|
PELVIC EXENTERATION
|
Facility
|
IP
|
$5,856.00
|
|
|
Service Code
|
CPT 45126
|
| Hospital Charge Code |
6145126
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,598.69 |
| Max. Negotiated Rate |
$5,563.20 |
| Rate for Payer: Cash Price |
$3,513.60
|
| Rate for Payer: Cigna Commercial |
$4,977.60
|
| Rate for Payer: First Health Commercial |
$5,270.40
|
| Rate for Payer: First Health Workers Compensation |
$2,261.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,270.40
|
| Rate for Payer: GEHA Commercial |
$4,099.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,270.40
|
| Rate for Payer: Multiplan All |
$5,328.96
|
| Rate for Payer: OMNI Networks Commercial |
$4,099.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5,270.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,563.20
|
| Rate for Payer: Three Rivers Provider Network All |
$4,392.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,446.08
|
| Rate for Payer: Zelis Auto |
$2,342.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1,598.69
|
|
|
PENICILLIN G 1200000 UNIT/2ML - IM
|
Facility
|
OP
|
$1,490.00
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
3300698
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.32 |
| Max. Negotiated Rate |
$1,415.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$11.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$894.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$11.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$9.32
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$30.01
|
| Rate for Payer: Cash Price |
$894.00
|
| Rate for Payer: Cash Price |
$894.00
|
| Rate for Payer: Cigna Commercial |
$1,266.50
|
| Rate for Payer: First Health Commercial |
$1,341.00
|
| Rate for Payer: First Health Workers Compensation |
$575.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,341.00
|
| Rate for Payer: GEHA Commercial |
$33.01
|
| Rate for Payer: GEHA Medicare |
$30.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,341.00
|
| Rate for Payer: Humana ChoiceCare |
$33.01
|
| Rate for Payer: Humana Medicare Advantage |
$30.01
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$50.42
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$9.51
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$30.01
|
| Rate for Payer: Multiplan All |
$1,355.90
|
| Rate for Payer: New Mexico Health Connections Medicare |
$51.02
|
| Rate for Payer: OMNI Networks Commercial |
$1,043.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,341.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$10.98
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$9.51
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$30.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,415.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$60.02
|
| Rate for Payer: Three Rivers Provider Network All |
$1,117.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$29.41
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,385.70
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$30.01
|
| Rate for Payer: Zelis Auto |
$596.00
|
| Rate for Payer: Zelis Medicare |
$25.51
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$36.01
|
| Rate for Payer: Zelis Worker's Compensation |
$406.77
|
|
|
PENICILLIN G 1200000 UNIT/2ML - IM
|
Facility
|
IP
|
$1,490.00
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
3300698
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$406.77 |
| Max. Negotiated Rate |
$1,415.50 |
| Rate for Payer: Cash Price |
$894.00
|
| Rate for Payer: Cigna Commercial |
$1,266.50
|
| Rate for Payer: First Health Commercial |
$1,341.00
|
| Rate for Payer: First Health Workers Compensation |
$575.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,341.00
|
| Rate for Payer: GEHA Commercial |
$1,043.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,341.00
|
| Rate for Payer: Multiplan All |
$1,355.90
|
| Rate for Payer: OMNI Networks Commercial |
$1,043.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,341.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,415.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,117.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,385.70
|
| Rate for Payer: Zelis Auto |
$596.00
|
| Rate for Payer: Zelis Worker's Compensation |
$406.77
|
|
|
PENICILLIN G INJ 20MILLION UNIT
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
CPT J2540
|
| Hospital Charge Code |
3300699
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.77 |
| Max. Negotiated Rate |
$155.80 |
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cigna Commercial |
$139.40
|
| Rate for Payer: First Health Commercial |
$147.60
|
| Rate for Payer: First Health Workers Compensation |
$63.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$147.60
|
| Rate for Payer: GEHA Commercial |
$114.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$147.60
|
| Rate for Payer: Multiplan All |
$149.24
|
| Rate for Payer: OMNI Networks Commercial |
$114.80
|
| Rate for Payer: One Health Plan PPO/POS |
$147.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$155.80
|
| Rate for Payer: Three Rivers Provider Network All |
$123.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$152.52
|
| Rate for Payer: Zelis Auto |
$65.60
|
| Rate for Payer: Zelis Worker's Compensation |
$44.77
|
|
|
PENICILLIN G INJ 20MILLION UNIT
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
CPT J2540
|
| Hospital Charge Code |
3300699
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$155.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$98.40
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cigna Commercial |
$139.40
|
| Rate for Payer: First Health Commercial |
$147.60
|
| Rate for Payer: First Health Workers Compensation |
$63.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$147.60
|
| Rate for Payer: GEHA Commercial |
$0.87
