|
PET CT SKULL TO THIGH
|
Facility
|
OP
|
$8,596.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
31000002
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,177.24 |
| Max. Negotiated Rate |
$8,166.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,556.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,157.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,556.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,232.67
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,384.99
|
| Rate for Payer: Cash Price |
$5,157.60
|
| Rate for Payer: Cash Price |
$5,157.60
|
| Rate for Payer: Cigna Commercial |
$7,306.60
|
| Rate for Payer: First Health Commercial |
$7,736.40
|
| Rate for Payer: First Health Workers Compensation |
$2,209.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,736.40
|
| Rate for Payer: GEHA Commercial |
$6,876.80
|
| Rate for Payer: GEHA Medicare |
$1,384.99
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,736.40
|
| Rate for Payer: Humana ChoiceCare |
$1,523.49
|
| Rate for Payer: Humana Medicare Advantage |
$1,384.99
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,326.78
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,257.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,384.99
|
| Rate for Payer: Multiplan All |
$7,822.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,354.48
|
| Rate for Payer: OMNI Networks Commercial |
$6,017.20
|
| Rate for Payer: One Health Plan PPO/POS |
$7,736.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,452.28
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,257.77
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,384.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,166.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$2,769.98
|
| Rate for Payer: Three Rivers Provider Network All |
$6,447.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,357.29
|
| Rate for Payer: United Healthcare Commercial |
$7,306.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,257.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,384.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,994.28
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,384.99
|
| Rate for Payer: Zelis Auto |
$3,438.40
|
| Rate for Payer: Zelis Medicare |
$1,177.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,661.99
|
| Rate for Payer: Zelis Worker's Compensation |
$1,562.32
|
|
|
PET CT SKULL TO THIGH
|
Facility
|
IP
|
$8,596.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
31000002
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,562.32 |
| Max. Negotiated Rate |
$8,166.20 |
| Rate for Payer: Cash Price |
$5,157.60
|
| Rate for Payer: Cash Price |
$5,157.60
|
| Rate for Payer: Cigna Commercial |
$7,306.60
|
| Rate for Payer: First Health Commercial |
$7,736.40
|
| Rate for Payer: First Health Workers Compensation |
$2,209.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,736.40
|
| Rate for Payer: GEHA Commercial |
$6,017.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,736.40
|
| Rate for Payer: Multiplan All |
$7,822.36
|
| Rate for Payer: OMNI Networks Commercial |
$6,017.20
|
| Rate for Payer: One Health Plan PPO/POS |
$7,736.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,166.20
|
| Rate for Payer: Three Rivers Provider Network All |
$6,447.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,994.28
|
| Rate for Payer: Zelis Auto |
$3,438.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1,562.32
|
|
|
PET CT WHOLE BODY
|
Facility
|
OP
|
$8,900.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
31000003
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,177.24 |
| Max. Negotiated Rate |
$8,455.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,556.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,340.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,556.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,232.67
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,384.99
|
| Rate for Payer: Cash Price |
$5,340.00
|
| Rate for Payer: Cash Price |
$5,340.00
|
| Rate for Payer: Cigna Commercial |
$7,565.00
|
| Rate for Payer: First Health Commercial |
$8,010.00
|
| Rate for Payer: First Health Workers Compensation |
$2,210.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,010.00
|
| Rate for Payer: GEHA Commercial |
$7,120.00
|
| Rate for Payer: GEHA Medicare |
$1,384.99
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,010.00
|
| Rate for Payer: Humana ChoiceCare |
$1,523.49
|
| Rate for Payer: Humana Medicare Advantage |
$1,384.99
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,326.78
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,257.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,384.99
|
| Rate for Payer: Multiplan All |
$8,099.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,354.48
|
| Rate for Payer: OMNI Networks Commercial |
$6,230.00
|
| Rate for Payer: One Health Plan PPO/POS |
$8,010.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,452.28
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,257.77
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,384.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,455.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$2,769.98
|
| Rate for Payer: Three Rivers Provider Network All |
$6,675.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,357.29
