|
OCRELIZUMAB 300 MG/10 ML INJ PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J2350
|
| Hospital Charge Code |
3303210
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
OCREVUS IV SOLUTION 300MG/10ML
|
Facility
|
OP
|
$50,243.00
|
|
|
Service Code
|
CPT J2350
|
| Hospital Charge Code |
3302698
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.50 |
| Max. Negotiated Rate |
$47,730.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$107.37
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30,145.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$107.37
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$85.06
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$59.41
|
| Rate for Payer: Cash Price |
$30,145.80
|
| Rate for Payer: Cash Price |
$30,145.80
|
| Rate for Payer: Cigna Commercial |
$42,706.55
|
| Rate for Payer: First Health Commercial |
$45,218.70
|
| Rate for Payer: First Health Workers Compensation |
$19,398.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45,218.70
|
| Rate for Payer: GEHA Commercial |
$65.35
|
| Rate for Payer: GEHA Medicare |
$59.41
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45,218.70
|
| Rate for Payer: Humana ChoiceCare |
$65.35
|
| Rate for Payer: Humana Medicare Advantage |
$59.41
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$99.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$86.79
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$59.41
|
| Rate for Payer: Multiplan All |
$45,721.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$101.00
|
| Rate for Payer: OMNI Networks Commercial |
$35,170.10
|
| Rate for Payer: One Health Plan PPO/POS |
$45,218.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$100.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$86.79
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$59.41
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47,730.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$118.82
|
| Rate for Payer: Three Rivers Provider Network All |
$37,682.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$58.22
|
| Rate for Payer: United Healthcare Managed Medicaid |
$86.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$59.41
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46,725.99
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$59.41
|
| Rate for Payer: Zelis Auto |
$20,097.20
|
| Rate for Payer: Zelis Medicare |
$50.50
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$71.29
|
| Rate for Payer: Zelis Worker's Compensation |
$13,716.34
|
|
|
OCREVUS IV SOLUTION 300MG/10ML
|
Facility
|
IP
|
$50,243.00
|
|
|
Service Code
|
CPT J2350
|
| Hospital Charge Code |
3302698
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13,716.34 |
| Max. Negotiated Rate |
$47,730.85 |
| Rate for Payer: Cash Price |
$30,145.80
|
| Rate for Payer: Cigna Commercial |
$42,706.55
|
| Rate for Payer: First Health Commercial |
$45,218.70
|
| Rate for Payer: First Health Workers Compensation |
$19,398.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45,218.70
|
| Rate for Payer: GEHA Commercial |
$35,170.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45,218.70
|
| Rate for Payer: Multiplan All |
$45,721.13
|
| Rate for Payer: OMNI Networks Commercial |
$35,170.10
|
| Rate for Payer: One Health Plan PPO/POS |
$45,218.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47,730.85
|
| Rate for Payer: Three Rivers Provider Network All |
$37,682.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46,725.99
|
| Rate for Payer: Zelis Auto |
$20,097.20
|
| Rate for Payer: Zelis Worker's Compensation |
$13,716.34
|
|
|
OCTAGAM 10% 10 GM/100 mL VIAL
|
Facility
|
OP
|
$3,045.00
|
|
|
Service Code
|
CPT J1568
|
| Hospital Charge Code |
3302816
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.40 |
| Max. Negotiated Rate |
$2,892.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$73.95
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,827.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$73.95
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$58.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$47.53
|
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: Cigna Commercial |
$2,588.25
|
| Rate for Payer: First Health Commercial |
$2,740.50
|
| Rate for Payer: First Health Workers Compensation |
$1,175.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,740.50
|
| Rate for Payer: GEHA Commercial |
$52.28
|
| Rate for Payer: GEHA Medicare |
$47.53
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,740.50
|
| Rate for Payer: Humana ChoiceCare |
$52.28
|
| Rate for Payer: Humana Medicare Advantage |
$47.53
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$79.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$59.78
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$47.53
|
| Rate for Payer: Multiplan All |
$2,770.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$80.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,131.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,740.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$69.02
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$59.78
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$47.53
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,892.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$95.06
|
| Rate for Payer: Three Rivers Provider Network All |
$2,283.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$46.58
|
| Rate for Payer: United Healthcare Managed Medicaid |
$59.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,831.85