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$147.60
|
| Rate for Payer: Humana ChoiceCare |
$42.64
|
| Rate for Payer: Multiplan All |
$149.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$98.40
|
| Rate for Payer: OMNI Networks Commercial |
$114.80
|
| Rate for Payer: One Health Plan PPO/POS |
$147.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$155.80
|
| Rate for Payer: Three Rivers Provider Network All |
$123.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$144.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$41.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$152.52
|
| Rate for Payer: Zelis Auto |
$65.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$82.00
|
| Rate for Payer: Zelis Worker's Compensation |
$44.77
|
|
|
PENICILLIN G INJ 5MILLION UNIT
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
CPT J2540
|
| Hospital Charge Code |
3300700
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.84 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$68.00
|
| Rate for Payer: First Health Commercial |
$72.00
|
| Rate for Payer: First Health Workers Compensation |
$30.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.00
|
| Rate for Payer: GEHA Commercial |
$56.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.00
|
| Rate for Payer: Multiplan All |
$72.80
|
| Rate for Payer: OMNI Networks Commercial |
$56.00
|
| Rate for Payer: One Health Plan PPO/POS |
$72.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.00
|
| Rate for Payer: Three Rivers Provider Network All |
$60.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$74.40
|
| Rate for Payer: Zelis Auto |
$32.00
|
| Rate for Payer: Zelis Worker's Compensation |
$21.84
|
|
|
PENICILLIN G INJ 5MILLION UNIT
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
CPT J2540
|
| Hospital Charge Code |
3300700
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$68.00
|
| Rate for Payer: First Health Commercial |
$72.00
|
| Rate for Payer: First Health Workers Compensation |
$30.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.00
|
| Rate for Payer: GEHA Commercial |
$0.87
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.00
|
| Rate for Payer: Humana ChoiceCare |
$20.80
|
| Rate for Payer: Multiplan All |
$72.80
|
| Rate for Payer: New Mexico Health Connections Medicare |
$48.00
|
| Rate for Payer: OMNI Networks Commercial |
$56.00
|
| Rate for Payer: One Health Plan PPO/POS |
$72.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.00
|
| Rate for Payer: Three Rivers Provider Network All |
$60.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$70.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$20.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$74.40
|
| Rate for Payer: Zelis Auto |
$32.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$40.00
|
| Rate for Payer: Zelis Worker's Compensation |
$21.84
|
|
|
penicillin, IgE REF067108
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2200805
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
penicillin, IgE REF067108
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2200805
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.22
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: GEHA Medicare |
$5.22
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.22
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.76
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.59
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.22
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10.44
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.12
|
| Rate for Payer: United Healthcare Commercial |
$47.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.22
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Medicare |
$4.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.26
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
Penicillin V Potassium 500 mg tablet
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 65862017601
|
| Hospital Charge Code |
3302818
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Humana ChoiceCare |
$1.56
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.60
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
Penicillin V Potassium 500 mg tablet
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 65862017601
|
| Hospital Charge Code |
3302818
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
PENICILLIN V POTASSIUM TAB 250MG
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 00093117201
|
| Hospital Charge Code |
3300701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$6.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Humana ChoiceCare |
$2.08
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.80
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
PENICILLIN V POTASSIUM TAB 250MG
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 00093117201
|
| Hospital Charge Code |
3300701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
penicillium chrysogen IgE REF602502
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299141
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
penicillium chrysogen IgE REF602502
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299141
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.22
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: GEHA Medicare |
$5.22
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.22
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.76
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.59
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.22
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10.44
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.12
|
| Rate for Payer: United Healthcare Commercial |
$47.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.22
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Medicare |