|
| Rate for Payer: United Healthcare Commercial |
$7,565.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,257.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,384.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,277.00
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,384.99
|
| Rate for Payer: Zelis Auto |
$3,560.00
|
| Rate for Payer: Zelis Medicare |
$1,177.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,661.99
|
| Rate for Payer: Zelis Worker's Compensation |
$1,563.12
|
|
|
PET CT WHOLE BODY
|
Facility
|
IP
|
$8,900.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
31000003
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,563.12 |
| Max. Negotiated Rate |
$8,455.00 |
| Rate for Payer: Cash Price |
$5,340.00
|
| Rate for Payer: Cash Price |
$5,340.00
|
| Rate for Payer: Cigna Commercial |
$7,565.00
|
| Rate for Payer: First Health Commercial |
$8,010.00
|
| Rate for Payer: First Health Workers Compensation |
$2,210.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,010.00
|
| Rate for Payer: GEHA Commercial |
$6,230.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,010.00
|
| Rate for Payer: Multiplan All |
$8,099.00
|
| Rate for Payer: OMNI Networks Commercial |
$6,230.00
|
| Rate for Payer: One Health Plan PPO/POS |
$8,010.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,455.00
|
| Rate for Payer: Three Rivers Provider Network All |
$6,675.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,277.00
|
| Rate for Payer: Zelis Auto |
$3,560.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,563.12
|
|
|
PF EXAM OTOLARYNGOLOGIC W/ANES
|
Facility
|
IP
|
$293.00
|
|
|
Service Code
|
CPT 92502
|
| Hospital Charge Code |
8300064
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$79.99 |
| Max. Negotiated Rate |
$278.35 |
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$249.05
|
| Rate for Payer: First Health Commercial |
$263.70
|
| Rate for Payer: First Health Workers Compensation |
$113.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$263.70
|
| Rate for Payer: GEHA Commercial |
$205.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$263.70
|
| Rate for Payer: Multiplan All |
$266.63
|
| Rate for Payer: OMNI Networks Commercial |
$205.10
|
| Rate for Payer: One Health Plan PPO/POS |
$263.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$278.35
|
| Rate for Payer: Three Rivers Provider Network All |
$219.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$272.49
|
| Rate for Payer: Zelis Auto |
$117.20
|
| Rate for Payer: Zelis Worker's Compensation |
$79.99
|
|
|
PF EXAM OTOLARYNGOLOGIC W/ANES
|
Facility
|
IP
|
$293.00
|
|
|
Service Code
|
CPT 92502
|
| Hospital Charge Code |
7992502
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$79.99 |
| Max. Negotiated Rate |
$278.35 |
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$249.05
|
| Rate for Payer: First Health Commercial |
$263.70
|
| Rate for Payer: First Health Workers Compensation |
$113.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$263.70
|
| Rate for Payer: GEHA Commercial |
$205.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$263.70
|
| Rate for Payer: Multiplan All |
$266.63
|
| Rate for Payer: OMNI Networks Commercial |
$205.10
|
| Rate for Payer: One Health Plan PPO/POS |
$263.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$278.35
|
| Rate for Payer: Three Rivers Provider Network All |
$219.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$272.49
|
| Rate for Payer: Zelis Auto |
$117.20
|
| Rate for Payer: Zelis Worker's Compensation |
$79.99
|
|
|
PF EXAM OTOLARYNGOLOGIC W/ANES
|
Facility
|
OP
|
$293.00
|
|
|
Service Code
|
CPT 92502
|
| Hospital Charge Code |
7992502
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$79.99 |
| Max. Negotiated Rate |
$967.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$346.31
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$175.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$346.31
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$274.34
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$483.55
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$249.05
|
| Rate for Payer: First Health Commercial |
$263.70
|
| Rate for Payer: First Health Workers Compensation |
$113.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$263.70
|
| Rate for Payer: GEHA Commercial |
$234.40
|
| Rate for Payer: GEHA Medicare |
$483.55
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$263.70
|
| Rate for Payer: Humana ChoiceCare |
$531.90
|
| Rate for Payer: Humana Medicare Advantage |
$483.55
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$812.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$279.93
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$483.55
|
| Rate for Payer: Multiplan All |
$266.63
|
| Rate for Payer: New Mexico Health Connections Medicare |
$822.03
|
| Rate for Payer: OMNI Networks Commercial |
$205.10
|
| Rate for Payer: One Health Plan PPO/POS |
$263.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$323.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$279.93
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$483.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$278.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$967.10
|
| Rate for Payer: Three Rivers Provider Network All |
