|
PHYS/QHP TELEPHONE EVALUATION 5-10 MIN
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
CPT 99441
|
| Hospital Charge Code |
23599441
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$9.28 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cigna Commercial |
$28.90
|
| Rate for Payer: First Health Commercial |
$30.60
|
| Rate for Payer: First Health Workers Compensation |
$13.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$30.60
|
| Rate for Payer: GEHA Commercial |
$23.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$30.60
|
| Rate for Payer: Multiplan All |
$30.94
|
| Rate for Payer: OMNI Networks Commercial |
$23.80
|
| Rate for Payer: One Health Plan PPO/POS |
$30.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$32.30
|
| Rate for Payer: Three Rivers Provider Network All |
$25.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$31.62
|
| Rate for Payer: Zelis Auto |
$13.60
|
| Rate for Payer: Zelis Worker's Compensation |
$9.28
|
|
|
PHYS/QHP TELEPHONE EVALUATION 5-10 MIN
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
9799441
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$20.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.46
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cigna Commercial |
$28.90
|
| Rate for Payer: First Health Commercial |
$30.60
|
| Rate for Payer: First Health Workers Compensation |
$13.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$30.60
|
| Rate for Payer: GEHA Commercial |
$27.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$30.60
|
| Rate for Payer: Humana ChoiceCare |
$8.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$16.79
|
| Rate for Payer: Multiplan All |
$30.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$20.40
|
| Rate for Payer: OMNI Networks Commercial |
$23.80
|
| Rate for Payer: One Health Plan PPO/POS |
$30.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$19.39
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$16.79
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$32.30
|
| Rate for Payer: Three Rivers Provider Network All |
$25.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$29.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.79
|
| Rate for Payer: United Payors & United Providers UP&UP |
$31.62
|
| Rate for Payer: Zelis Auto |
$13.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.28
|
|
|
PHYS/QHP TELEPHONE EVALUATION 5-10 MIN
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
CPT 99441
|
| Hospital Charge Code |
1900062
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$29.48 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$91.80
|
| Rate for Payer: First Health Commercial |
$97.20
|
| Rate for Payer: First Health Workers Compensation |
$41.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$97.20
|
| Rate for Payer: GEHA Commercial |
$75.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$97.20
|
| Rate for Payer: Multiplan All |
$98.28
|
| Rate for Payer: OMNI Networks Commercial |
$75.60
|
| Rate for Payer: One Health Plan PPO/POS |
$97.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$102.60
|
| Rate for Payer: Three Rivers Provider Network All |
$81.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$100.44
|
| Rate for Payer: Zelis Auto |
$43.20
|
| Rate for Payer: Zelis Worker's Compensation |
$29.48
|
|
|
PHYS/QHP TELEPHONE EVALUATION 5-10 MIN
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
CPT 99441
|
| Hospital Charge Code |
23599441
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$20.40
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cigna Commercial |
$28.90
|
| Rate for Payer: First Health Commercial |
$30.60
|
| Rate for Payer: First Health Workers Compensation |
$13.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$30.60
|
| Rate for Payer: GEHA Commercial |
$27.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$30.60
|
| Rate for Payer: Humana ChoiceCare |
$8.84
|
| Rate for Payer: Multiplan All |
$30.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$20.40
|
| Rate for Payer: OMNI Networks Commercial |
$23.80
|
| Rate for Payer: One Health Plan PPO/POS |
$30.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$32.30
|
| Rate for Payer: Three Rivers Provider Network All |
$25.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$29.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$31.62
|
| Rate for Payer: Zelis Auto |
$13.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.28
|
|
|
PHYS RE-CERT MCR-COVR HOM HLTH SRVC
|
Facility
|
OP
|
$195.00
|
|
|
Service Code
|
CPT G0179
|
| Hospital Charge Code |
8500179
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$48.75 |
| Max. Negotiated Rate |
$185.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$117.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$165.75
|
| Rate for Payer: First Health Commercial |
$175.50
|
| Rate for Payer: First Health Workers Compensation |
$75.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$175.50
|
| Rate for Payer: GEHA Commercial |
$156.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$175.50
|
| Rate for Payer: Humana ChoiceCare |
$50.70
|
| Rate for Payer: Multiplan All |
$177.45
|
| Rate for Payer: New Mexico Health Connections Medicare |
$117.00
|
| Rate for Payer: OMNI Networks Commercial |
$136.50
|