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$47.53
|
| Rate for Payer: Zelis Auto |
$1,218.00
|
| Rate for Payer: Zelis Medicare |
$40.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$57.04
|
| Rate for Payer: Zelis Worker's Compensation |
$831.28
|
|
|
OCTAGAM 10% 10 GM/100 mL VIAL
|
Facility
|
IP
|
$3,045.00
|
|
|
Service Code
|
CPT J1568
|
| Hospital Charge Code |
3302816
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$831.28 |
| Max. Negotiated Rate |
$2,892.75 |
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: Cigna Commercial |
$2,588.25
|
| Rate for Payer: First Health Commercial |
$2,740.50
|
| Rate for Payer: First Health Workers Compensation |
$1,175.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,740.50
|
| Rate for Payer: GEHA Commercial |
$2,131.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,740.50
|
| Rate for Payer: Multiplan All |
$2,770.95
|
| Rate for Payer: OMNI Networks Commercial |
$2,131.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,740.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,892.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,283.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,831.85
|
| Rate for Payer: Zelis Auto |
$1,218.00
|
| Rate for Payer: Zelis Worker's Compensation |
$831.28
|
|
|
OCTAGAM 10% - 20 GM/200 ML VIAL
|
Facility
|
IP
|
$5,207.00
|
|
|
Service Code
|
CPT J1568
|
| Hospital Charge Code |
3301319
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,421.51 |
| Max. Negotiated Rate |
$4,946.65 |
| Rate for Payer: Cash Price |
$3,124.20
|
| Rate for Payer: Cigna Commercial |
$4,425.95
|
| Rate for Payer: First Health Commercial |
$4,686.30
|
| Rate for Payer: First Health Workers Compensation |
$2,010.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,686.30
|
| Rate for Payer: GEHA Commercial |
$3,644.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,686.30
|
| Rate for Payer: Multiplan All |
$4,738.37
|
| Rate for Payer: OMNI Networks Commercial |
$3,644.90
|
| Rate for Payer: One Health Plan PPO/POS |
$4,686.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,946.65
|
| Rate for Payer: Three Rivers Provider Network All |
$3,905.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,842.51
|
| Rate for Payer: Zelis Auto |
$2,082.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1,421.51
|
|
|
OCTAGAM 10% - 20 GM/200 ML VIAL
|
Facility
|
OP
|
$5,207.00
|
|
|
Service Code
|
CPT J1568
|
| Hospital Charge Code |
3301319
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.40 |
| Max. Negotiated Rate |
$4,946.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$73.95
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,124.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$73.95
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$58.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$47.53
|
| Rate for Payer: Cash Price |
$3,124.20
|
| Rate for Payer: Cash Price |
$3,124.20
|
| Rate for Payer: Cigna Commercial |
$4,425.95
|
| Rate for Payer: First Health Commercial |
$4,686.30
|
| Rate for Payer: First Health Workers Compensation |
$2,010.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,686.30
|
| Rate for Payer: GEHA Commercial |
$52.28
|
| Rate for Payer: GEHA Medicare |
$47.53
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,686.30
|
| Rate for Payer: Humana ChoiceCare |
$52.28
|
| Rate for Payer: Humana Medicare Advantage |
$47.53
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$79.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$59.78
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$47.53
|
| Rate for Payer: Multiplan All |
$4,738.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$80.80
|
| Rate for Payer: OMNI Networks Commercial |
$3,644.90
|
| Rate for Payer: One Health Plan PPO/POS |
$4,686.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$69.02
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$59.78
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$47.53
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,946.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$95.06
|
| Rate for Payer: Three Rivers Provider Network All |
$3,905.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$46.58
|
| Rate for Payer: United Healthcare Managed Medicaid |
$59.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,842.51
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$47.53
|
| Rate for Payer: Zelis Auto |
$2,082.80
|
| Rate for Payer: Zelis Medicare |
$40.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$57.04
|
| Rate for Payer: Zelis Worker's Compensation |
$1,421.51
|
|
|
OCTAGAM 10% 5 GM/50 mL VIAL
|
Facility
|
OP
|
$654.00
|
|
|
Service Code
|
CPT J1568
|
| Hospital Charge Code |
3303076
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.40 |
| Max. Negotiated Rate |
$621.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$73.95
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$392.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$73.95
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$58.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$47.53
|
| Rate for Payer: Cash Price |
$392.40
|
| Rate for Payer: Cash Price |
$392.40
|
| Rate for Payer: Cigna Commercial |
$555.90
|
| Rate for Payer: First Health Commercial |
$588.60
|
| Rate for Payer: First Health Workers Compensation |
$252.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$588.60
|
| Rate for Payer: GEHA Commercial |
$52.28
|
| Rate for Payer: GEHA Medicare |
$47.53
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$588.60
|
| Rate for Payer: Humana ChoiceCare |
