|
METHYLENE BLUE INJ 1%
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
CPT Q9968
|
| Hospital Charge Code |
3300578
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$52.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$8.73
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$46.75
|
| Rate for Payer: First Health Commercial |
$49.50
|
| Rate for Payer: First Health Workers Compensation |
$21.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$49.50
|
| Rate for Payer: GEHA Commercial |
$44.00
|
| Rate for Payer: GEHA Medicare |
$8.73
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$49.50
|
| Rate for Payer: Humana ChoiceCare |
$9.60
|
| Rate for Payer: Humana Medicare Advantage |
$8.73
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$14.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2.15
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$8.73
|
| Rate for Payer: Multiplan All |
$50.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$14.84
|
| Rate for Payer: OMNI Networks Commercial |
$38.50
|
| Rate for Payer: One Health Plan PPO/POS |
$49.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2.48
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2.15
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$8.73
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$52.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$17.46
|
| Rate for Payer: Three Rivers Provider Network All |
$41.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.73
|
| Rate for Payer: United Payors & United Providers UP&UP |
$51.15
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$8.73
|
| Rate for Payer: Zelis Auto |
$22.00
|
| Rate for Payer: Zelis Medicare |
$7.42
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.48
|
| Rate for Payer: Zelis Worker's Compensation |
$15.02
|
|
|
METHYLENE BLUE INJ 1%
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
CPT Q9968
|
| Hospital Charge Code |
3300578
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.02 |
| Max. Negotiated Rate |
$52.25 |
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$46.75
|
| Rate for Payer: First Health Commercial |
$49.50
|
| Rate for Payer: First Health Workers Compensation |
$21.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$49.50
|
| Rate for Payer: GEHA Commercial |
$38.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$49.50
|
| Rate for Payer: Multiplan All |
$50.05
|
| Rate for Payer: OMNI Networks Commercial |
$38.50
|
| Rate for Payer: One Health Plan PPO/POS |
$49.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$52.25
|
| Rate for Payer: Three Rivers Provider Network All |
$41.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$51.15
|
| Rate for Payer: Zelis Auto |
$22.00
|
| Rate for Payer: Zelis Worker's Compensation |
$15.02
|
|
|
METHYLERGONOVINE INJ 0.2MG/ML
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
CPT J2210
|
| Hospital Charge Code |
3300579
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$51.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$45.90
|
| Rate for Payer: First Health Commercial |
$48.60
|
| Rate for Payer: First Health Workers Compensation |
$20.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$48.60
|
| Rate for Payer: GEHA Commercial |
$22.79
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$48.60
|
| Rate for Payer: Humana ChoiceCare |
$14.04
|
| Rate for Payer: Multiplan All |
$49.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$32.40
|
| Rate for Payer: OMNI Networks Commercial |
$37.80
|
| Rate for Payer: One Health Plan PPO/POS |
$48.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$51.30
|
| Rate for Payer: Three Rivers Provider Network All |
$40.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$47.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$50.22
|
| Rate for Payer: Zelis Auto |
$21.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$27.00
|
| Rate for Payer: Zelis Worker's Compensation |
$14.74
|
|
|
METHYLERGONOVINE INJ 0.2MG/ML
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
CPT J2210
|
| Hospital Charge Code |
3300579
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.74 |
| Max. Negotiated Rate |
$51.30 |
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$45.90
|
| Rate for Payer: First Health Commercial |
$48.60
|
| Rate for Payer: First Health Workers Compensation |
$20.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$48.60
|
| Rate for Payer: GEHA Commercial |
$37.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$48.60
|
| Rate for Payer: Multiplan All |
$49.14
|
| Rate for Payer: OMNI Networks Commercial |
$37.80
|
| Rate for Payer: One Health Plan PPO/POS |
$48.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$51.30
|
| Rate for Payer: Three Rivers Provider Network All |
$40.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$50.22
|
| Rate for Payer: Zelis Auto |
$21.60
|
| Rate for Payer: Zelis Worker's Compensation |
$14.74
|
|
|
MethylLPREDNISolone IM 80MG/ML (DEPO)
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