$219.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$473.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$279.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$483.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$272.49
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$483.55
|
| Rate for Payer: Zelis Auto |
$117.20
|
| Rate for Payer: Zelis Medicare |
$411.02
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$580.26
|
| Rate for Payer: Zelis Worker's Compensation |
$79.99
|
|
|
PF EXAM OTOLARYNGOLOGIC W/ANES
|
Facility
|
OP
|
$293.00
|
|
|
Service Code
|
CPT 92502
|
| Hospital Charge Code |
8300064
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$79.99 |
| Max. Negotiated Rate |
$967.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$346.31
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$175.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$346.31
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$274.34
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$483.55
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$249.05
|
| Rate for Payer: First Health Commercial |
$263.70
|
| Rate for Payer: First Health Workers Compensation |
$113.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$263.70
|
| Rate for Payer: GEHA Commercial |
$234.40
|
| Rate for Payer: GEHA Medicare |
$483.55
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$263.70
|
| Rate for Payer: Humana ChoiceCare |
$531.90
|
| Rate for Payer: Humana Medicare Advantage |
$483.55
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$812.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$279.93
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$483.55
|
| Rate for Payer: Multiplan All |
$266.63
|
| Rate for Payer: New Mexico Health Connections Medicare |
$822.03
|
| Rate for Payer: OMNI Networks Commercial |
$205.10
|
| Rate for Payer: One Health Plan PPO/POS |
$263.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$323.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$279.93
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$483.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$278.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$967.10
|
| Rate for Payer: Three Rivers Provider Network All |
$219.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$473.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$279.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$483.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$272.49
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$483.55
|
| Rate for Payer: Zelis Auto |
$117.20
|
| Rate for Payer: Zelis Medicare |
$411.02
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$580.26
|
| Rate for Payer: Zelis Worker's Compensation |
$79.99
|
|
|
PF HOLTER INTERP
|
Facility
|
OP
|
$940.00
|
|
|
Service Code
|
CPT 93227
|
| Hospital Charge Code |
4009008
|
|
Hospital Revenue Code
|
985
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$893.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$564.00
|
| Rate for Payer: Cash Price |
$564.00
|
| Rate for Payer: Cigna Commercial |
$799.00
|
| Rate for Payer: First Health Commercial |
$846.00
|
| Rate for Payer: First Health Workers Compensation |
$362.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$846.00
|
| Rate for Payer: GEHA Commercial |
$752.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$846.00
|
| Rate for Payer: Humana ChoiceCare |
$244.40
|
| Rate for Payer: Multiplan All |
$855.40
|
| Rate for Payer: New Mexico Health Connections Medicare |
$564.00
|
| Rate for Payer: OMNI Networks Commercial |
$658.00
|
| Rate for Payer: One Health Plan PPO/POS |
$846.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$893.00
|
| Rate for Payer: Three Rivers Provider Network All |
$705.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$827.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$235.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$874.20
|
| Rate for Payer: Zelis Auto |
$376.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$470.00
|
| Rate for Payer: Zelis Worker's Compensation |
$256.62
|
|
|
PF HOLTER INTERP
|
Facility
|
IP
|
$940.00
|
|
|
Service Code
|
CPT 93227
|
| Hospital Charge Code |
4009008
|
|
Hospital Revenue Code
|
985
|
| Min. Negotiated Rate |
$256.62 |
| Max. Negotiated Rate |
$893.00 |
| Rate for Payer: Cash Price |
$564.00
|
| Rate for Payer: Cigna Commercial |
$799.00
|
| Rate for Payer: First Health Commercial |
$846.00
|
| Rate for Payer: First Health Workers Compensation |
$362.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$846.00
|
| Rate for Payer: GEHA Commercial |
$658.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$846.00
|
| Rate for Payer: Multiplan All |
$855.40
|
| Rate for Payer: OMNI Networks Commercial |
$658.00
|
| Rate for Payer: One Health Plan PPO/POS |
$846.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$893.00
|
| Rate for Payer: Three Rivers Provider Network All |
$705.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$874.20
|
| Rate for Payer: Zelis Auto |
$376.00
|
| Rate for Payer: Zelis Worker's Compensation |
$256.62
|
|
|
PF RECONSTRUCT CANAL AUDITORY EXTERNAL
|
Facility
|
IP
|
$2,200.00
|
|
|
Service Code
|
CPT 69310
|
| Hospital Charge Code |
6169434
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$600.60 |
| Max. Negotiated Rate |
