|
ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION [106773]
|
Facility
|
OP
|
$4,132.00
|
|
|
Service Code
|
HCPCS J9179
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.76 |
| Max. Negotiated Rate |
$4,008.04 |
| Rate for Payer: AlohaCare Medicaid |
$76.76
|
| Rate for Payer: AlohaCare Medicaid |
$76.76
|
| Rate for Payer: AlohaCare Medicare |
$76.76
|
| Rate for Payer: AlohaCare Medicare |
$76.76
|
| Rate for Payer: Cash Price |
$2,479.20
|
| Rate for Payer: Cash Price |
$2,479.20
|
| Rate for Payer: Cash Price |
$1,522.80
|
| Rate for Payer: Cash Price |
$1,522.80
|
| Rate for Payer: Devoted Health Medicare |
$84.44
|
| Rate for Payer: Devoted Health Medicare |
$84.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$104.58
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$104.58
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$95.95
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$95.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$76.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$76.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$104.58
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$104.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,411.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,925.40
|
| Rate for Payer: Health Management Network Commercial |
$2,157.30
|
| Rate for Payer: Health Management Network Commercial |
$3,512.20
|
| Rate for Payer: Humana Medicare |
$76.76
|
| Rate for Payer: Humana Medicare |
$76.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,598.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,603.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,107.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,294.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$76.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$76.76
|
| Rate for Payer: MDX Hawaii PPO |
$4,008.04
|
| Rate for Payer: MDX Hawaii PPO |
$2,461.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$84.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$84.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$76.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$76.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,479.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,522.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$76.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$76.76
|
| Rate for Payer: University Health Alliance Commercial |
$3,011.81
|
| Rate for Payer: University Health Alliance Commercial |
$1,849.95
|
|
|
ERTAPENEM 1 G IN 50 ML NS ADD-A-VIAL (SIMPLE) [4080039]
|
Facility
|
OP
|
$253.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.71 |
| Max. Negotiated Rate |
$245.41 |
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$59.71
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$59.71
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$240.35
|
| Rate for Payer: Health Management Network Commercial |
$215.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$159.39
|
| Rate for Payer: Kaiser Permanente Medicaid |
$129.03
|
| Rate for Payer: MDX Hawaii PPO |
$245.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$151.80
|
| Rate for Payer: University Health Alliance Commercial |
$184.41
|
|
|
ERTAPENEM 1 G IN 50 ML NS ADD-A-VIAL (SIMPLE) [4080039]
|
Facility
|
IP
|
$253.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$215.05 |
| Max. Negotiated Rate |
$245.41 |
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Health Management Network Commercial |
$215.05
|
| Rate for Payer: MDX Hawaii PPO |
$245.41
|
|
|
ERTAPENEM 1 GRAM SOLUTION FOR INJECTION [31922]
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.71 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$59.71
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$59.71
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$136.80
|
| Rate for Payer: Health Management Network Commercial |
$122.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$73.44
|
| Rate for Payer: MDX Hawaii PPO |
$139.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$86.40
|
| Rate for Payer: University Health Alliance Commercial |
$104.96
|
|
|
ERTAPENEM 1 GRAM SOLUTION FOR INJECTION [31922]
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$122.40 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Health Management Network Commercial |
$122.40
|
| Rate for Payer: MDX Hawaii PPO |
$139.68
|
|
|
ERTAPENEM SODIUM 1 G/10ML IJ (WET SOLR VIAL) [43031922]
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.71 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$59.71
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$59.71
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$59.71
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$59.71
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$136.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$88.35
|
| Rate for Payer: Health Management Network Commercial |
$79.05
|
| Rate for Payer: Health Management Network Commercial |
$122.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$58.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$47.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$73.44
|
| Rate for Payer: MDX Hawaii PPO |
$90.21
|
| Rate for Payer: MDX Hawaii PPO |
$139.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$86.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$55.80
|
| Rate for Payer: University Health Alliance Commercial |
$67.79
|
| Rate for Payer: University Health Alliance Commercial |
$104.96
|
|
|
ERTAPENEM SODIUM 1 G/10ML IJ (WET SOLR VIAL) [43031922]
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$122.40 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Health Management Network Commercial |
$122.40
|
| Rate for Payer: Health Management Network Commercial |
$79.05
|
| Rate for Payer: MDX Hawaii PPO |
$139.68
|
| Rate for Payer: MDX Hawaii PPO |
$90.21
|
|
|
ERYTHROMYCIN 0.5% OPHTH OINTMENT (1 GRAM) (TAKE HOME) [4080360]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080148
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
ERYTHROMYCIN 0.5% OPHTH OINTMENT (1 GRAM) (TAKE HOME) [4080360]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080148
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
NDC 72485067031
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.01 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.45
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: University Health Alliance Commercial |
$37.17
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
NDC 24208091055
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.09 |
| Max. Negotiated Rate |
$57.23 |
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$56.05
|
| Rate for Payer: Health Management Network Commercial |
$50.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.09
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
| Rate for Payer: University Health Alliance Commercial |
$43.01
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
NDC 72485067031
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.35 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
NDC 24208091055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.15 |
| Max. Negotiated Rate |
$57.23 |
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Health Management Network Commercial |
$50.15
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 00574402450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.77 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 00574402450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
NDC 24208091019
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.20 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
NDC 24208091019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.32 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.40
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.32
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
| Rate for Payer: University Health Alliance Commercial |
$23.32
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 52536013413
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.14 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]
|
Facility
|
OP
|
$609.00
|
|
|
Service Code
|
NDC 62559063001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$310.59 |
| Max. Negotiated Rate |
$590.73 |
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$578.55
|
| Rate for Payer: Health Management Network Commercial |
$517.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$383.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$310.59
|
| Rate for Payer: MDX Hawaii PPO |
$590.73
|
| Rate for Payer: University Health Alliance Commercial |
$443.90
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 52536013213
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 52536013413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]
|
Facility
|
IP
|
$609.00
|
|
|
Service Code
|
NDC 62559063001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$517.65 |
| Max. Negotiated Rate |
$590.73 |
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Health Management Network Commercial |
$517.65
|
| Rate for Payer: MDX Hawaii PPO |
$590.73
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 52536013213
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
ERYTHROMYCIN LACTOBIONATE 500 MG/10ML IV (WET SOLR VIAL) [4302903]
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
HCPCS J1364
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$64.02 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Health Management Network Commercial |
$130.05
|
| Rate for Payer: Health Management Network Commercial |
$259.25
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
| Rate for Payer: MDX Hawaii PPO |
$295.85
|
| Rate for Payer: MDX Hawaii PPO |
$148.41
|
|
|
ERYTHROMYCIN LACTOBIONATE 500 MG/10ML IV (WET SOLR VIAL) [4302903]
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
HCPCS J1364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.05 |
| Max. Negotiated Rate |
$295.85 |
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$75.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$75.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$75.05
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$75.05
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$75.05
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$75.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$145.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$289.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$62.70
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Health Management Network Commercial |
$130.05
|
| Rate for Payer: Health Management Network Commercial |
$259.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$192.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.39
|
| Rate for Payer: Kaiser Permanente Medicaid |
$78.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$155.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.66
|
| Rate for Payer: MDX Hawaii PPO |
$148.41
|
| Rate for Payer: MDX Hawaii PPO |
$295.85
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$183.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$39.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$91.80
|
| Rate for Payer: University Health Alliance Commercial |
$111.52
|
| Rate for Payer: University Health Alliance Commercial |
$222.31
|
| Rate for Payer: University Health Alliance Commercial |
$48.11
|
|
