Workers Compensation |
$32.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$257.40
|
| Rate for Payer: GEHA Commercial |
$228.80
|
| Rate for Payer: GEHA Medicare |
$17.63
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$257.40
|
| Rate for Payer: Humana ChoiceCare |
$19.39
|
| Rate for Payer: Humana Medicare Advantage |
$17.63
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$29.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$25.66
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$17.63
|
| Rate for Payer: Multiplan All |
$260.26
|
| Rate for Payer: New Mexico Health Connections Medicare |
$29.97
|
| Rate for Payer: OMNI Networks Commercial |
$200.20
|
| Rate for Payer: One Health Plan PPO/POS |
$257.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$29.62
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$25.66
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$17.63
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$271.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$35.26
|
| Rate for Payer: Three Rivers Provider Network All |
$214.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17.28
|
| Rate for Payer: United Healthcare Commercial |
$243.10
|
| Rate for Payer: United Healthcare Managed Medicaid |
$25.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.63
|
| Rate for Payer: United Payors & United Providers UP&UP |
$265.98
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$17.63
|
| Rate for Payer: Zelis Auto |
$114.40
|
| Rate for Payer: Zelis Medicare |
$14.99
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.16
|
| Rate for Payer: Zelis Worker's Compensation |
$23.22
|
|
|
GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)
|
Facility
|
OP
|
$6,161.78
|
|
|
Service Code
|
CPT 27687
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,544.86 |
| Max. Negotiated Rate |
$6,161.78 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$3,212.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$3,212.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2,544.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,080.89
|
| Rate for Payer: First Health Workers Compensation |
$3,965.11
|
| Rate for Payer: GEHA Medicare |
$3,080.89
|
| Rate for Payer: Humana ChoiceCare |
$3,388.98
|
| Rate for Payer: Humana Medicare Advantage |
$3,080.89
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,175.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,596.69
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,080.89
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,237.51
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,998.24
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,596.69
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,080.89
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,161.78
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,019.27
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,596.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,080.89
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,080.89
|
| Rate for Payer: Zelis Medicare |
$2,618.76
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,697.07
|
| Rate for Payer: Zelis Worker's Compensation |
$2,803.61
|
|
|
GASTROESOPHAGEAL REFLUX TEST
|
Facility
|
OP
|
$556.00
|
|
|
Service Code
|
CPT 91034
|
| Hospital Charge Code |
6191034
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$151.79 |
| Max. Negotiated Rate |
$1,007.66 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$492.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$333.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$492.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$390.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$503.83
|
| Rate for Payer: Cash Price |
$333.60
|
| Rate for Payer: Cash Price |
$333.60
|
| Rate for Payer: Cigna Commercial |
$472.60
|
| Rate for Payer: First Health Commercial |
$500.40
|
| Rate for Payer: First Health Workers Compensation |
$214.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$500.40
|
| Rate for Payer: GEHA Commercial |
$444.80
|
| Rate for Payer: GEHA Medicare |
$503.83
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$500.40
|
| Rate for Payer: Humana ChoiceCare |
$554.21
|
| Rate for Payer: Humana Medicare Advantage |
$503.83
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$846.43
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$398.44
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$503.83
|
| Rate for Payer: Multiplan All |
$505.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$856.51
|
| Rate for Payer: OMNI Networks Commercial |
$389.20
|
| Rate for Payer: One Health Plan PPO/POS |
$500.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$460.05
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$398.44
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$503.83
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$528.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,007.66
|
| Rate for Payer: Three Rivers Provider Network All |
$417.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$493.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$398.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$503.83
|
| Rate for Payer: United Payors & United Providers UP&UP |
$517.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$503.83
|
| Rate for Payer: Zelis Auto |
$222.40
|
| Rate for Payer: Zelis Medicare |
$428.26
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$604.60
|
| Rate for Payer: Zelis Worker's Compensation |
$151.79
|
|
|
GASTROESOPHAGEAL REFLUX TEST
|
Facility
|
IP
|
$556.00
|
|
|
Service Code
|
CPT 91034
|