$2,090.00 |
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Cigna Commercial |
$1,870.00
|
| Rate for Payer: First Health Commercial |
$1,980.00
|
| Rate for Payer: First Health Workers Compensation |
$849.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,980.00
|
| Rate for Payer: GEHA Commercial |
$1,540.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,980.00
|
| Rate for Payer: Multiplan All |
$2,002.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,540.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,980.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,090.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,650.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,046.00
|
| Rate for Payer: Zelis Auto |
$880.00
|
| Rate for Payer: Zelis Worker's Compensation |
$600.60
|
|
|
PF RECONSTRUCT CANAL AUDITORY EXTERNAL
|
Facility
|
OP
|
$2,200.00
|
|
|
Service Code
|
CPT 69310
|
| Hospital Charge Code |
6169434
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$600.60 |
| Max. Negotiated Rate |
$11,234.32 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$4,345.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,320.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$4,345.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3,442.85
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5,617.16
|
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Cigna Commercial |
$1,870.00
|
| Rate for Payer: First Health Commercial |
$1,980.00
|
| Rate for Payer: First Health Workers Compensation |
$849.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,980.00
|
| Rate for Payer: GEHA Commercial |
$1,760.00
|
| Rate for Payer: GEHA Medicare |
$5,617.16
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,980.00
|
| Rate for Payer: Humana ChoiceCare |
$6,178.88
|
| Rate for Payer: Humana Medicare Advantage |
$5,617.16
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$9,436.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,512.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5,617.16
|
| Rate for Payer: Multiplan All |
$2,002.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9,549.17
|
| Rate for Payer: OMNI Networks Commercial |
$1,540.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,980.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$4,056.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3,512.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5,617.16
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,090.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11,234.32
|
| Rate for Payer: Three Rivers Provider Network All |
$1,650.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,504.82
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,512.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,617.16
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,046.00
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5,617.16
|
| Rate for Payer: Zelis Auto |
$880.00
|
| Rate for Payer: Zelis Medicare |
$4,774.59
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,740.59
|
| Rate for Payer: Zelis Worker's Compensation |
$600.60
|
|
|
PFT COMPLETE
|
Facility
|
OP
|
$831.25
|
|
|
Service Code
|
CPT 94726
|
| Hospital Charge Code |
4094726
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$191.58 |
| Max. Negotiated Rate |
$789.69 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$241.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$498.75
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$241.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$191.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$295.69
|
| Rate for Payer: Cash Price |
$498.75
|
| Rate for Payer: Cash Price |
$498.75
|
| Rate for Payer: Cigna Commercial |
$706.56
|
| Rate for Payer: First Health Commercial |
$748.12
|
| Rate for Payer: First Health Workers Compensation |
$320.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$748.12
|
| Rate for Payer: GEHA Commercial |
$665.00
|
| Rate for Payer: GEHA Medicare |
$295.69
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$748.12
|
| 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 |
$195.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$295.69
|
| Rate for Payer: Multiplan All |
$756.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$502.67
|
| Rate for Payer: OMNI Networks Commercial |
$581.88
|
| Rate for Payer: One Health Plan PPO/POS |
$748.12
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$225.71
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$195.48
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$295.69
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$789.69
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$591.38
|
| Rate for Payer: Three Rivers Provider Network All |
$623.44
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$289.78
|
| Rate for Payer: United Healthcare Commercial |
$706.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$295.69
|
| Rate for Payer: United Payors & United Providers UP&UP |
$773.06
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$295.69
|
| Rate for Payer: Zelis Auto |
$332.50
|
| Rate for Payer: Zelis Medicare |
$251.34
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$354.83
|
| Rate for Payer: Zelis Worker's Compensation |
$226.93
|
|
|
PFT COMPLETE
|
Facility
|
IP