CPT J1010
|
| Hospital Charge Code |
3300581
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$109.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$69.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$0.12
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cigna Commercial |
$97.75
|
| Rate for Payer: First Health Commercial |
$103.50
|
| Rate for Payer: First Health Workers Compensation |
$44.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$103.50
|
| Rate for Payer: GEHA Commercial |
$0.13
|
| Rate for Payer: GEHA Medicare |
$0.12
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$103.50
|
| Rate for Payer: Humana ChoiceCare |
$0.13
|
| Rate for Payer: Humana Medicare Advantage |
$0.12
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$0.20
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$0.12
|
| Rate for Payer: Multiplan All |
$104.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.20
|
| Rate for Payer: OMNI Networks Commercial |
$80.50
|
| Rate for Payer: One Health Plan PPO/POS |
$103.50
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$0.12
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$109.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$0.24
|
| Rate for Payer: Three Rivers Provider Network All |
$86.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$28.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.12
|
| Rate for Payer: United Payors & United Providers UP&UP |
$106.95
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$0.12
|
| Rate for Payer: Zelis Auto |
$46.00
|
| Rate for Payer: Zelis Medicare |
$0.10
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.14
|
| Rate for Payer: Zelis Worker's Compensation |
$31.39
|
|
|
MethylLPREDNISolone IM 80MG/ML (DEPO)
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
CPT J1010
|
| Hospital Charge Code |
3300581
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.39 |
| Max. Negotiated Rate |
$109.25 |
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cigna Commercial |
$97.75
|
| Rate for Payer: First Health Commercial |
$103.50
|
| Rate for Payer: First Health Workers Compensation |
$44.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$103.50
|
| Rate for Payer: GEHA Commercial |
$80.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$103.50
|
| Rate for Payer: Multiplan All |
$104.65
|
| Rate for Payer: OMNI Networks Commercial |
$80.50
|
| Rate for Payer: One Health Plan PPO/POS |
$103.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$109.25
|
| Rate for Payer: Three Rivers Provider Network All |
$86.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$106.95
|
| Rate for Payer: Zelis Auto |
$46.00
|
| Rate for Payer: Zelis Worker's Compensation |
$31.39
|
|
|
methylmalonic acid REF706961
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
CPT 83921
|
| Hospital Charge Code |
2299303
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.03 |
| Max. Negotiated Rate |
$237.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$38.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$150.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$38.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$30.24
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$21.21
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$212.50
|
| Rate for Payer: First Health Commercial |
$225.00
|
| Rate for Payer: First Health Workers Compensation |
$28.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$225.00
|
| Rate for Payer: GEHA Commercial |
$200.00
|
| Rate for Payer: GEHA Medicare |
$21.21
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$225.00
|
| Rate for Payer: Humana ChoiceCare |
$23.33
|
| Rate for Payer: Humana Medicare Advantage |
$21.21
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$35.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$30.86
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$21.21
|
| Rate for Payer: Multiplan All |
$227.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$36.06
|
| Rate for Payer: OMNI Networks Commercial |
$175.00
|
| Rate for Payer: One Health Plan PPO/POS |
$225.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$35.63
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$30.86
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$21.21
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$237.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$42.42
|
| Rate for Payer: Three Rivers Provider Network All |
$187.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$20.79
|
| Rate for Payer: United Healthcare Commercial |
$212.50
|
| Rate for Payer: United Healthcare Managed Medicaid |
$30.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.21
|
| Rate for Payer: United Payors & United Providers UP&UP |
$232.50
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$21.21
|
| Rate for Payer: Zelis Auto |
$100.00
|
| Rate for Payer: Zelis Medicare |
$18.03
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$25.45
|
| Rate for Payer: Zelis Worker's Compensation |
$20.38