$52.28
|
| Rate for Payer: Humana Medicare Advantage |
$47.53
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$79.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$59.78
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$47.53
|
| Rate for Payer: Multiplan All |
$595.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$80.80
|
| Rate for Payer: OMNI Networks Commercial |
$457.80
|
| Rate for Payer: One Health Plan PPO/POS |
$588.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$69.02
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$59.78
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$47.53
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$621.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$95.06
|
| Rate for Payer: Three Rivers Provider Network All |
$490.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$46.58
|
| Rate for Payer: United Healthcare Managed Medicaid |
$59.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$608.22
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$47.53
|
| Rate for Payer: Zelis Auto |
$261.60
|
| Rate for Payer: Zelis Medicare |
$40.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$57.04
|
| Rate for Payer: Zelis Worker's Compensation |
$178.54
|
|
|
OCTAGAM 10% 5 GM/50 mL VIAL
|
Facility
|
IP
|
$654.00
|
|
|
Service Code
|
CPT J1568
|
| Hospital Charge Code |
3303076
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$178.54 |
| Max. Negotiated Rate |
$621.30 |
| Rate for Payer: Cash Price |
$392.40
|
| Rate for Payer: Cigna Commercial |
$555.90
|
| Rate for Payer: First Health Commercial |
$588.60
|
| Rate for Payer: First Health Workers Compensation |
$252.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$588.60
|
| Rate for Payer: GEHA Commercial |
$457.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$588.60
|
| Rate for Payer: Multiplan All |
$595.14
|
| Rate for Payer: OMNI Networks Commercial |
$457.80
|
| Rate for Payer: One Health Plan PPO/POS |
$588.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$621.30
|
| Rate for Payer: Three Rivers Provider Network All |
$490.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$608.22
|
| Rate for Payer: Zelis Auto |
$261.60
|
| Rate for Payer: Zelis Worker's Compensation |
$178.54
|
|
|
OCTREOTIDE 1,000 MCG/5 ML INJ
|
Facility
|
OP
|
$259.00
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
3303034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$155.40
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$220.15
|
| Rate for Payer: First Health Commercial |
$233.10
|
| Rate for Payer: First Health Workers Compensation |
$100.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$233.10
|
| Rate for Payer: GEHA Commercial |
$0.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$233.10
|
| Rate for Payer: Humana ChoiceCare |
$67.34
|
| Rate for Payer: Multiplan All |
$235.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$155.40
|
| Rate for Payer: OMNI Networks Commercial |
$181.30
|
| Rate for Payer: One Health Plan PPO/POS |
$233.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$246.05
|
| Rate for Payer: Three Rivers Provider Network All |
$194.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$227.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$64.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$240.87
|
| Rate for Payer: Zelis Auto |
$103.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$129.50
|
| Rate for Payer: Zelis Worker's Compensation |
$70.71
|
|
|
OCTREOTIDE 1,000 MCG/5 ML INJ
|
Facility
|
IP
|
$259.00
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
3303034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.71 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$220.15
|
| Rate for Payer: First Health Commercial |
$233.10
|
| Rate for Payer: First Health Workers Compensation |
$100.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$233.10
|
| Rate for Payer: GEHA Commercial |
$181.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$233.10
|
| Rate for Payer: Multiplan All |
$235.69
|
| Rate for Payer: OMNI Networks Commercial |
$181.30
|
| Rate for Payer: One Health Plan PPO/POS |
$233.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$246.05
|
| Rate for Payer: Three Rivers Provider Network All |
$194.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$240.87
|
| Rate for Payer: Zelis Auto |
$103.60
|
| Rate for Payer: Zelis Worker's Compensation |
$70.71
|
|
|
OCTREOTIDE 1,000 MCG/NS 250 ML IVPB
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
NDC 00703333301
|
| Hospital Charge Code |
3302897
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$72.07 |
| Max. Negotiated Rate |
$250.80 |
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cigna Commercial |
$224.40
|
| Rate for Payer: First Health Commercial |
$237.60
|
| Rate for Payer: First Health Workers Compensation |
$101.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$237.60
|
| Rate for Payer: GEHA Commercial |
$184.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$237.60
|
| Rate for Payer: Multiplan All |
$240.24
|
| Rate for Payer: OMNI Networks Commercial |
$184.80
|
| Rate for Payer: One Health Plan PPO/POS |
$237.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$250.80
|
| Rate for Payer: Three Rivers Provider Network All |
$198.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$245.52
|
| Rate for Payer: Zelis Auto |
$105.60
|
| Rate for Payer: Zelis Worker's Compensation |
$72.07
|
|
|
OCTREOTIDE 1,000 MCG/NS 250 ML IVPB
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