$4.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.26
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
penicillium glabrum, IgE REF806871
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2200818
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.22
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: GEHA Medicare |
$5.22
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.22
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.76
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.59
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.22
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10.44
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.12
|
| Rate for Payer: United Healthcare Commercial |
$47.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.22
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Medicare |
$4.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.26
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
penicillium glabrum, IgE REF806871
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2200818
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
PENIS PLASTIC SURGERY
|
Facility
|
IP
|
$1,483.00
|
|
|
Service Code
|
CPT 54360
|
| Hospital Charge Code |
6154360
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$404.86 |
| Max. Negotiated Rate |
$1,408.85 |
| Rate for Payer: Cash Price |
$889.80
|
| Rate for Payer: Cigna Commercial |
$1,260.55
|
| Rate for Payer: First Health Commercial |
$1,334.70
|
| Rate for Payer: First Health Workers Compensation |
$572.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,334.70
|
| Rate for Payer: GEHA Commercial |
$1,038.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,334.70
|
| Rate for Payer: Multiplan All |
$1,349.53
|
| Rate for Payer: OMNI Networks Commercial |
$1,038.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,334.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,408.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,112.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,379.19
|
| Rate for Payer: Zelis Auto |
$593.20
|
| Rate for Payer: Zelis Worker's Compensation |
$404.86
|
|
|
PENIS PLASTIC SURGERY
|
Facility
|
OP
|
$1,483.00
|
|
|
Service Code
|
CPT 54360
|
| Hospital Charge Code |
6154360
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$404.86 |
| Max. Negotiated Rate |
$6,549.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$3,527.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$889.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$3,527.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2,794.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,274.93
|
| Rate for Payer: Cash Price |
$889.80
|
| Rate for Payer: Cash Price |
$889.80
|
| Rate for Payer: Cigna Commercial |
$1,260.55
|
| Rate for Payer: First Health Commercial |
$1,334.70
|
| Rate for Payer: First Health Workers Compensation |
$572.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,334.70
|
| Rate for Payer: GEHA Commercial |
$1,186.40
|
| Rate for Payer: GEHA Medicare |
$3,274.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,334.70
|
| Rate for Payer: Humana ChoiceCare |
$3,602.42
|
| Rate for Payer: Humana Medicare Advantage |
$3,274.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,501.88
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,851.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,274.93
|
| Rate for Payer: Multiplan All |
$1,349.53
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,567.38
|
| Rate for Payer: OMNI Networks Commercial |
$1,038.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,334.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$3,291.92
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,851.04
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,274.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,408.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,549.86
|
| Rate for Payer: Three Rivers Provider Network All |
$1,112.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,209.43
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,851.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,274.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,379.19
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,274.93
|
| Rate for Payer: Zelis Auto |
$593.20
|
| Rate for Payer: Zelis Medicare |
$2,783.69
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,929.92
|
| Rate for Payer: Zelis Worker's Compensation |
$404.86
|
|
|
PENIS STUDY
|
Facility
|
IP
|
$309.00
|
|
|
Service Code
|
CPT 54240
|
| Hospital Charge Code |
6154240
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$84.36 |
| Max. Negotiated Rate |
$293.55 |
| Rate for Payer: Cash Price |
$185.40
|
| Rate for Payer: Cigna Commercial |
$262.65
|
| Rate for Payer: First Health Commercial |
$278.10
|
| Rate for Payer: First Health Workers Compensation |
$119.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$278.10
|
| Rate for Payer: GEHA Commercial |
$216.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$278.10
|
| Rate for Payer: Multiplan All |
$281.19
|
| Rate for Payer: OMNI Networks Commercial |
$216.30
|
| Rate for Payer: One Health Plan PPO/POS |
$278.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$293.55
|
| Rate for Payer: Three Rivers Provider Network All |
$231.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$287.37
|
| Rate for Payer: Zelis Auto |
$123.60
|
| Rate for Payer: Zelis Worker's Compensation |
$84.36
|
|
|
PENIS STUDY
|
Facility
|
OP
|
$371.00
|
|
|
Service Code
|
CPT 54250
|
| Hospital Charge Code |
6154250
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$101.28 |
| Max. Negotiated Rate |
$461.88 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$204.18
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$222.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$204.18