|
|
|
methylmalonic acid REF706961
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
CPT 83921
|
| Hospital Charge Code |
2299303
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.38 |
| Max. Negotiated Rate |
$237.50 |
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$212.50
|
| Rate for Payer: First Health Commercial |
$225.00
|
| Rate for Payer: First Health Workers Compensation |
$28.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$225.00
|
| Rate for Payer: GEHA Commercial |
$175.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$225.00
|
| Rate for Payer: Multiplan All |
$227.50
|
| Rate for Payer: OMNI Networks Commercial |
$175.00
|
| Rate for Payer: One Health Plan PPO/POS |
$225.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$237.50
|
| Rate for Payer: Three Rivers Provider Network All |
$187.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$232.50
|
| Rate for Payer: Zelis Auto |
$100.00
|
| Rate for Payer: Zelis Worker's Compensation |
$20.38
|
|
|
METHYLNALTREXONE 12 MG/0.6 ML INJ
|
Facility
|
OP
|
$841.00
|
|
|
Service Code
|
CPT J2212
|
| Hospital Charge Code |
3303148
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$798.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$0.56
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$504.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$0.56
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$0.44
|
| Rate for Payer: Cash Price |
$504.60
|
| Rate for Payer: Cash Price |
$504.60
|
| Rate for Payer: Cigna Commercial |
$714.85
|
| Rate for Payer: First Health Commercial |
$756.90
|
| Rate for Payer: First Health Workers Compensation |
$324.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$756.90
|
| Rate for Payer: GEHA Commercial |
$672.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$756.90
|
| Rate for Payer: Humana ChoiceCare |
$218.66
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$0.45
|
| Rate for Payer: Multiplan All |
$765.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$504.60
|
| Rate for Payer: OMNI Networks Commercial |
$588.70
|
| Rate for Payer: One Health Plan PPO/POS |
$756.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$0.52
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$0.45
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$798.95
|
| Rate for Payer: Three Rivers Provider Network All |
$630.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$740.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$782.13
|
| Rate for Payer: Zelis Auto |
$336.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$420.50
|
| Rate for Payer: Zelis Worker's Compensation |
$229.59
|
|
|
METHYLNALTREXONE 12 MG/0.6 ML INJ
|
Facility
|
IP
|
$841.00
|
|
|
Service Code
|
CPT J2212
|
| Hospital Charge Code |
3303148
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$229.59 |
| Max. Negotiated Rate |
$798.95 |
| Rate for Payer: Cash Price |
$504.60
|
| Rate for Payer: Cigna Commercial |
$714.85
|
| Rate for Payer: First Health Commercial |
$756.90
|
| Rate for Payer: First Health Workers Compensation |
$324.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$756.90
|
| Rate for Payer: GEHA Commercial |
$588.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$756.90
|
| Rate for Payer: Multiplan All |
$765.31
|
| Rate for Payer: OMNI Networks Commercial |
$588.70
|
| Rate for Payer: One Health Plan PPO/POS |
$756.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$798.95
|
| Rate for Payer: Three Rivers Provider Network All |
$630.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$782.13
|
| Rate for Payer: Zelis Auto |
$336.40
|
| Rate for Payer: Zelis Worker's Compensation |
$229.59
|
|
|
METHYLPHENIDATE HCL 10MG TAB
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 68084082321
|
| Hospital Charge Code |
3302285
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: First Health Commercial |
$12.60
|
| Rate for Payer: First Health Workers Compensation |
$5.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12.60
|
| Rate for Payer: GEHA Commercial |
$9.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12.60
|
| Rate for Payer: Multiplan All |
$12.74
|
| Rate for Payer: OMNI Networks Commercial |
$9.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.02
|
| Rate for Payer: Zelis Auto |
$5.60
|
| Rate for Payer: Zelis Worker's Compensation |
$3.82
|
|
|
METHYLPHENIDATE HCL 10MG TAB
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 68084082321
|
| Hospital Charge Code |
3302285
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: First Health Commercial |
$12.60
|
| Rate for Payer: First Health Workers Compensation |
$5.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12.60
|
| Rate for Payer: GEHA Commercial |
$11.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12.60
|
| Rate for Payer: Humana ChoiceCare |
$3.64
|
| Rate for Payer: Multiplan All |
$12.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.40
|
| Rate for Payer: OMNI Networks Commercial |
$9.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.02
