|
GEMCITABINE 1 GM/26.3 ML INJ
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
3303029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$8.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$100.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$8.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$6.51
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$64.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$3.44
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Humana ChoiceCare |
$43.68
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$6.64
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$100.80
|
| Rate for Payer: OMNI Networks Commercial |
$117.60
|
| Rate for Payer: One Health Plan PPO/POS |
$151.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$7.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$6.64
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$147.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.64
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$84.00
|
| Rate for Payer: Zelis Worker's Compensation |
$45.86
|
|
|
GEMCITABINE 1 GM POWDER
|
Facility
|
OP
|
$260.00
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
3303236
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$247.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$8.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$156.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$8.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$6.51
|
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cigna Commercial |
$221.00
|
| Rate for Payer: First Health Commercial |
$234.00
|
| Rate for Payer: First Health Workers Compensation |
$100.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$234.00
|
| Rate for Payer: GEHA Commercial |
$3.44
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$234.00
|
| Rate for Payer: Humana ChoiceCare |
$67.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$6.64
|
| Rate for Payer: Multiplan All |
$236.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$156.00
|
| Rate for Payer: OMNI Networks Commercial |
$182.00
|
| Rate for Payer: One Health Plan PPO/POS |
$234.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$7.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$6.64
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$247.00
|
| Rate for Payer: Three Rivers Provider Network All |
$195.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$228.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.64
|
| Rate for Payer: United Payors & United Providers UP&UP |
$241.80
|
| Rate for Payer: Zelis Auto |
$104.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$130.00
|
| Rate for Payer: Zelis Worker's Compensation |
$70.98
|
|
|
GEMCITABINE 1 GM POWDER
|
Facility
|
IP
|
$260.00
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
3303236
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.98 |
| Max. Negotiated Rate |
$247.00 |
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cigna Commercial |
$221.00
|
| Rate for Payer: First Health Commercial |
$234.00
|
| Rate for Payer: First Health Workers Compensation |
$100.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$234.00
|
| Rate for Payer: GEHA Commercial |
$182.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$234.00
|
| Rate for Payer: Multiplan All |
$236.60
|
| Rate for Payer: OMNI Networks Commercial |
$182.00
|
| Rate for Payer: One Health Plan PPO/POS |
$234.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$247.00
|
| Rate for Payer: Three Rivers Provider Network All |
$195.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$241.80
|
| Rate for Payer: Zelis Auto |
$104.00
|
| Rate for Payer: Zelis Worker's Compensation |
$70.98
|
|
|
GEMFIBROZIL TAB 600MG
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 50268035015
|
| Hospital Charge Code |
3300376
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$8.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Humana ChoiceCare |
$2.86
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.60
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
GEMFIBROZIL TAB 600MG
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 50268035015
|
| Hospital Charge Code |
3300376
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$7.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
GENERAL HEALTH PANEL
|
Facility
|
OP
|
$710.00
|
|
|
Service Code
|
CPT 80050
|
| Hospital Charge Code |
2280050
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$36.78 |
| Max. Negotiated Rate |
$674.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$426.00
|
| Rate for Payer: Cash Price |
$426.00
|
| Rate for Payer: Cash Price |
$426.00
|
| Rate for Payer: Cigna Commercial |
$603.50
|
| Rate for Payer: First Health Commercial |
$639.00
|
| Rate for Payer: First Health Workers Compensation |
$52.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$639.00
|
| Rate for Payer: GEHA Commercial |
$568.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$639.00
|
| Rate for Payer: Humana ChoiceCare |
$184.60
|
| Rate for Payer: Multiplan All |
$646.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$426.00
|
| Rate for Payer: OMNI Networks Commercial |
$497.00
|
| Rate for Payer: One Health Plan PPO/POS |
$639.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$674.50
|
| Rate for Payer: Three Rivers Provider Network All |
$532.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$624.80
|
| Rate for Payer: United Healthcare Commercial |
$603.50
|
| Rate for Payer: United Healthcare Managed Medicaid |
$177.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$660.30
|
| Rate for Payer: Zelis Auto |
$284.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$355.00
|
| Rate for Payer: Zelis Worker's Compensation |
$36.78
|
|
|
GENERAL HEALTH PANEL
|
Facility
|
IP
|