NDC 00703333301
|
| Hospital Charge Code |
3302897
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$66.00 |
| Max. Negotiated Rate |
$250.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$158.40
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cigna Commercial |
$224.40
|
| Rate for Payer: First Health Commercial |
$237.60
|
| Rate for Payer: First Health Workers Compensation |
$101.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$237.60
|
| Rate for Payer: GEHA Commercial |
$211.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$237.60
|
| Rate for Payer: Humana ChoiceCare |
$68.64
|
| Rate for Payer: Multiplan All |
$240.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$158.40
|
| Rate for Payer: OMNI Networks Commercial |
$184.80
|
| Rate for Payer: One Health Plan PPO/POS |
$237.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$250.80
|
| Rate for Payer: Three Rivers Provider Network All |
$198.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$232.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$66.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$245.52
|
| Rate for Payer: Zelis Auto |
$105.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$132.00
|
| Rate for Payer: Zelis Worker's Compensation |
$72.07
|
|
|
OCTREOTIDE ACETATE INJ 100MCG/ML
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
3300661
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
OCTREOTIDE ACETATE INJ 100MCG/ML
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
3300661
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$0.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Humana ChoiceCare |
$5.46
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.60
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
OCULAR RECONST TRANSPLANT
|
Facility
|
OP
|
$1,417.00
|
|
|
Service Code
|
CPT 65780
|
| Hospital Charge Code |
6165780
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$386.84 |
| Max. Negotiated Rate |
$7,161.44 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$3,795.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$850.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$3,795.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3,006.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,580.72
|
| Rate for Payer: Cash Price |
$850.20
|
| Rate for Payer: Cash Price |
$850.20
|
| Rate for Payer: Cigna Commercial |
$1,204.45
|
| Rate for Payer: First Health Commercial |
$1,275.30
|
| Rate for Payer: First Health Workers Compensation |
$547.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,275.30
|
| Rate for Payer: GEHA Commercial |
$1,133.60
|
| Rate for Payer: GEHA Medicare |
$3,580.72
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,275.30
|
| Rate for Payer: Humana ChoiceCare |
$3,938.79
|
| Rate for Payer: Humana Medicare Advantage |
$3,580.72
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$6,015.61
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,068.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,580.72
|
| Rate for Payer: Multiplan All |
$1,289.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,087.22
|
| Rate for Payer: OMNI Networks Commercial |
$991.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,275.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$3,542.48
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3,068.04
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,580.72
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,346.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$7,161.44
|
| Rate for Payer: Three Rivers Provider Network All |
$1,062.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,509.11
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,068.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,580.72
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,317.81
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,580.72
|
| Rate for Payer: Zelis Auto |
$566.80
|
| Rate for Payer: Zelis Medicare |
$3,043.61
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,296.86
|
| Rate for Payer: Zelis Worker's Compensation |
$386.84
|
|
|
OCULAR RECONST TRANSPLANT
|
Facility
|
IP
|
$1,417.00
|
|
|
Service Code
|
CPT 65780
|
| Hospital Charge Code |
6165780
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$386.84 |
| Max. Negotiated Rate |
$1,346.15 |
| Rate for Payer: Cash Price |
$850.20
|
| Rate for Payer: Cigna Commercial |
$1,204.45
|
| Rate for Payer: First Health Commercial |
$1,275.30
|
| Rate for Payer: First Health Workers Compensation |
$547.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,275.30
|
| Rate for Payer: GEHA Commercial |
$991.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,275.30
|
| Rate for Payer: Multiplan All |
$1,289.47
|
| Rate for Payer: OMNI Networks Commercial |
$991.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,275.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,346.15
|
| Rate for Payer: Three Rivers Provider Network All |
$1,062.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,317.81
|
| Rate for Payer: Zelis Auto |
$566.80
|
| Rate for Payer: Zelis Worker's Compensation |
$386.84
|
|
|
OCUVITE
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 24208038760
|
| Hospital Charge Code |
3300626
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
OCUVITE
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 24208038760
|
| Hospital Charge Code |
3300626
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
OFC CON NEW PT MOD MDM AT LEAST 45 MINS
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
20300094