|
| Rate for Payer: Zelis Auto |
$5.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.82
|
|
|
MethylPREDNISolone 125 MG IV, INJ
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
CPT J2919
|
| Hospital Charge Code |
3300583
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.56 |
| Max. Negotiated Rate |
$64.60 |
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cigna Commercial |
$57.80
|
| Rate for Payer: First Health Commercial |
$61.20
|
| Rate for Payer: First Health Workers Compensation |
$26.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$61.20
|
| Rate for Payer: GEHA Commercial |
$47.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$61.20
|
| Rate for Payer: Multiplan All |
$61.88
|
| Rate for Payer: OMNI Networks Commercial |
$47.60
|
| Rate for Payer: One Health Plan PPO/POS |
$61.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$64.60
|
| Rate for Payer: Three Rivers Provider Network All |
$51.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$63.24
|
| Rate for Payer: Zelis Auto |
$27.20
|
| Rate for Payer: Zelis Worker's Compensation |
$18.56
|
|
|
MethylPREDNISolone 125 MG IV, INJ
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
CPT J2919
|
| Hospital Charge Code |
3300583
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$64.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$40.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$0.21
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cigna Commercial |
$57.80
|
| Rate for Payer: First Health Commercial |
$61.20
|
| Rate for Payer: First Health Workers Compensation |
$26.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$61.20
|
| Rate for Payer: GEHA Commercial |
$0.23
|
| Rate for Payer: GEHA Medicare |
$0.21
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$61.20
|
| Rate for Payer: Humana ChoiceCare |
$0.23
|
| Rate for Payer: Humana Medicare Advantage |
$0.21
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$0.35
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$0.21
|
| Rate for Payer: Multiplan All |
$61.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.36
|
| Rate for Payer: OMNI Networks Commercial |
$47.60
|
| Rate for Payer: One Health Plan PPO/POS |
$61.20
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$0.21
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$64.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$0.42
|
| Rate for Payer: Three Rivers Provider Network All |
$51.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.21
|
| Rate for Payer: United Healthcare Managed Medicaid |
$17.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.21
|
| Rate for Payer: United Payors & United Providers UP&UP |
$63.24
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$0.21
|
| Rate for Payer: Zelis Auto |
$27.20
|
| Rate for Payer: Zelis Medicare |
$0.18
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.25
|
| Rate for Payer: Zelis Worker's Compensation |
$18.56
|
|
|
MethylPREDNISolone 40 MG IV, INJ
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT J2919
|
| Hospital Charge Code |
3300584
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$0.21
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$0.23
|
| Rate for Payer: GEHA Medicare |
$0.21
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Humana ChoiceCare |
$0.23
|
| Rate for Payer: Humana Medicare Advantage |
$0.21
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$0.35
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$0.21
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.36
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$0.21
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$0.42
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.21
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.21
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$0.21
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Medicare |
$0.18
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.25
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
MethylPREDNISolone 40 MG IV, INJ
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT J2919
|
| Hospital Charge Code |
3300584
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.56 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$32.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
MethylPREDNISolone 4 MG TAB
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
CPT J7509
|
| Hospital Charge Code |
3300585
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.55 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$11.05
|
| Rate for Payer: First Health Commercial |
$11.70
|
| Rate for Payer: First Health Workers Compensation |
$5.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11.70
|
| Rate for Payer: GEHA Commercial |
$9.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11.70
|
| Rate for Payer: Multiplan All |
$11.83
|
| Rate for Payer: OMNI Networks Commercial |
$9.10
|
| Rate for Payer: One Health Plan PPO/POS |
$11.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12.35
