|
POWERPORT 9.6FR IVU SYSTEM
|
Facility
|
OP
|
$1,309.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
7003204
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$327.25 |
| Max. Negotiated Rate |
$1,243.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$785.40
|
| Rate for Payer: Cash Price |
$785.40
|
| Rate for Payer: Cash Price |
$785.40
|
| Rate for Payer: Cigna Commercial |
$1,112.65
|
| Rate for Payer: First Health Commercial |
$1,178.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,178.10
|
| Rate for Payer: GEHA Commercial |
$1,047.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,178.10
|
| Rate for Payer: Humana ChoiceCare |
$340.34
|
| Rate for Payer: Multiplan All |
$1,191.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$785.40
|
| Rate for Payer: OMNI Networks Commercial |
$916.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,178.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,243.55
|
| Rate for Payer: Three Rivers Provider Network All |
$981.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,151.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$327.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,217.37
|
| Rate for Payer: Zelis Auto |
$523.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$654.50
|
|
|
POWERPORT 9.6FR IVU SYSTEM
|
Facility
|
IP
|
$1,309.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
7003204
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$523.60 |
| Max. Negotiated Rate |
$1,243.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,047.20
|
| Rate for Payer: Cash Price |
$785.40
|
| Rate for Payer: Cash Price |
$785.40
|
| Rate for Payer: Cigna Commercial |
$1,112.65
|
| Rate for Payer: First Health Commercial |
$1,178.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,178.10
|
| Rate for Payer: GEHA Commercial |
$916.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,178.10
|
| Rate for Payer: Multiplan All |
$1,191.19
|
| Rate for Payer: OMNI Networks Commercial |
$916.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,178.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,243.55
|
| Rate for Payer: Three Rivers Provider Network All |
$981.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,217.37
|
| Rate for Payer: Zelis Auto |
$523.60
|
|
|
POWERPORT 9FR INTRO SYSTEM
|
Facility
|
IP
|
$1,309.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
7003196
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$523.60 |
| Max. Negotiated Rate |
$1,243.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,047.20
|
| Rate for Payer: Cash Price |
$785.40
|
| Rate for Payer: Cash Price |
$785.40
|
| Rate for Payer: Cigna Commercial |
$1,112.65
|
| Rate for Payer: First Health Commercial |
$1,178.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,178.10
|
| Rate for Payer: GEHA Commercial |
$916.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,178.10
|
| Rate for Payer: Multiplan All |
$1,191.19
|
| Rate for Payer: OMNI Networks Commercial |
$916.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,178.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,243.55
|
| Rate for Payer: Three Rivers Provider Network All |
$981.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,217.37
|
| Rate for Payer: Zelis Auto |
$523.60
|
|
|
POWERPORT 9FR INTRO SYSTEM
|
Facility
|
OP
|
$1,309.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
7003196
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$327.25 |
| Max. Negotiated Rate |
$1,243.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$785.40
|
| Rate for Payer: Cash Price |
$785.40
|
| Rate for Payer: Cash Price |
$785.40
|
| Rate for Payer: Cigna Commercial |
$1,112.65
|
| Rate for Payer: First Health Commercial |
$1,178.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,178.10
|
| Rate for Payer: GEHA Commercial |
$1,047.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,178.10
|
| Rate for Payer: Humana ChoiceCare |
$340.34
|
| Rate for Payer: Multiplan All |
$1,191.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$785.40
|
| Rate for Payer: OMNI Networks Commercial |
$916.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,178.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,243.55
|
| Rate for Payer: Three Rivers Provider Network All |
$981.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,151.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$327.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,217.37
|
| Rate for Payer: Zelis Auto |
$523.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$654.50
|
|
|
POWERPORT 9FR INTRO SYSTEM
|
Facility
|
IP
|
$1,061.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
90030024
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$424.40 |
| Max. Negotiated Rate |
$1,007.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$848.80
|
| Rate for Payer: Cash Price |
$636.60
|
| Rate for Payer: Cash Price |
$636.60
|
| Rate for Payer: Cigna Commercial |
$901.85
|
| Rate for Payer: First Health Commercial |