$710.00
|
|
|
Service Code
|
CPT 80050
|
| Hospital Charge Code |
2280050
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$36.78 |
| Max. Negotiated Rate |
$674.50 |
| Rate for Payer: Cash Price |
$426.00
|
| Rate for Payer: Cash Price |
$426.00
|
| Rate for Payer: Cigna Commercial |
$603.50
|
| Rate for Payer: First Health Commercial |
$639.00
|
| Rate for Payer: First Health Workers Compensation |
$52.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$639.00
|
| Rate for Payer: GEHA Commercial |
$497.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$639.00
|
| Rate for Payer: Multiplan All |
$646.10
|
| Rate for Payer: OMNI Networks Commercial |
$497.00
|
| Rate for Payer: One Health Plan PPO/POS |
$639.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$674.50
|
| Rate for Payer: Three Rivers Provider Network All |
$532.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$660.30
|
| Rate for Payer: Zelis Auto |
$284.00
|
| Rate for Payer: Zelis Worker's Compensation |
$36.78
|
|
|
GENERATOR, NEUROSTIMULATOR
|
Facility
|
IP
|
$63,585.33
|
|
|
Service Code
|
CPT C1767
|
| Hospital Charge Code |
7002709
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$25,434.13 |
| Max. Negotiated Rate |
$60,406.06 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$50,868.26
|
| Rate for Payer: Cash Price |
$38,151.20
|
| Rate for Payer: Cash Price |
$38,151.20
|
| Rate for Payer: Cigna Commercial |
$54,047.53
|
| Rate for Payer: First Health Commercial |
$57,226.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$57,226.80
|
| Rate for Payer: GEHA Commercial |
$44,509.73
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$57,226.80
|
| Rate for Payer: Multiplan All |
$57,862.65
|
| Rate for Payer: OMNI Networks Commercial |
$44,509.73
|
| Rate for Payer: One Health Plan PPO/POS |
$57,226.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$60,406.06
|
| Rate for Payer: Three Rivers Provider Network All |
$47,689.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$59,134.36
|
| Rate for Payer: Zelis Auto |
$25,434.13
|
|
|
GENERATOR, NEUROSTIMULATOR
|
Facility
|
OP
|
$63,585.33
|
|
|
Service Code
|
CPT C1767
|
| Hospital Charge Code |
7002709
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$15,896.33 |
| Max. Negotiated Rate |
$60,406.06 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$38,151.20
|
| Rate for Payer: Cash Price |
$38,151.20
|
| Rate for Payer: Cash Price |
$38,151.20
|
| Rate for Payer: Cigna Commercial |
$54,047.53
|
| Rate for Payer: First Health Commercial |
$57,226.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$57,226.80
|
| Rate for Payer: GEHA Commercial |
$50,868.26
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$57,226.80
|
| Rate for Payer: Humana ChoiceCare |
$16,532.19
|
| Rate for Payer: Multiplan All |
$57,862.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$38,151.20
|
| Rate for Payer: OMNI Networks Commercial |
$44,509.73
|
| Rate for Payer: One Health Plan PPO/POS |
$57,226.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$60,406.06
|
| Rate for Payer: Three Rivers Provider Network All |
$47,689.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$55,955.09
|
| Rate for Payer: United Healthcare Managed Medicaid |
$15,896.33
|
| Rate for Payer: United Payors & United Providers UP&UP |
$59,134.36
|
| Rate for Payer: Zelis Auto |
$25,434.13
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$31,792.67
|
|
|
genital mycoplasma, naa swab REF180089
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
CPT 87563
|
| Hospital Charge Code |
2200761
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.55 |
| Max. Negotiated Rate |
$215.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$52.63
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$136.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$52.63
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$41.70
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$35.09
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cigna Commercial |
$192.95
|
| Rate for Payer: First Health Commercial |
$204.30
|
| Rate for Payer: First Health Workers Compensation |
$40.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$204.30
|
| Rate for Payer: GEHA Commercial |
$181.60
|
| Rate for Payer: GEHA Medicare |
$35.09
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$204.30
|
| Rate for Payer: Humana ChoiceCare |
$38.60
|
| Rate for Payer: Humana Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$58.95
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$42.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$35.09
|
| Rate for Payer: Multiplan All |
$206.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$59.65
|
| Rate for Payer: OMNI Networks Commercial |
$158.90
|
| Rate for Payer: One Health Plan PPO/POS |
$204.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$49.13
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$42.55
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$35.09
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$215.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$70.18
|
| Rate for Payer: Three Rivers Provider Network All |
$170.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$34.39
|
| Rate for Payer: United Healthcare Commercial |
$192.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$42.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Payors & United Providers UP&UP |
$211.11
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$35.09
|
| Rate for Payer: Zelis Auto |
$90.80
|
| Rate for Payer: Zelis Medicare |
$29.83
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$42.11
|
| Rate for Payer: Zelis Worker's Compensation |
$28.55
|
|
|
genital mycoplasma, naa swab REF180089
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
CPT 87563
|
| Hospital Charge Code |