|
| Rate for Payer: Three Rivers Provider Network All |
$9.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12.09
|
| Rate for Payer: Zelis Auto |
$5.20
|
| Rate for Payer: Zelis Worker's Compensation |
$3.55
|
|
|
MethylPREDNISolone 4 MG TAB
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
CPT J7509
|
| Hospital Charge Code |
3300585
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$11.05
|
| Rate for Payer: First Health Commercial |
$11.70
|
| Rate for Payer: First Health Workers Compensation |
$5.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11.70
|
| Rate for Payer: GEHA Commercial |
$0.12
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11.70
|
| Rate for Payer: Humana ChoiceCare |
$3.38
|
| Rate for Payer: Multiplan All |
$11.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.80
|
| Rate for Payer: OMNI Networks Commercial |
$9.10
|
| Rate for Payer: One Health Plan PPO/POS |
$11.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12.35
|
| Rate for Payer: Three Rivers Provider Network All |
$9.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12.09
|
| Rate for Payer: Zelis Auto |
$5.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.55
|
|
|
MethylPREDNISolone 4 MG TAB DOSE PACK
|
Facility
|
OP
|
$157.00
|
|
|
Service Code
|
CPT J7509
|
| Hospital Charge Code |
3300586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$149.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$94.20
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cigna Commercial |
$133.45
|
| Rate for Payer: First Health Commercial |
$141.30
|
| Rate for Payer: First Health Workers Compensation |
$60.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$141.30
|
| Rate for Payer: GEHA Commercial |
$0.12
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$141.30
|
| Rate for Payer: Humana ChoiceCare |
$40.82
|
| Rate for Payer: Multiplan All |
$142.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$94.20
|
| Rate for Payer: OMNI Networks Commercial |
$109.90
|
| Rate for Payer: One Health Plan PPO/POS |
$141.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$149.15
|
| Rate for Payer: Three Rivers Provider Network All |
$117.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$138.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$39.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$146.01
|
| Rate for Payer: Zelis Auto |
$62.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$78.50
|
| Rate for Payer: Zelis Worker's Compensation |
$42.86
|
|
|
MethylPREDNISolone 4 MG TAB DOSE PACK
|
Facility
|
IP
|
$157.00
|
|
|
Service Code
|
CPT J7509
|
| Hospital Charge Code |
3300586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.86 |
| Max. Negotiated Rate |
$149.15 |
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cigna Commercial |
$133.45
|
| Rate for Payer: First Health Commercial |
$141.30
|
| Rate for Payer: First Health Workers Compensation |
$60.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$141.30
|
| Rate for Payer: GEHA Commercial |
$109.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$141.30
|
| Rate for Payer: Multiplan All |
$142.87
|
| Rate for Payer: OMNI Networks Commercial |
$109.90
|
| Rate for Payer: One Health Plan PPO/POS |
$141.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$149.15
|
| Rate for Payer: Three Rivers Provider Network All |
$117.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$146.01
|
| Rate for Payer: Zelis Auto |
$62.80
|
| Rate for Payer: Zelis Worker's Compensation |
$42.86
|
|
|
MethylPREDNISolone 500 MG VIAL
|
Facility
|
IP
|
$145.00
|
|
|
Service Code
|
CPT J2919
|
| Hospital Charge Code |
3303057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.59 |
| Max. Negotiated Rate |
$137.75 |
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$123.25
|
| Rate for Payer: First Health Commercial |
$130.50
|
| Rate for Payer: First Health Workers Compensation |
$55.98
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$130.50
|
| Rate for Payer: GEHA Commercial |
$101.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$130.50
|
| Rate for Payer: Multiplan All |
$131.95
|
| Rate for Payer: OMNI Networks Commercial |
$101.50
|
| Rate for Payer: One Health Plan PPO/POS |
$130.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$137.75
|
| Rate for Payer: Three Rivers Provider Network All |
$108.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$134.85
|
| Rate for Payer: Zelis Auto |
$58.00
|
| Rate for Payer: Zelis Worker's Compensation |
$39.59
|
|
|
MethylPREDNISolone 500 MG VIAL
|
Facility
|
OP
|
$145.00
|
|
|
Service Code
|
CPT J2919
|
| Hospital Charge Code |
3303057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$137.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$87.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$0.21
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$123.25
|
| Rate for Payer: First Health Commercial |
$130.50
|
| Rate for Payer: First Health Workers Compensation |
$55.98
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$130.50