$954.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$954.90
|
| Rate for Payer: GEHA Commercial |
$742.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$954.90
|
| Rate for Payer: Multiplan All |
$965.51
|
| Rate for Payer: OMNI Networks Commercial |
$742.70
|
| Rate for Payer: One Health Plan PPO/POS |
$954.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,007.95
|
| Rate for Payer: Three Rivers Provider Network All |
$795.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$986.73
|
| Rate for Payer: Zelis Auto |
$424.40
|
|
|
POWERPORT 9FR INTRO SYSTEM
|
Facility
|
OP
|
$1,061.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
90030024
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$265.25 |
| Max. Negotiated Rate |
$1,007.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$636.60
|
| Rate for Payer: Cash Price |
$636.60
|
| Rate for Payer: Cash Price |
$636.60
|
| Rate for Payer: Cigna Commercial |
$901.85
|
| Rate for Payer: First Health Commercial |
$954.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$954.90
|
| Rate for Payer: GEHA Commercial |
$848.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$954.90
|
| Rate for Payer: Humana ChoiceCare |
$275.86
|
| Rate for Payer: Multiplan All |
$965.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$636.60
|
| Rate for Payer: OMNI Networks Commercial |
$742.70
|
| Rate for Payer: One Health Plan PPO/POS |
$954.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,007.95
|
| Rate for Payer: Three Rivers Provider Network All |
$795.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$933.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$265.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$986.73
|
| Rate for Payer: Zelis Auto |
$424.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$530.50
|
|
|
POWERPORT CLEARVUE ISP 8F CHRONOFLEX CAT
|
Facility
|
OP
|
$1,707.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
90030025
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$426.75 |
| Max. Negotiated Rate |
$1,621.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,024.20
|
| Rate for Payer: Cash Price |
$1,024.20
|
| Rate for Payer: Cash Price |
$1,024.20
|
| Rate for Payer: Cigna Commercial |
$1,450.95
|
| Rate for Payer: First Health Commercial |
$1,536.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,536.30
|
| Rate for Payer: GEHA Commercial |
$1,365.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,536.30
|
| Rate for Payer: Humana ChoiceCare |
$443.82
|
| Rate for Payer: Multiplan All |
$1,553.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,024.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,194.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,536.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,621.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,280.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,502.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$426.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,587.51
|
| Rate for Payer: Zelis Auto |
$682.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$853.50
|
|
|
POWERPORT CLEARVUE ISP 8F CHRONOFLEX CAT
|
Facility
|
OP
|
$1,707.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
7003197
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$426.75 |
| Max. Negotiated Rate |
$1,621.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,024.20
|
| Rate for Payer: Cash Price |
$1,024.20
|
| Rate for Payer: Cash Price |
$1,024.20
|
| Rate for Payer: Cigna Commercial |
$1,450.95
|
| Rate for Payer: First Health Commercial |
$1,536.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,536.30
|
| Rate for Payer: GEHA Commercial |
$1,365.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,536.30
|
| Rate for Payer: Humana ChoiceCare |
$443.82
|
| Rate for Payer: Multiplan All |
$1,553.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,024.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,194.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,536.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,621.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,280.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,502.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$426.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,587.51
|
| Rate for Payer: Zelis Auto |
$682.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$853.50
|
|
|
POWERPORT CLEARVUE ISP 8F CHRONOFLEX CAT
|
Facility
|
IP
|
$1,707.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
90030025
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$682.80 |
| Max. Negotiated Rate |
$1,621.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,365.60
|
| Rate for Payer: Cash Price |
$1,024.20
|
| Rate for Payer: Cash Price |
$1,024.20
|
| Rate for Payer: Cigna Commercial |
$1,450.95
|
| Rate for Payer: First Health Commercial |
$1,536.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,536.30
|
| Rate for Payer: GEHA Commercial |
$1,194.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,536.30
|
| Rate for Payer: Multiplan All |