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$121.25 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$291.00
|
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$388.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Humana ChoiceCare |
$126.10
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$291.00
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$426.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$121.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$242.50
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
OFC CON NEW PT MOD MDM AT LEAST 45 MINS
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
20300094
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$132.41 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$339.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
OFC CONS ESTB PT HIGH MDM AT LEAST 40 MI
|
Facility
|
OP
|
$520.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
20300153
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$130.00 |
| Max. Negotiated Rate |
$494.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$312.00
|
| Rate for Payer: Cash Price |
$312.00
|
| Rate for Payer: Cigna Commercial |
$442.00
|
| Rate for Payer: First Health Commercial |
$468.00
|
| Rate for Payer: First Health Workers Compensation |
$200.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$468.00
|
| Rate for Payer: GEHA Commercial |
$416.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$468.00
|
| Rate for Payer: Humana ChoiceCare |
$135.20
|
| Rate for Payer: Multiplan All |
$473.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$312.00
|
| Rate for Payer: OMNI Networks Commercial |
$364.00
|
| Rate for Payer: One Health Plan PPO/POS |
$468.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$494.00
|
| Rate for Payer: Three Rivers Provider Network All |
$390.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$457.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$130.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$483.60
|
| Rate for Payer: Zelis Auto |
$208.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$260.00
|
| Rate for Payer: Zelis Worker's Compensation |
$141.96
|
|
|
OFC CONS ESTB PT HIGH MDM AT LEAST 40 MI
|
Facility
|
IP
|
$520.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
20300153
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$141.96 |
| Max. Negotiated Rate |
$494.00 |
| Rate for Payer: Cash Price |
$312.00
|
| Rate for Payer: Cigna Commercial |
$442.00
|
| Rate for Payer: First Health Commercial |
$468.00
|
| Rate for Payer: First Health Workers Compensation |
$200.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$468.00
|
| Rate for Payer: GEHA Commercial |
$364.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$468.00
|
| Rate for Payer: Multiplan All |
$473.20
|
| Rate for Payer: OMNI Networks Commercial |
$364.00
|
| Rate for Payer: One Health Plan PPO/POS |
$468.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$494.00
|
| Rate for Payer: Three Rivers Provider Network All |
$390.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$483.60
|
| Rate for Payer: Zelis Auto |
$208.00
|
| Rate for Payer: Zelis Worker's Compensation |
$141.96
|
|
|
OFC CONS ESTB PT LOW MDM AT LEAST 20 MIN
|
Facility
|
IP
|
$261.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
20300151
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.25 |
| Max. Negotiated Rate |
$247.95 |
| Rate for Payer: Cash Price |
$156.60
|
| Rate for Payer: Cigna Commercial |
$221.85
|
| Rate for Payer: First Health Commercial |
$234.90
|
| Rate for Payer: First Health Workers Compensation |
$100.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$234.90
|
| Rate for Payer: GEHA Commercial |
$182.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$234.90
|
| Rate for Payer: Multiplan All |
$237.51
|
| Rate for Payer: OMNI Networks Commercial |
$182.70
|
| Rate for Payer: One Health Plan PPO/POS |
$234.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$247.95
|
| Rate for Payer: Three Rivers Provider Network All |
$195.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$242.73
|
| Rate for Payer: Zelis Auto |
$104.40
|
| Rate for Payer: Zelis Worker's Compensation |
$71.25
|
|
|
OFC CONS ESTB PT LOW MDM AT LEAST 20 MIN
|
Facility
|
OP
|
$261.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
20300151
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$65.25 |
| Max. Negotiated Rate |
$247.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$156.60
|
| Rate for Payer: Cash Price |
$156.60
|
| Rate for Payer: Cigna Commercial |
$221.85
|
| Rate for Payer: First Health Commercial |
$234.90
|
| Rate for Payer: First Health Workers Compensation |
$100.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$234.90
|
| Rate for Payer: GEHA Commercial |
$208.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$234.90
|
| Rate for Payer: Humana ChoiceCare |
$67.86
|
| Rate for Payer: Multiplan All |
$237.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$156.60
|
| Rate for Payer: OMNI Networks Commercial |
$182.70
|
| Rate for Payer: One Health Plan PPO/POS |
$234.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$247.95
|
| Rate for Payer: Three Rivers Provider Network All |
$195.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$229.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$65.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$242.73
|
| Rate for Payer: Zelis Auto |
$104.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$130.50
|
| Rate for Payer: Zelis Worker's Compensation |
$71.25
|
|