|
| Rate for Payer: GEHA Commercial |
$0.23
|
| Rate for Payer: GEHA Medicare |
$0.21
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$130.50
|
| Rate for Payer: Humana ChoiceCare |
$0.23
|
| Rate for Payer: Humana Medicare Advantage |
$0.21
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$0.35
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$0.21
|
| Rate for Payer: Multiplan All |
$131.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.36
|
| Rate for Payer: OMNI Networks Commercial |
$101.50
|
| Rate for Payer: One Health Plan PPO/POS |
$130.50
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$0.21
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$137.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$0.42
|
| Rate for Payer: Three Rivers Provider Network All |
$108.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.21
|
| Rate for Payer: United Healthcare Managed Medicaid |
$36.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.21
|
| Rate for Payer: United Payors & United Providers UP&UP |
$134.85
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$0.21
|
| Rate for Payer: Zelis Auto |
$58.00
|
| Rate for Payer: Zelis Medicare |
$0.18
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.25
|
| Rate for Payer: Zelis Worker's Compensation |
$39.59
|
|
|
MethylPREDNISolone Ace 40 MG/ML (DEPO)
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT J1010
|
| Hospital Charge Code |
3300580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.83 |
| Max. Negotiated Rate |
$55.10 |
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$49.30
|
| Rate for Payer: First Health Commercial |
$52.20
|
| Rate for Payer: First Health Workers Compensation |
$22.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$52.20
|
| Rate for Payer: GEHA Commercial |
$40.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$52.20
|
| Rate for Payer: Multiplan All |
$52.78
|
| Rate for Payer: OMNI Networks Commercial |
$40.60
|
| Rate for Payer: One Health Plan PPO/POS |
$52.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$55.10
|
| Rate for Payer: Three Rivers Provider Network All |
$43.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.94
|
| Rate for Payer: Zelis Auto |
$23.20
|
| Rate for Payer: Zelis Worker's Compensation |
$15.83
|
|
|
MethylPREDNISolone Ace 40 MG/ML (DEPO)
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT J1010
|
| Hospital Charge Code |
3300580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$55.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$34.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$0.12
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$49.30
|
| Rate for Payer: First Health Commercial |
$52.20
|
| Rate for Payer: First Health Workers Compensation |
$22.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$52.20
|
| Rate for Payer: GEHA Commercial |
$0.13
|
| Rate for Payer: GEHA Medicare |
$0.12
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$52.20
|
| Rate for Payer: Humana ChoiceCare |
$0.13
|
| Rate for Payer: Humana Medicare Advantage |
$0.12
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$0.20
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$0.12
|
| Rate for Payer: Multiplan All |
$52.78
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.20
|
| Rate for Payer: OMNI Networks Commercial |
$40.60
|
| Rate for Payer: One Health Plan PPO/POS |
$52.20
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$0.12
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$55.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$0.24
|
| Rate for Payer: Three Rivers Provider Network All |
$43.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.12
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.94
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$0.12
|
| Rate for Payer: Zelis Auto |
$23.20
|
| Rate for Payer: Zelis Medicare |
$0.10
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.14
|
| Rate for Payer: Zelis Worker's Compensation |
$15.83
|
|
|
MethylPREDNISolone IVPB 1000 MG VIAL
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
CPT J2919
|
| Hospital Charge Code |
3300582
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.76 |
| Max. Negotiated Rate |
$103.55 |
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cigna Commercial |
$92.65
|
| Rate for Payer: First Health Commercial |
$98.10
|
| Rate for Payer: First Health Workers Compensation |
$42.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$98.10
|
| Rate for Payer: GEHA Commercial |
$76.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$98.10
|
| Rate for Payer: Multiplan All |
$99.19
|
| Rate for Payer: OMNI Networks Commercial |
$76.30
|
| Rate for Payer: One Health Plan PPO/POS |
$98.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$103.55
|
| Rate for Payer: Three Rivers Provider Network All |
$81.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$101.37
|
| Rate for Payer: Zelis Auto |
$43.60
|
| Rate for Payer: Zelis Worker's Compensation |
$29.76
|
|