|
$831.25
|
|
|
Service Code
|
CPT 94726
|
| Hospital Charge Code |
4094726
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$226.93 |
| Max. Negotiated Rate |
$789.69 |
| Rate for Payer: Cash Price |
$498.75
|
| Rate for Payer: Cigna Commercial |
$706.56
|
| Rate for Payer: First Health Commercial |
$748.12
|
| Rate for Payer: First Health Workers Compensation |
$320.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$748.12
|
| Rate for Payer: GEHA Commercial |
$581.88
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$748.12
|
| Rate for Payer: Multiplan All |
$756.44
|
| Rate for Payer: OMNI Networks Commercial |
$581.88
|
| Rate for Payer: One Health Plan PPO/POS |
$748.12
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$789.69
|
| Rate for Payer: Three Rivers Provider Network All |
$623.44
|
| Rate for Payer: United Payors & United Providers UP&UP |
$773.06
|
| Rate for Payer: Zelis Auto |
$332.50
|
| Rate for Payer: Zelis Worker's Compensation |
$226.93
|
|
|
PH BODY FLUID REF
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
2300018
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$70.30 |
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$62.90
|
| Rate for Payer: First Health Commercial |
$66.60
|
| Rate for Payer: First Health Workers Compensation |
$6.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$66.60
|
| Rate for Payer: GEHA Commercial |
$51.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$66.60
|
| Rate for Payer: Multiplan All |
$67.34
|
| Rate for Payer: OMNI Networks Commercial |
$51.80
|
| Rate for Payer: One Health Plan PPO/POS |
$66.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$70.30
|
| Rate for Payer: Three Rivers Provider Network All |
$55.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$68.82
|
| Rate for Payer: Zelis Auto |
$29.60
|
| Rate for Payer: Zelis Worker's Compensation |
$4.35
|
|
|
PH BODY FLUID REF
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
2300018
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.04 |
| Max. Negotiated Rate |
$70.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$6.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$44.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$6.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$5.11
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3.58
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$62.90
|
| Rate for Payer: First Health Commercial |
$66.60
|
| Rate for Payer: First Health Workers Compensation |
$6.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$66.60
|
| Rate for Payer: GEHA Commercial |
$59.20
|
| Rate for Payer: GEHA Medicare |
$3.58
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$66.60
|
| Rate for Payer: Humana ChoiceCare |
$3.94
|
| Rate for Payer: Humana Medicare Advantage |
$3.58
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$6.01
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$5.21
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3.58
|
| Rate for Payer: Multiplan All |
$67.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.09
|
| Rate for Payer: OMNI Networks Commercial |
$51.80
|
| Rate for Payer: One Health Plan PPO/POS |
$66.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$6.02
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$5.21
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3.58
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$70.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$7.16
|
| Rate for Payer: Three Rivers Provider Network All |
$55.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.51
|
| Rate for Payer: United Healthcare Commercial |
$62.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$68.82
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3.58
|
| Rate for Payer: Zelis Auto |
$29.60
|
| Rate for Payer: Zelis Medicare |
$3.04
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.30
|
| Rate for Payer: Zelis Worker's Compensation |
$4.35
|
|
|
ph bodyfluid REF011254
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
2200069
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$70.30 |
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$62.90
|
| Rate for Payer: First Health Commercial |
$66.60
|
| Rate for Payer: First Health Workers Compensation |
$6.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$66.60
|
| Rate for Payer: GEHA Commercial |
$51.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$66.60
|
| Rate for Payer: Multiplan All |
$67.34
|
| Rate for Payer: OMNI Networks Commercial |
$51.80
|
| Rate for Payer: One Health Plan PPO/POS |
$66.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$70.30
|
| Rate for Payer: Three Rivers Provider Network All |
$55.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$68.82
|
| Rate for Payer: Zelis Auto |
$29.60
|
| Rate for Payer: Zelis Worker's Compensation |
$4.35
|
|
|
ph bodyfluid REF011254
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
2200069
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.04 |
| Max. Negotiated Rate |
$70.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$6.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$44.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$6.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$5.11
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3.58