$1,553.37
|
| Rate for Payer: OMNI Networks Commercial |
$1,194.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,536.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,621.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,280.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,587.51
|
| Rate for Payer: Zelis Auto |
$682.80
|
|
|
POWERPORT CLEARVUE ISP 8F CHRONOFLEX CAT
|
Facility
|
IP
|
$1,707.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
7003197
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$682.80 |
| Max. Negotiated Rate |
$1,621.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,365.60
|
| Rate for Payer: Cash Price |
$1,024.20
|
| Rate for Payer: Cash Price |
$1,024.20
|
| Rate for Payer: Cigna Commercial |
$1,450.95
|
| Rate for Payer: First Health Commercial |
$1,536.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,536.30
|
| Rate for Payer: GEHA Commercial |
$1,194.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,536.30
|
| Rate for Payer: Multiplan All |
$1,553.37
|
| Rate for Payer: OMNI Networks Commercial |
$1,194.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,536.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,621.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,280.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,587.51
|
| Rate for Payer: Zelis Auto |
$682.80
|
|
|
PPH03 HEMMOROID STAPLER
|
Facility
|
OP
|
$625.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006716
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$156.25 |
| Max. Negotiated Rate |
$593.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$531.25
|
| Rate for Payer: First Health Commercial |
$562.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$562.50
|
| Rate for Payer: GEHA Commercial |
$500.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$562.50
|
| Rate for Payer: Humana ChoiceCare |
$162.50
|
| Rate for Payer: Multiplan All |
$568.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$375.00
|
| Rate for Payer: OMNI Networks Commercial |
$437.50
|
| Rate for Payer: One Health Plan PPO/POS |
$562.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$593.75
|
| Rate for Payer: Three Rivers Provider Network All |
$468.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$550.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$156.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$581.25
|
| Rate for Payer: Zelis Auto |
$250.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$312.50
|
|
|
PPH03 HEMMOROID STAPLER
|
Facility
|
IP
|
$625.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006716
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$250.00 |
| Max. Negotiated Rate |
$593.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$500.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$531.25
|
| Rate for Payer: First Health Commercial |
$562.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$562.50
|
| Rate for Payer: GEHA Commercial |
$437.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$562.50
|
| Rate for Payer: Multiplan All |
$568.75
|
| Rate for Payer: OMNI Networks Commercial |
$437.50
|
| Rate for Payer: One Health Plan PPO/POS |
$562.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$593.75
|
| Rate for Payer: Three Rivers Provider Network All |
$468.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$581.25
|
| Rate for Payer: Zelis Auto |
$250.00
|
|
|
PPN CENTRAL 4.25/10+E 2L
|
Facility
|
OP
|
$487.00
|
|
|
Service Code
|
NDC 00338111504
|
| Hospital Charge Code |
3300909
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$121.75 |
| Max. Negotiated Rate |
$462.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$292.20
|
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cigna Commercial |
$413.95
|
| Rate for Payer: First Health Commercial |
$438.30
|
| Rate for Payer: First Health Workers Compensation |
$188.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$438.30
|
| Rate for Payer: GEHA Commercial |
$389.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$438.30
|
| Rate for Payer: Humana ChoiceCare |
$126.62
|
| Rate for Payer: Multiplan All |
$443.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$292.20
|
| Rate for Payer: OMNI Networks Commercial |
$340.90
|
| Rate for Payer: One Health Plan PPO/POS |
$438.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$462.65
|
| Rate for Payer: Three Rivers Provider Network All |
$365.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$428.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$121.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$452.91
|
| Rate for Payer: Zelis Auto |
$194.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$243.50
|
| Rate for Payer: Zelis Worker's Compensation |
$132.95
|
|
|
PPN CENTRAL 4.25/10+E 2L
|
Facility
|
IP
|
$487.00
|
|
|
Service Code
|
NDC 00338111504
|
| Hospital Charge Code |
3300909
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$132.95 |
| Max. Negotiated Rate |
$462.65 |
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cigna Commercial |