| Rate for Payer: One Health Plan PPO/POS |
$175.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$185.25
|
| Rate for Payer: Three Rivers Provider Network All |
$146.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$171.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$48.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$181.35
|
| Rate for Payer: Zelis Auto |
$78.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$97.50
|
| Rate for Payer: Zelis Worker's Compensation |
$53.23
|
|
|
PHYS RE-CERT MCR-COVR HOM HLTH SRVC
|
Facility
|
IP
|
$195.00
|
|
|
Service Code
|
CPT G0179
|
| Hospital Charge Code |
8500179
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$53.23 |
| Max. Negotiated Rate |
$185.25 |
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$165.75
|
| Rate for Payer: First Health Commercial |
$175.50
|
| Rate for Payer: First Health Workers Compensation |
$75.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$175.50
|
| Rate for Payer: GEHA Commercial |
$136.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$175.50
|
| Rate for Payer: Multiplan All |
$177.45
|
| Rate for Payer: OMNI Networks Commercial |
$136.50
|
| Rate for Payer: One Health Plan PPO/POS |
$175.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$185.25
|
| Rate for Payer: Three Rivers Provider Network All |
$146.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$181.35
|
| Rate for Payer: Zelis Auto |
$78.00
|
| Rate for Payer: Zelis Worker's Compensation |
$53.23
|
|
|
PHYS SUPV PT RECV MCR-COVR HOM HLTH
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
CPT G0181
|
| Hospital Charge Code |
8500181
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$67.50 |
| Max. Negotiated Rate |
$256.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$162.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$229.50
|
| Rate for Payer: First Health Commercial |
$243.00
|
| Rate for Payer: First Health Workers Compensation |
$104.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$243.00
|
| Rate for Payer: GEHA Commercial |
$216.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$243.00
|
| Rate for Payer: Humana ChoiceCare |
$70.20
|
| Rate for Payer: Multiplan All |
$245.70
|
| Rate for Payer: New Mexico Health Connections Medicare |
$162.00
|
| Rate for Payer: OMNI Networks Commercial |
$189.00
|
| Rate for Payer: One Health Plan PPO/POS |
$243.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$256.50
|
| Rate for Payer: Three Rivers Provider Network All |
$202.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$237.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$67.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$251.10
|
| Rate for Payer: Zelis Auto |
$108.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$135.00
|
| Rate for Payer: Zelis Worker's Compensation |
$73.71
|
|
|
PHYS SUPV PT RECV MCR-COVR HOM HLTH
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
CPT G0181
|
| Hospital Charge Code |
8500181
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$73.71 |
| Max. Negotiated Rate |
$256.50 |
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$229.50
|
| Rate for Payer: First Health Commercial |
$243.00
|
| Rate for Payer: First Health Workers Compensation |
$104.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$243.00
|
| Rate for Payer: GEHA Commercial |
$189.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$243.00
|
| Rate for Payer: Multiplan All |
$245.70
|
| Rate for Payer: OMNI Networks Commercial |
$189.00
|
| Rate for Payer: One Health Plan PPO/POS |
$243.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$256.50
|
| Rate for Payer: Three Rivers Provider Network All |
$202.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$251.10
|
| Rate for Payer: Zelis Auto |
$108.00
|
| Rate for Payer: Zelis Worker's Compensation |
$73.71
|
|
|
PHYS SUPV PT UND MCR-APPRVD HOSPICE
|
Facility
|
IP
|
$951.00
|
|
|
Service Code
|
CPT G0182
|
| Hospital Charge Code |
8500182
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$259.62 |
| Max. Negotiated Rate |
$903.45 |
| Rate for Payer: Cash Price |
$570.60
|
| Rate for Payer: Cigna Commercial |
$808.35
|
| Rate for Payer: First Health Commercial |
$855.90
|
| Rate for Payer: First Health Workers Compensation |
$367.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$855.90
|
| Rate for Payer: GEHA Commercial |
$665.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$855.90
|
| Rate for Payer: Multiplan All |
$865.41
|
| Rate for Payer: OMNI Networks Commercial |
$665.70
|
| Rate for Payer: One Health Plan PPO/POS |
$855.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$903.45
|
| Rate for Payer: Three Rivers Provider Network All |
$713.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$884.43
|
| Rate for Payer: Zelis Auto |
$380.40
|
| Rate for Payer: Zelis Worker's Compensation |
$259.62
|
|
|
PHYS SUPV PT UND MCR-APPRVD HOSPICE
|
Facility
|
OP
|
$951.00
|
|
|
Service Code
|
CPT G0182
|
| Hospital Charge Code |
8500182
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$237.75 |
| Max. Negotiated Rate |
$903.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$570.60
|
| Rate for Payer: Cash Price |
$570.60
|
| Rate for Payer: Cigna Commercial |
$808.35
|
| Rate for Payer: First Health Commercial |
$855.90
|