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$62.90
|
| Rate for Payer: First Health Commercial |
$66.60
|
| Rate for Payer: First Health Workers Compensation |
$6.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$66.60
|
| Rate for Payer: GEHA Commercial |
$59.20
|
| Rate for Payer: GEHA Medicare |
$3.58
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$66.60
|
| Rate for Payer: Humana ChoiceCare |
$3.94
|
| Rate for Payer: Humana Medicare Advantage |
$3.58
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$6.01
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$5.21
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3.58
|
| Rate for Payer: Multiplan All |
$67.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.09
|
| Rate for Payer: OMNI Networks Commercial |
$51.80
|
| Rate for Payer: One Health Plan PPO/POS |
$66.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$6.02
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$5.21
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3.58
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$70.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$7.16
|
| Rate for Payer: Three Rivers Provider Network All |
$55.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.51
|
| Rate for Payer: United Healthcare Commercial |
$62.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$68.82
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3.58
|
| Rate for Payer: Zelis Auto |
$29.60
|
| Rate for Payer: Zelis Medicare |
$3.04
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.30
|
| Rate for Payer: Zelis Worker's Compensation |
$4.35
|
|
|
PHENAZOPYRIDINE HCL 200 MG TAB
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 65162068210
|
| Hospital Charge Code |
3303259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
PHENAZOPYRIDINE HCL 200 MG TAB
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 65162068210
|
| Hospital Charge Code |
3303259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$4.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Humana ChoiceCare |
$1.30
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.00
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
PHENAZOPYRIDINE HCL TAB 100MG
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 75826011410
|
| Hospital Charge Code |
3300705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
PHENAZOPYRIDINE HCL TAB 100MG
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 75826011410
|
| Hospital Charge Code |
3300705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$4.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Humana ChoiceCare |
$1.30
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.00
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
PHENOBARBITAL 130 MG/1 ML VIAL, INJ
|
Facility
|
OP
|
$418.00
|
|
|
Service Code
|
CPT J2560
|
| Hospital Charge Code |
3303146
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.19 |
| Max. Negotiated Rate |
$397.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$250.80
|
| Rate for Payer: Cash Price |
$250.80
|
| Rate for Payer: Cash Price |
$250.80
|
| Rate for Payer: Cigna Commercial |
$355.30
|
| Rate for Payer: First Health Commercial |
$376.20
|
| Rate for Payer: First Health Workers Compensation |
$161.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$376.20
|
| Rate for Payer: GEHA Commercial |
$33.19
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$376.20
|
| Rate for Payer: Humana ChoiceCare |
$108.68
|
| Rate for Payer: Multiplan All |
$380.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$250.80
|
| Rate for Payer: OMNI Networks Commercial |
$292.60
|
| Rate for Payer: One Health Plan PPO/POS |
$376.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$397.10
|
| Rate for Payer: Three Rivers Provider Network All |
$313.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$367.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$104.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$388.74
|
| Rate for Payer: Zelis Auto |
$167.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$209.00
|
| Rate for Payer: Zelis Worker's Compensation |
$114.11
|
|
|
PHENOBARBITAL 130 MG/1 ML VIAL, INJ
|
Facility
|
IP
|
$418.00
|
|
|
Service Code
|
CPT J2560
|
| Hospital Charge Code |
3303146
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.11 |
| Max. Negotiated Rate |
$397.10 |
| Rate for Payer: Cash Price |
$250.80
|
| Rate for Payer: Cigna Commercial |
$355.30
|
| Rate for Payer: First Health Commercial |
$376.20
|
| Rate for Payer: First Health Workers Compensation |
$161.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$376.20
|
| Rate for Payer: GEHA Commercial |
$292.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$376.20
|
| Rate for Payer: Multiplan All |
$380.38
|
| Rate for Payer: OMNI Networks Commercial |
$292.60
|
| Rate for Payer: One Health Plan PPO/POS |
$376.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$397.10
|
| Rate for Payer: Three Rivers Provider Network All |
$313.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$388.74
|
| Rate for Payer: Zelis Auto |
$167.20
|
| Rate for Payer: Zelis Worker's Compensation |
$114.11
|
|
|
PHENOBARBITAL 30 MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00143150001
|
| Hospital Charge Code |
3302959
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