2200761
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.55 |
| Max. Negotiated Rate |
$215.65 |
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cigna Commercial |
$192.95
|
| Rate for Payer: First Health Commercial |
$204.30
|
| Rate for Payer: First Health Workers Compensation |
$40.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$204.30
|
| Rate for Payer: GEHA Commercial |
$158.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$204.30
|
| Rate for Payer: Multiplan All |
$206.57
|
| Rate for Payer: OMNI Networks Commercial |
$158.90
|
| Rate for Payer: One Health Plan PPO/POS |
$204.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$215.65
|
| Rate for Payer: Three Rivers Provider Network All |
$170.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$211.11
|
| Rate for Payer: Zelis Auto |
$90.80
|
| Rate for Payer: Zelis Worker's Compensation |
$28.55
|
|
|
genital mycoplasma naa, urine REF180040
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
CPT 87563
|
| Hospital Charge Code |
2200813
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.55 |
| Max. Negotiated Rate |
$215.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$52.63
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$136.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$52.63
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$41.70
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$35.09
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cigna Commercial |
$192.95
|
| Rate for Payer: First Health Commercial |
$204.30
|
| Rate for Payer: First Health Workers Compensation |
$40.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$204.30
|
| Rate for Payer: GEHA Commercial |
$181.60
|
| Rate for Payer: GEHA Medicare |
$35.09
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$204.30
|
| Rate for Payer: Humana ChoiceCare |
$38.60
|
| Rate for Payer: Humana Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$58.95
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$42.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$35.09
|
| Rate for Payer: Multiplan All |
$206.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$59.65
|
| Rate for Payer: OMNI Networks Commercial |
$158.90
|
| Rate for Payer: One Health Plan PPO/POS |
$204.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$49.13
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$42.55
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$35.09
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$215.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$70.18
|
| Rate for Payer: Three Rivers Provider Network All |
$170.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$34.39
|
| Rate for Payer: United Healthcare Commercial |
$192.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$42.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Payors & United Providers UP&UP |
$211.11
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$35.09
|
| Rate for Payer: Zelis Auto |
$90.80
|
| Rate for Payer: Zelis Medicare |
$29.83
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$42.11
|
| Rate for Payer: Zelis Worker's Compensation |
$28.55
|
|
|
genital mycoplasma naa, urine REF180040
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
CPT 87563
|
| Hospital Charge Code |
2200813
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.55 |
| Max. Negotiated Rate |
$215.65 |
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cigna Commercial |
$192.95
|
| Rate for Payer: First Health Commercial |
$204.30
|
| Rate for Payer: First Health Workers Compensation |
$40.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$204.30
|
| Rate for Payer: GEHA Commercial |
$158.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$204.30
|
| Rate for Payer: Multiplan All |
$206.57
|
| Rate for Payer: OMNI Networks Commercial |
$158.90
|
| Rate for Payer: One Health Plan PPO/POS |
$204.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$215.65
|
| Rate for Payer: Three Rivers Provider Network All |
$170.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$211.11
|
| Rate for Payer: Zelis Auto |
$90.80
|
| Rate for Payer: Zelis Worker's Compensation |
$28.55
|
|
|
GENTAMICIN 800 MG/20 ML VIAL (FOR IVPB)
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
CPT J1580
|
| Hospital Charge Code |
3302838
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.13 |
| Max. Negotiated Rate |
$150.10 |
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cigna Commercial |
$134.30
|
| Rate for Payer: First Health Commercial |
$142.20
|
| Rate for Payer: First Health Workers Compensation |
$61.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$142.20
|
| Rate for Payer: GEHA Commercial |
$110.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$142.20
|
| Rate for Payer: Multiplan All |
$143.78
|
| Rate for Payer: OMNI Networks Commercial |
$110.60
|
| Rate for Payer: One Health Plan PPO/POS |
$142.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$150.10
|
| Rate for Payer: Three Rivers Provider Network All |
$118.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$146.94
|
| Rate for Payer: Zelis Auto |
$63.20
|
| Rate for Payer: Zelis Worker's Compensation |
$43.13
|
|
|
GENTAMICIN 800 MG/20 ML VIAL (FOR IVPB)
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
CPT J1580
|
| Hospital Charge Code |
3302838
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$150.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$94.80
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cigna Commercial |
$134.30
|
| Rate for Payer: First Health Commercial |
$142.20
|
| Rate for Payer: First Health Workers Compensation |
$61.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$142.20
|
| Rate for Payer: GEHA Commercial |
$2.43
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$142.20
|