| Rate for Payer: First Health Workers Compensation |
$367.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$855.90
|
| Rate for Payer: GEHA Commercial |
$760.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$855.90
|
| Rate for Payer: Humana ChoiceCare |
$247.26
|
| Rate for Payer: Multiplan All |
$865.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$570.60
|
| Rate for Payer: OMNI Networks Commercial |
$665.70
|
| Rate for Payer: One Health Plan PPO/POS |
$855.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$903.45
|
| Rate for Payer: Three Rivers Provider Network All |
$713.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$836.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$237.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$884.43
|
| Rate for Payer: Zelis Auto |
$380.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$475.50
|
| Rate for Payer: Zelis Worker's Compensation |
$259.62
|
|
|
PHYTONADIONE INJ 10MG/ML - ADULT
|
Facility
|
IP
|
$333.00
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
3300719
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$90.91 |
| Max. Negotiated Rate |
$316.35 |
| Rate for Payer: Cash Price |
$199.80
|
| Rate for Payer: Cigna Commercial |
$283.05
|
| Rate for Payer: First Health Commercial |
$299.70
|
| Rate for Payer: First Health Workers Compensation |
$128.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$299.70
|
| Rate for Payer: GEHA Commercial |
$233.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$299.70
|
| Rate for Payer: Multiplan All |
$303.03
|
| Rate for Payer: OMNI Networks Commercial |
$233.10
|
| Rate for Payer: One Health Plan PPO/POS |
$299.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$316.35
|
| Rate for Payer: Three Rivers Provider Network All |
$249.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$309.69
|
| Rate for Payer: Zelis Auto |
$133.20
|
| Rate for Payer: Zelis Worker's Compensation |
$90.91
|
|
|
PHYTONADIONE INJ 10MG/ML - ADULT
|
Facility
|
OP
|
$333.00
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
3300719
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$316.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$199.80
|
| Rate for Payer: Cash Price |
$199.80
|
| Rate for Payer: Cash Price |
$199.80
|
| Rate for Payer: Cigna Commercial |
$283.05
|
| Rate for Payer: First Health Commercial |
$299.70
|
| Rate for Payer: First Health Workers Compensation |
$128.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$299.70
|
| Rate for Payer: GEHA Commercial |
$3.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$299.70
|
| Rate for Payer: Humana ChoiceCare |
$86.58
|
| Rate for Payer: Multiplan All |
$303.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$199.80
|
| Rate for Payer: OMNI Networks Commercial |
$233.10
|
| Rate for Payer: One Health Plan PPO/POS |
$299.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$316.35
|
| Rate for Payer: Three Rivers Provider Network All |
$249.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$293.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$83.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$309.69
|
| Rate for Payer: Zelis Auto |
$133.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$166.50
|
| Rate for Payer: Zelis Worker's Compensation |
$90.91
|
|
|
PHYTONADIONE TAB 5MG
|
Facility
|
OP
|
$99.00
|
|
|
Service Code
|
NDC 00187170405
|
| Hospital Charge Code |
3300721
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$84.15
|
| Rate for Payer: First Health Commercial |
$89.10
|
| Rate for Payer: First Health Workers Compensation |
$38.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$89.10
|
| Rate for Payer: GEHA Commercial |
$79.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$89.10
|
| Rate for Payer: Humana ChoiceCare |
$25.74
|
| Rate for Payer: Multiplan All |
$90.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$59.40
|
| Rate for Payer: OMNI Networks Commercial |
$69.30
|
| Rate for Payer: One Health Plan PPO/POS |
$89.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$94.05
|
| Rate for Payer: Three Rivers Provider Network All |
$74.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$87.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$24.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$92.07
|
| Rate for Payer: Zelis Auto |
$39.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$49.50
|
| Rate for Payer: Zelis Worker's Compensation |
$27.03
|
|
|
PHYTONADIONE TAB 5MG
|
Facility
|
IP
|
$99.00
|
|
|
Service Code
|
NDC 00187170405
|
| Hospital Charge Code |
3300721
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.03 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$84.15
|
| Rate for Payer: First Health Commercial |
$89.10
|
| Rate for Payer: First Health Workers Compensation |
$38.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$89.10
|
| Rate for Payer: GEHA Commercial |
$69.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$89.10
|
| Rate for Payer: Multiplan All |
$90.09
|
| Rate for Payer: OMNI Networks Commercial |
$69.30
|
| Rate for Payer: One Health Plan PPO/POS |
$89.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$94.05
|
| Rate for Payer: Three Rivers Provider Network All |
$74.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$92.07
|