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$161.75
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$230.94
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cigna Commercial |
$315.35
|
| Rate for Payer: First Health Commercial |
$333.90
|
| Rate for Payer: First Health Workers Compensation |
$143.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$333.90
|
| Rate for Payer: GEHA Commercial |
$296.80
|
| Rate for Payer: GEHA Medicare |
$230.94
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$333.90
|
| Rate for Payer: Humana ChoiceCare |
$254.03
|
| Rate for Payer: Humana Medicare Advantage |
$230.94
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$387.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$165.05
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$230.94
|
| Rate for Payer: Multiplan All |
$337.61
|
| Rate for Payer: New Mexico Health Connections Medicare |
$392.60
|
| Rate for Payer: OMNI Networks Commercial |
$259.70
|
| Rate for Payer: One Health Plan PPO/POS |
$333.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$190.57
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$165.05
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$230.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$352.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$461.88
|
| Rate for Payer: Three Rivers Provider Network All |
$278.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$226.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$165.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$230.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$345.03
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$230.94
|
| Rate for Payer: Zelis Auto |
$148.40
|
| Rate for Payer: Zelis Medicare |
$196.30
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$277.13
|
| Rate for Payer: Zelis Worker's Compensation |
$101.28
|
|
|
PENIS STUDY
|
Facility
|
OP
|
$309.00
|
|
|
Service Code
|
CPT 54240
|
| Hospital Charge Code |
6154240
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$84.36 |
| Max. Negotiated Rate |
$591.38 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$110.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$185.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$110.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$87.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$295.69
|
| Rate for Payer: Cash Price |
$185.40
|
| Rate for Payer: Cash Price |
$185.40
|
| Rate for Payer: Cigna Commercial |
$262.65
|
| Rate for Payer: First Health Commercial |
$278.10
|
| Rate for Payer: First Health Workers Compensation |
$119.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$278.10
|
| Rate for Payer: GEHA Commercial |
$247.20
|
| Rate for Payer: GEHA Medicare |
$295.69
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$278.10
|
| Rate for Payer: Humana ChoiceCare |
$325.26
|
| Rate for Payer: Humana Medicare Advantage |
$295.69
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$496.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$89.56
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$295.69
|
| Rate for Payer: Multiplan All |
$281.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$502.67
|
| Rate for Payer: OMNI Networks Commercial |
$216.30
|
| Rate for Payer: One Health Plan PPO/POS |
$278.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$103.40
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$89.56
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$295.69
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$293.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$591.38
|
| Rate for Payer: Three Rivers Provider Network All |
$231.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$289.78
|
| Rate for Payer: United Healthcare Managed Medicaid |
$89.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$295.69
|
| Rate for Payer: United Payors & United Providers UP&UP |
$287.37
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$295.69
|
| Rate for Payer: Zelis Auto |
$123.60
|
| Rate for Payer: Zelis Medicare |
$251.34
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$354.83
|
| Rate for Payer: Zelis Worker's Compensation |
$84.36
|
|
|
PENIS STUDY
|
Facility
|
IP
|
$371.00
|
|
|
Service Code
|
CPT 54250
|
| Hospital Charge Code |
6154250
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$101.28 |
| Max. Negotiated Rate |
$352.45 |
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cigna Commercial |
$315.35
|
| Rate for Payer: First Health Commercial |
$333.90
|
| Rate for Payer: First Health Workers Compensation |
$143.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$333.90
|
| Rate for Payer: GEHA Commercial |
$259.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$333.90
|
| Rate for Payer: Multiplan All |
$337.61
|
| Rate for Payer: OMNI Networks Commercial |
$259.70
|
| Rate for Payer: One Health Plan PPO/POS |
$333.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$352.45
|
| Rate for Payer: Three Rivers Provider Network All |
$278.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$345.03
|
| Rate for Payer: Zelis Auto |
$148.40
|
| Rate for Payer: Zelis Worker's Compensation |
$101.28
|
|
|
PENTOXIFYLLINE TAB ER 400MG
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 00904544861
|
| Hospital Charge Code |
3300702
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$7.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
PENTOXIFYLLINE TAB ER 400MG
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 00904544861
|
| Hospital Charge Code |
3300702
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$8.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Humana ChoiceCare |
$2.60
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.00
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