| Rate for Payer: Humana ChoiceCare |
$41.08
|
| Rate for Payer: Multiplan All |
$143.78
|
| Rate for Payer: New Mexico Health Connections Medicare |
$94.80
|
| Rate for Payer: OMNI Networks Commercial |
$110.60
|
| Rate for Payer: One Health Plan PPO/POS |
$142.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$150.10
|
| Rate for Payer: Three Rivers Provider Network All |
$118.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$139.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$39.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$146.94
|
| Rate for Payer: Zelis Auto |
$63.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$79.00
|
| Rate for Payer: Zelis Worker's Compensation |
$43.13
|
|
|
gentamicin peak REF007162
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
2200493
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.43 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$30.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$152.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Worker's Compensation |
$21.43
|
|
|
gentamicin peak REF007162
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
2200493
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.92 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$29.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$29.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$23.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$16.38
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$30.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$174.40
|
| Rate for Payer: GEHA Medicare |
$16.38
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Humana ChoiceCare |
$18.02
|
| Rate for Payer: Humana Medicare Advantage |
$16.38
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$27.52
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$23.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$16.38
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.85
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$27.52
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$23.84
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$16.38
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$32.76
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16.05
|
| Rate for Payer: United Healthcare Commercial |
$185.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$23.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.38
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$16.38
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Medicare |
$13.92
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$19.66
|
| Rate for Payer: Zelis Worker's Compensation |
$21.43
|
|
|
gentamicin random REF007161
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
2200494
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.43 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$30.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$152.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Worker's Compensation |
$21.43
|
|
|
gentamicin random REF007161
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
2200494
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.92 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$29.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$29.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$23.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$16.38
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$30.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$174.40
|
| Rate for Payer: GEHA Medicare |
$16.38
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Humana ChoiceCare |
$18.02
|
| Rate for Payer: Humana Medicare Advantage |
$16.38
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$27.52
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$23.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$16.38
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.85
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$27.52
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$23.84
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$16.38
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$32.76
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16.05
|
| Rate for Payer: United Healthcare Commercial |
$185.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$23.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.38
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$16.38
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Medicare |
$13.92
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$19.66
|
| Rate for Payer: Zelis Worker's Compensation |
$21.43
|
|
|
GENTAMICIN SULF 0.1% OINT 15 GM
|
Facility
|
OP
|
$244.00
|
|
|
Service Code
|
NDC 00713068215
|
| Hospital Charge Code |
3302891
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.00 |
| Max. Negotiated Rate |
$231.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$146.40
|
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cigna Commercial |
$207.40
|
| Rate for Payer: First Health Commercial |
$219.60
|
| Rate for Payer: First Health Workers Compensation |
$94.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$219.60
|
| Rate for Payer: GEHA Commercial |
$195.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$219.60
|
| Rate for Payer: Humana ChoiceCare |
$63.44
|
| Rate for Payer: Multiplan All |
$222.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$146.40
|
| Rate for Payer: OMNI Networks Commercial |
$170.80
|
| Rate for Payer: One Health Plan PPO/POS |
$219.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$231.80
|
| Rate for Payer: Three Rivers Provider Network All |
$183.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$214.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$61.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$226.92