$413.95
|
| Rate for Payer: First Health Commercial |
$438.30
|
| Rate for Payer: First Health Workers Compensation |
$188.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$438.30
|
| Rate for Payer: GEHA Commercial |
$340.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$438.30
|
| Rate for Payer: Multiplan All |
$443.17
|
| Rate for Payer: OMNI Networks Commercial |
$340.90
|
| Rate for Payer: One Health Plan PPO/POS |
$438.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$462.65
|
| Rate for Payer: Three Rivers Provider Network All |
$365.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$452.91
|
| Rate for Payer: Zelis Auto |
$194.80
|
| Rate for Payer: Zelis Worker's Compensation |
$132.95
|
|
|
PPN PERIPH 4.25/5+E 1L
|
Facility
|
IP
|
$258.00
|
|
|
Service Code
|
NDC 00338114403
|
| Hospital Charge Code |
3303229
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.43 |
| Max. Negotiated Rate |
$245.10 |
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$219.30
|
| Rate for Payer: First Health Commercial |
$232.20
|
| Rate for Payer: First Health Workers Compensation |
$99.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$232.20
|
| Rate for Payer: GEHA Commercial |
$180.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$232.20
|
| Rate for Payer: Multiplan All |
$234.78
|
| Rate for Payer: OMNI Networks Commercial |
$180.60
|
| Rate for Payer: One Health Plan PPO/POS |
$232.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$245.10
|
| Rate for Payer: Three Rivers Provider Network All |
$193.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$239.94
|
| Rate for Payer: Zelis Auto |
$103.20
|
| Rate for Payer: Zelis Worker's Compensation |
$70.43
|
|
|
PPN PERIPH 4.25/5+E 1L
|
Facility
|
OP
|
$258.00
|
|
|
Service Code
|
NDC 00338114403
|
| Hospital Charge Code |
3303229
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.50 |
| Max. Negotiated Rate |
$245.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$154.80
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$219.30
|
| Rate for Payer: First Health Commercial |
$232.20
|
| Rate for Payer: First Health Workers Compensation |
$99.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$232.20
|
| Rate for Payer: GEHA Commercial |
$206.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$232.20
|
| Rate for Payer: Humana ChoiceCare |
$67.08
|
| Rate for Payer: Multiplan All |
$234.78
|
| Rate for Payer: New Mexico Health Connections Medicare |
$154.80
|
| Rate for Payer: OMNI Networks Commercial |
$180.60
|
| Rate for Payer: One Health Plan PPO/POS |
$232.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$245.10
|
| Rate for Payer: Three Rivers Provider Network All |
$193.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$227.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$64.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$239.94
|
| Rate for Payer: Zelis Auto |
$103.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$129.00
|
| Rate for Payer: Zelis Worker's Compensation |
$70.43
|
|
|
PPN PERIPH 4.25/5+E 2L
|
Facility
|
OP
|
$466.00
|
|
|
Service Code
|
NDC 00338111304
|
| Hospital Charge Code |
3300910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$116.50 |
| Max. Negotiated Rate |
$442.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$279.60
|
| Rate for Payer: Cash Price |
$279.60
|
| Rate for Payer: Cigna Commercial |
$396.10
|
| Rate for Payer: First Health Commercial |
$419.40
|
| Rate for Payer: First Health Workers Compensation |
$179.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$419.40
|
| Rate for Payer: GEHA Commercial |
$372.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$419.40
|
| Rate for Payer: Humana ChoiceCare |
$121.16
|
| Rate for Payer: Multiplan All |
$424.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$279.60
|
| Rate for Payer: OMNI Networks Commercial |
$326.20
|
| Rate for Payer: One Health Plan PPO/POS |
$419.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$442.70
|
| Rate for Payer: Three Rivers Provider Network All |
$349.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$410.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$116.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$433.38
|
| Rate for Payer: Zelis Auto |
$186.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$233.00
|
| Rate for Payer: Zelis Worker's Compensation |
$127.22
|
|
|
PPN PERIPH 4.25/5+E 2L
|
Facility
|
IP
|
$466.00
|
|
|
Service Code
|
NDC 00338111304
|
| Hospital Charge Code |
3300910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$127.22 |
| Max. Negotiated Rate |
$442.70 |
| Rate for Payer: Cash Price |
$279.60
|
| Rate for Payer: Cigna Commercial |
$396.10
|
| Rate for Payer: First Health Commercial |
$419.40
|
| Rate for Payer: First Health Workers Compensation |
$179.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$419.40
|
| Rate for Payer: GEHA Commercial |
$326.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$419.40
|
| Rate for Payer: Multiplan All |
$424.06
|