| Hospital Charge Code |
6191034
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$151.79 |
| Max. Negotiated Rate |
$528.20 |
| Rate for Payer: Cash Price |
$333.60
|
| Rate for Payer: Cigna Commercial |
$472.60
|
| Rate for Payer: First Health Commercial |
$500.40
|
| Rate for Payer: First Health Workers Compensation |
$214.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$500.40
|
| Rate for Payer: GEHA Commercial |
$389.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$500.40
|
| Rate for Payer: Multiplan All |
$505.96
|
| Rate for Payer: OMNI Networks Commercial |
$389.20
|
| Rate for Payer: One Health Plan PPO/POS |
$500.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$528.20
|
| Rate for Payer: Three Rivers Provider Network All |
$417.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$517.08
|
| Rate for Payer: Zelis Auto |
$222.40
|
| Rate for Payer: Zelis Worker's Compensation |
$151.79
|
|
|
GASTROGRAFIN 66-10% SOLN
|
Facility
|
OP
|
$308.00
|
|
|
Service Code
|
CPT Q9963
|
| Hospital Charge Code |
3300243
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$292.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$184.80
|
| Rate for Payer: Cash Price |
$184.80
|
| Rate for Payer: Cash Price |
$184.80
|
| Rate for Payer: Cigna Commercial |
$261.80
|
| Rate for Payer: First Health Commercial |
$277.20
|
| Rate for Payer: First Health Workers Compensation |
$118.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$277.20
|
| Rate for Payer: GEHA Commercial |
$0.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$277.20
|
| Rate for Payer: Humana ChoiceCare |
$80.08
|
| Rate for Payer: Multiplan All |
$280.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$184.80
|
| Rate for Payer: OMNI Networks Commercial |
$215.60
|
| Rate for Payer: One Health Plan PPO/POS |
$277.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$292.60
|
| Rate for Payer: Three Rivers Provider Network All |
$231.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$271.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$77.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$286.44
|
| Rate for Payer: Zelis Auto |
$123.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$154.00
|
| Rate for Payer: Zelis Worker's Compensation |
$84.08
|
|
|
GASTROGRAFIN 66-10% SOLN
|
Facility
|
IP
|
$308.00
|
|
|
Service Code
|
CPT Q9963
|
| Hospital Charge Code |
3300243
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$84.08 |
| Max. Negotiated Rate |
$292.60 |
| Rate for Payer: Cash Price |
$184.80
|
| Rate for Payer: Cigna Commercial |
$261.80
|
| Rate for Payer: First Health Commercial |
$277.20
|
| Rate for Payer: First Health Workers Compensation |
$118.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$277.20
|
| Rate for Payer: GEHA Commercial |
$215.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$277.20
|
| Rate for Payer: Multiplan All |
$280.28
|
| Rate for Payer: OMNI Networks Commercial |
$215.60
|
| Rate for Payer: One Health Plan PPO/POS |
$277.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$292.60
|
| Rate for Payer: Three Rivers Provider Network All |
$231.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$286.44
|
| Rate for Payer: Zelis Auto |
$123.20
|
| Rate for Payer: Zelis Worker's Compensation |
$84.08
|
|
|
GASTROINTESTINAL REPAIR
|
Facility
|
IP
|
$5,424.00
|
|
|
Service Code
|
CPT 43361
|
| Hospital Charge Code |
6143361
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,480.75 |
| Max. Negotiated Rate |
$5,152.80 |
| Rate for Payer: Cash Price |
$3,254.40
|
| Rate for Payer: Cigna Commercial |
$4,610.40
|
| Rate for Payer: First Health Commercial |
$4,881.60
|
| Rate for Payer: First Health Workers Compensation |
$2,094.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,881.60
|
| Rate for Payer: GEHA Commercial |
$3,796.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,881.60
|
| Rate for Payer: Multiplan All |
$4,935.84
|
| Rate for Payer: OMNI Networks Commercial |
$3,796.80
|
| Rate for Payer: One Health Plan PPO/POS |
$4,881.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,152.80
|
| Rate for Payer: Three Rivers Provider Network All |
$4,068.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,044.32
|
| Rate for Payer: Zelis Auto |
$2,169.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1,480.75
|
|
|
GASTROINTESTINAL REPAIR
|
Facility
|
OP
|
$4,999.00
|
|
|
Service Code
|
CPT 43360
|
| Hospital Charge Code |
6143360
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,249.75 |
| Max. Negotiated Rate |
$4,749.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,999.40
|
| Rate for Payer: Cash Price |
$2,999.40
|
| Rate for Payer: Cigna Commercial |
$4,249.15
|
| Rate for Payer: First Health Commercial |
$4,499.10
|
| Rate for Payer: First Health Workers Compensation |
$1,930.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,499.10
|
| Rate for Payer: GEHA Commercial |
$3,999.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,499.10
|
| Rate for Payer: Humana ChoiceCare |
$1,299.74
|
| Rate for Payer: Multiplan All |
$4,549.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,999.40
|
| Rate for Payer: OMNI Networks Commercial |
$3,499.30
|
| Rate for Payer: One Health Plan PPO/POS |
$4,499.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,749.05
|
| Rate for Payer: Three Rivers Provider Network All |
$3,749.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,399.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,249.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,649.07
|
| Rate for Payer: Zelis Auto |
$1,999.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,499.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1,364.73