| Rate for Payer: Zelis Auto |
$39.60
|
| Rate for Payer: Zelis Worker's Compensation |
$27.03
|
|
|
PICC LINE PLACEMENT
|
Facility
|
OP
|
$3,048.00
|
|
| Hospital Charge Code |
8136569
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$762.00 |
| Max. Negotiated Rate |
$2,895.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,828.80
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$2,590.80
|
| Rate for Payer: First Health Commercial |
$2,743.20
|
| Rate for Payer: First Health Workers Compensation |
$1,176.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,743.20
|
| Rate for Payer: GEHA Commercial |
$2,438.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,743.20
|
| Rate for Payer: Humana ChoiceCare |
$792.48
|
| Rate for Payer: Multiplan All |
$2,773.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,828.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,133.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,743.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,895.60
|
| Rate for Payer: Three Rivers Provider Network All |
$2,286.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,682.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$762.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,834.64
|
| Rate for Payer: Zelis Auto |
$1,219.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,524.00
|
| Rate for Payer: Zelis Worker's Compensation |
$832.10
|
|
|
PICC LINE PLACEMENT
|
Facility
|
IP
|
$3,048.00
|
|
| Hospital Charge Code |
8136569
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$832.10 |
| Max. Negotiated Rate |
$2,895.60 |
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$2,590.80
|
| Rate for Payer: First Health Commercial |
$2,743.20
|
| Rate for Payer: First Health Workers Compensation |
$1,176.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,743.20
|
| Rate for Payer: GEHA Commercial |
$2,133.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,743.20
|
| Rate for Payer: Multiplan All |
$2,773.68
|
| Rate for Payer: OMNI Networks Commercial |
$2,133.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,743.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,895.60
|
| Rate for Payer: Three Rivers Provider Network All |
$2,286.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,834.64
|
| Rate for Payer: Zelis Auto |
$1,219.20
|
| Rate for Payer: Zelis Worker's Compensation |
$832.10
|
|
|
PICO DRESSING 10 X 20
|
Facility
|
OP
|
$1,203.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7009206
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$300.75 |
| Max. Negotiated Rate |
$1,142.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$721.80
|
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Cigna Commercial |
$1,022.55
|
| Rate for Payer: First Health Commercial |
$1,082.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,082.70
|
| Rate for Payer: GEHA Commercial |
$962.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,082.70
|
| Rate for Payer: Humana ChoiceCare |
$312.78
|
| Rate for Payer: Multiplan All |
$1,094.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$721.80
|
| Rate for Payer: OMNI Networks Commercial |
$842.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,082.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,142.85
|
| Rate for Payer: Three Rivers Provider Network All |
$902.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,058.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$300.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,118.79
|
| Rate for Payer: Zelis Auto |
$481.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$601.50
|
|
|
PICO DRESSING 10 X 20
|
Facility
|
IP
|
$1,203.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7009206
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$481.20 |
| Max. Negotiated Rate |
$1,142.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$962.40
|
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Cigna Commercial |
$1,022.55
|
| Rate for Payer: First Health Commercial |
$1,082.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,082.70
|
| Rate for Payer: GEHA Commercial |
$842.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,082.70
|
| Rate for Payer: Multiplan All |
$1,094.73
|
| Rate for Payer: OMNI Networks Commercial |
$842.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,082.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,142.85
|
| Rate for Payer: Three Rivers Provider Network All |
$902.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,118.79
|
| Rate for Payer: Zelis Auto |
$481.20
|
|
|
PICO DRESSING 15 X 15
|
Facility
|
IP
|
$2,742.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7009207
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,096.80 |
| Max. Negotiated Rate |
$2,604.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,193.60
|
| Rate for Payer: Cash Price |
$1,645.20
|
| Rate for Payer: Cash Price |
$1,645.20
|
| Rate for Payer: Cigna Commercial |
$2,330.70
|
| Rate for Payer: First Health Commercial |
$2,467.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,467.80
|
| Rate for Payer: GEHA Commercial |
$1,919.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,467.80
|
| Rate for Payer: Multiplan All |
$2,495.22
|
| Rate for Payer: OMNI Networks Commercial |