|
| Rate for Payer: Zelis Auto |
$97.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$122.00
|
| Rate for Payer: Zelis Worker's Compensation |
$66.61
|
|
|
GENTAMICIN SULF 0.1% OINT 15 GM
|
Facility
|
IP
|
$244.00
|
|
|
Service Code
|
NDC 00713068215
|
| Hospital Charge Code |
3302891
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$66.61 |
| Max. Negotiated Rate |
$231.80 |
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cigna Commercial |
$207.40
|
| Rate for Payer: First Health Commercial |
$219.60
|
| Rate for Payer: First Health Workers Compensation |
$94.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$219.60
|
| Rate for Payer: GEHA Commercial |
$170.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$219.60
|
| Rate for Payer: Multiplan All |
$222.04
|
| Rate for Payer: OMNI Networks Commercial |
$170.80
|
| Rate for Payer: One Health Plan PPO/POS |
$219.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$231.80
|
| Rate for Payer: Three Rivers Provider Network All |
$183.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$226.92
|
| Rate for Payer: Zelis Auto |
$97.60
|
| Rate for Payer: Zelis Worker's Compensation |
$66.61
|
|
|
GENTAMICIN SULF 0.3% OPHTH OINT
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
NDC 17478028435
|
| Hospital Charge Code |
3300379
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.00 |
| Max. Negotiated Rate |
$110.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$69.60
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cigna Commercial |
$98.60
|
| Rate for Payer: First Health Commercial |
$104.40
|
| Rate for Payer: First Health Workers Compensation |
$44.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$104.40
|
| Rate for Payer: GEHA Commercial |
$92.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$104.40
|
| Rate for Payer: Humana ChoiceCare |
$30.16
|
| Rate for Payer: Multiplan All |
$105.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$69.60
|
| Rate for Payer: OMNI Networks Commercial |
$81.20
|
| Rate for Payer: One Health Plan PPO/POS |
$104.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$110.20
|
| Rate for Payer: Three Rivers Provider Network All |
$87.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$102.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$29.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$107.88
|
| Rate for Payer: Zelis Auto |
$46.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$58.00
|
| Rate for Payer: Zelis Worker's Compensation |
$31.67
|
|
|
GENTAMICIN SULF 0.3% OPHTH OINT
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
NDC 17478028435
|
| Hospital Charge Code |
3300379
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.67 |
| Max. Negotiated Rate |
$110.20 |
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cigna Commercial |
$98.60
|
| Rate for Payer: First Health Commercial |
$104.40
|
| Rate for Payer: First Health Workers Compensation |
$44.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$104.40
|
| Rate for Payer: GEHA Commercial |
$81.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$104.40
|
| Rate for Payer: Multiplan All |
$105.56
|
| Rate for Payer: OMNI Networks Commercial |
$81.20
|
| Rate for Payer: One Health Plan PPO/POS |
$104.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$110.20
|
| Rate for Payer: Three Rivers Provider Network All |
$87.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$107.88
|
| Rate for Payer: Zelis Auto |
$46.40
|
| Rate for Payer: Zelis Worker's Compensation |
$31.67
|
|
|
GENTAMICIN SULF 0.3% OPHTH SOLN 5 ML
|
Facility
|
OP
|
$122.00
|
|
|
Service Code
|
NDC 24208058060
|
| Hospital Charge Code |
3300380
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.50 |
| Max. Negotiated Rate |
$115.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$103.70
|
| Rate for Payer: First Health Commercial |
$109.80
|
| Rate for Payer: First Health Workers Compensation |
$47.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$109.80
|
| Rate for Payer: GEHA Commercial |
$97.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$109.80
|
| Rate for Payer: Humana ChoiceCare |
$31.72
|
| Rate for Payer: Multiplan All |
$111.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$73.20
|
| Rate for Payer: OMNI Networks Commercial |
$85.40
|
| Rate for Payer: One Health Plan PPO/POS |
$109.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$115.90
|
| Rate for Payer: Three Rivers Provider Network All |
$91.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$107.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$30.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$113.46
|
| Rate for Payer: Zelis Auto |
$48.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$61.00
|
| Rate for Payer: Zelis Worker's Compensation |
$33.31
|
|
|
GENTAMICIN SULF 0.3% OPHTH SOLN 5 ML
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
NDC 24208058060
|
| Hospital Charge Code |
3300380
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.31 |
| Max. Negotiated Rate |
$115.90 |
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$103.70
|
| Rate for Payer: First Health Commercial |
$109.80
|
| Rate for Payer: First Health Workers Compensation |
$47.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$109.80
|
| Rate for Payer: GEHA Commercial |
$85.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$109.80
|
| Rate for Payer: Multiplan All |
$111.02
|
| Rate for Payer: OMNI Networks Commercial |
$85.40
|
| Rate for Payer: One Health Plan PPO/POS |
$109.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$115.90
|
| Rate for Payer: Three Rivers Provider Network All |
$91.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$113.46
|
| Rate for Payer: Zelis Auto |
$48.80
|
| Rate for Payer: Zelis Worker's Compensation |
$33.31
|
|