|
|
|
GASTROINTESTINAL REPAIR
|
Facility
|
OP
|
$5,424.00
|
|
|
Service Code
|
CPT 43361
|
| Hospital Charge Code |
6143361
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,356.00 |
| Max. Negotiated Rate |
$5,152.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,254.40
|
| Rate for Payer: Cash Price |
$3,254.40
|
| Rate for Payer: Cigna Commercial |
$4,610.40
|
| Rate for Payer: First Health Commercial |
$4,881.60
|
| Rate for Payer: First Health Workers Compensation |
$2,094.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,881.60
|
| Rate for Payer: GEHA Commercial |
$4,339.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,881.60
|
| Rate for Payer: Humana ChoiceCare |
$1,410.24
|
| Rate for Payer: Multiplan All |
$4,935.84
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,254.40
|
| Rate for Payer: OMNI Networks Commercial |
$3,796.80
|
| Rate for Payer: One Health Plan PPO/POS |
$4,881.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,152.80
|
| Rate for Payer: Three Rivers Provider Network All |
$4,068.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,773.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,356.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,044.32
|
| Rate for Payer: Zelis Auto |
$2,169.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,712.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,480.75
|
|
|
GASTROINTESTINAL REPAIR
|
Facility
|
IP
|
$4,999.00
|
|
|
Service Code
|
CPT 43360
|
| Hospital Charge Code |
6143360
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,364.73 |
| Max. Negotiated Rate |
$4,749.05 |
| Rate for Payer: Cash Price |
$2,999.40
|
| Rate for Payer: Cigna Commercial |
$4,249.15
|
| Rate for Payer: First Health Commercial |
$4,499.10
|
| Rate for Payer: First Health Workers Compensation |
$1,930.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,499.10
|
| Rate for Payer: GEHA Commercial |
$3,499.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,499.10
|
| Rate for Payer: Multiplan All |
$4,549.09
|
| Rate for Payer: OMNI Networks Commercial |
$3,499.30
|
| Rate for Payer: One Health Plan PPO/POS |
$4,499.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,749.05
|
| Rate for Payer: Three Rivers Provider Network All |
$3,749.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,649.07
|
| Rate for Payer: Zelis Auto |
$1,999.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1,364.73
|
|
|
gastrointestinl prof stool pcr REF183480
|
Facility
|
OP
|
$1,358.00
|
|
|
Service Code
|
CPT 87507
|
| Hospital Charge Code |
2299558
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$339.50 |
| Max. Negotiated Rate |
$1,290.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$814.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$416.78
|
| Rate for Payer: Cash Price |
$814.80
|
| Rate for Payer: Cash Price |
$814.80
|
| Rate for Payer: Cigna Commercial |
$1,154.30
|
| Rate for Payer: First Health Commercial |
$1,222.20
|
| Rate for Payer: First Health Workers Compensation |
$547.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,222.20
|
| Rate for Payer: GEHA Commercial |
$1,086.40
|
| Rate for Payer: GEHA Medicare |
$416.78
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,222.20
|
| Rate for Payer: Humana ChoiceCare |
$458.46
|
| Rate for Payer: Humana Medicare Advantage |
$416.78
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$700.19
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$416.78
|
| Rate for Payer: Multiplan All |
$1,235.78
|
| Rate for Payer: New Mexico Health Connections Medicare |
$708.53
|
| Rate for Payer: OMNI Networks Commercial |
$950.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,222.20
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$416.78
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,290.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$833.56
|
| Rate for Payer: Three Rivers Provider Network All |
$1,018.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$408.44
|
| Rate for Payer: United Healthcare Commercial |
$1,154.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$339.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$416.78
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,262.94
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$416.78
|
| Rate for Payer: Zelis Auto |
$543.20
|
| Rate for Payer: Zelis Medicare |
$354.26
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$500.14
|
| Rate for Payer: Zelis Worker's Compensation |
$387.00
|
|
|
gastrointestinl prof stool pcr REF183480
|
Facility
|
IP
|
$1,358.00
|
|
|
Service Code
|
CPT 87507
|
| Hospital Charge Code |
2299558
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$387.00 |
| Max. Negotiated Rate |
$1,290.10 |
| Rate for Payer: Cash Price |
$814.80
|
| Rate for Payer: Cash Price |
$814.80
|
| Rate for Payer: Cigna Commercial |
$1,154.30
|
| Rate for Payer: First Health Commercial |
$1,222.20
|
| Rate for Payer: First Health Workers Compensation |
$547.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,222.20
|
| Rate for Payer: GEHA Commercial |
$950.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,222.20
|
| Rate for Payer: Multiplan All |
$1,235.78
|
| Rate for Payer: OMNI Networks Commercial |
$950.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,222.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,290.10
|
| Rate for Payer: Three Rivers Provider Network All |
$1,018.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,262.94
|
| Rate for Payer: Zelis Auto |
$543.20
|
| Rate for Payer: Zelis Worker's Compensation |
$387.00
|
|