$1,919.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,467.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,604.90
|
| Rate for Payer: Three Rivers Provider Network All |
$2,056.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,550.06
|
| Rate for Payer: Zelis Auto |
$1,096.80
|
|
|
PICO DRESSING 15 X 15
|
Facility
|
OP
|
$2,742.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7009207
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$685.50 |
| Max. Negotiated Rate |
$2,604.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,645.20
|
| Rate for Payer: Cash Price |
$1,645.20
|
| Rate for Payer: Cash Price |
$1,645.20
|
| Rate for Payer: Cigna Commercial |
$2,330.70
|
| Rate for Payer: First Health Commercial |
$2,467.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,467.80
|
| Rate for Payer: GEHA Commercial |
$2,193.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,467.80
|
| Rate for Payer: Humana ChoiceCare |
$712.92
|
| Rate for Payer: Multiplan All |
$2,495.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,645.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,919.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,467.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,604.90
|
| Rate for Payer: Three Rivers Provider Network All |
$2,056.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,412.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$685.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,550.06
|
| Rate for Payer: Zelis Auto |
$1,096.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,371.00
|
|
|
PILL SPLITTER
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 07957300115
|
| Hospital Charge Code |
3301131
|
|
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
|
|
|
PILL SPLITTER
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 07957300115
|
| Hospital Charge Code |
3301131
|
|
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
|
|
|
PILOCARPINE HCL OPTH SOLN 1%
|
Facility
|
IP
|
$359.00
|
|
|
Service Code
|
NDC 61314020315
|
| Hospital Charge Code |
3300722
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.01 |
| Max. Negotiated Rate |
$341.05 |
| Rate for Payer: Cash Price |
$215.40
|
| Rate for Payer: Cigna Commercial |
$305.15
|
| Rate for Payer: First Health Commercial |
$323.10
|
| Rate for Payer: First Health Workers Compensation |
$138.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$323.10
|
| Rate for Payer: GEHA Commercial |
$251.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$323.10
|
| Rate for Payer: Multiplan All |
$326.69
|
| Rate for Payer: OMNI Networks Commercial |
$251.30
|
| Rate for Payer: One Health Plan PPO/POS |
$323.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$341.05
|
| Rate for Payer: Three Rivers Provider Network All |
$269.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$333.87
|
| Rate for Payer: Zelis Auto |
$143.60
|
| Rate for Payer: Zelis Worker's Compensation |
$98.01
|
|
|
PILOCARPINE HCL OPTH SOLN 1%
|
Facility
|
OP
|
$359.00
|
|
|
Service Code
|
NDC 61314020315
|
| Hospital Charge Code |
3300722
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.75 |
| Max. Negotiated Rate |
$341.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$215.40
|
| Rate for Payer: Cash Price |
$215.40
|
| Rate for Payer: Cigna Commercial |
$305.15
|
| Rate for Payer: First Health Commercial |
$323.10
|
| Rate for Payer: First Health Workers Compensation |
$138.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$323.10
|
| Rate for Payer: GEHA Commercial |
$287.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$323.10
|
| Rate for Payer: Humana ChoiceCare |
$93.34
|
| Rate for Payer: Multiplan All |
$326.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$215.40
|
| Rate for Payer: OMNI Networks Commercial |
$251.30
|
| Rate for Payer: One Health Plan PPO/POS |
$323.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$341.05
|
| Rate for Payer: Three Rivers Provider Network All |
$269.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$315.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$89.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$333.87
|
| Rate for Payer: Zelis Auto |
$143.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$179.50
|
| Rate for Payer: Zelis Worker's Compensation |
$98.01
|
|
|
PILOCARPINE HCL OPTH SOLN 2%
|
Facility
|
IP
|
$365.00
|
|
|
Service Code
|
NDC 61314020415
|
| Hospital Charge Code |
3300723
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.64 |
| Max. Negotiated Rate |
$346.75 |
| Rate for Payer: Cash Price |
$219.00
|
| Rate for Payer: Cigna Commercial |
$310.25
|
| Rate for Payer: First Health Commercial |
$328.50
|
| Rate for Payer: First Health Workers Compensation |
$140.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$328.50
|
| Rate for Payer: GEHA Commercial |
$255.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$328.50
|
| Rate for Payer: Multiplan All |
$332.15
|
| Rate for Payer: OMNI Networks Commercial |
$255.50
|
| Rate for Payer: One Health Plan PPO/POS |
$328.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$346.75
|
| Rate for Payer: Three Rivers Provider Network All |
$273.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$339.45
|
| Rate for Payer: Zelis Auto |
$146.00
|
| Rate for Payer: Zelis Worker's Compensation |
$99.64
|
|