| Rate for Payer: OMNI Networks Commercial |
$326.20
|
| Rate for Payer: One Health Plan PPO/POS |
$419.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$442.70
|
| Rate for Payer: Three Rivers Provider Network All |
$349.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$433.38
|
| Rate for Payer: Zelis Auto |
$186.40
|
| Rate for Payer: Zelis Worker's Compensation |
$127.22
|
|
|
PPS INITIAL VISIT
|
Facility
|
OP
|
$722.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
21500005
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$134.80 |
| Max. Negotiated Rate |
$685.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$433.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$433.20
|
| Rate for Payer: Cash Price |
$433.20
|
| Rate for Payer: Cigna Commercial |
$613.70
|
| Rate for Payer: First Health Commercial |
$649.80
|
| Rate for Payer: First Health Workers Compensation |
$278.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$649.80
|
| Rate for Payer: GEHA Commercial |
$577.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$649.80
|
| Rate for Payer: Humana ChoiceCare |
$187.72
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$657.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$433.20
|
| Rate for Payer: OMNI Networks Commercial |
$505.40
|
| Rate for Payer: One Health Plan PPO/POS |
$649.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$685.90
|
| Rate for Payer: Three Rivers Provider Network All |
$541.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$635.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$671.46
|
| Rate for Payer: Zelis Auto |
$288.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$361.00
|
| Rate for Payer: Zelis Worker's Compensation |
$197.11
|
|
|
PPS INITIAL VISIT
|
Facility
|
OP
|
$722.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
9300438
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$134.80 |
| Max. Negotiated Rate |
$685.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$433.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$433.20
|
| Rate for Payer: Cash Price |
$433.20
|
| Rate for Payer: Cigna Commercial |
$613.70
|
| Rate for Payer: First Health Commercial |
$649.80
|
| Rate for Payer: First Health Workers Compensation |
$278.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$649.80
|
| Rate for Payer: GEHA Commercial |
$577.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$649.80
|
| Rate for Payer: Humana ChoiceCare |
$187.72
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$657.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$433.20
|
| Rate for Payer: OMNI Networks Commercial |
$505.40
|
| Rate for Payer: One Health Plan PPO/POS |
$649.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$685.90
|
| Rate for Payer: Three Rivers Provider Network All |
$541.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$635.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$671.46
|
| Rate for Payer: Zelis Auto |
$288.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$361.00
|
| Rate for Payer: Zelis Worker's Compensation |
$197.11
|
|
|
PPS INITIAL VISIT
|
Facility
|
IP
|
$722.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
25500005
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$197.11 |
| Max. Negotiated Rate |
$685.90 |
| Rate for Payer: Cash Price |
$433.20
|
| Rate for Payer: Cigna Commercial |
$613.70
|
| Rate for Payer: First Health Commercial |
$649.80
|
| Rate for Payer: First Health Workers Compensation |
$278.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$649.80
|
| Rate for Payer: GEHA Commercial |
$505.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$649.80
|
| Rate for Payer: Multiplan All |
$657.02
|
| Rate for Payer: OMNI Networks Commercial |
$505.40
|
| Rate for Payer: One Health Plan PPO/POS |
$649.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$685.90
|
| Rate for Payer: Three Rivers Provider Network All |
$541.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$671.46
|
| Rate for Payer: Zelis Auto |
$288.80
|
| Rate for Payer: Zelis Worker's Compensation |
$197.11
|
|
|
PPS INITIAL VISIT
|
Facility
|
IP
|
$722.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
9300438
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$197.11 |
| Max. Negotiated Rate |
$685.90 |
| Rate for Payer: Cash Price |
$433.20
|
| Rate for Payer: Cigna Commercial |
$613.70
|
| Rate for Payer: First Health Commercial |
$649.80
|
| Rate for Payer: First Health Workers Compensation |
$278.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$649.80
|
| Rate for Payer: GEHA Commercial |
$505.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$649.80
|
| Rate for Payer: Multiplan All |
$657.02
|
| Rate for Payer: OMNI Networks Commercial |
$505.40
|
| Rate for Payer: One Health Plan PPO/POS |
$649.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$685.90
|
| Rate for Payer: Three Rivers Provider Network All |
$541.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$671.46
|
| Rate for Payer: Zelis Auto |
$288.80
|
| Rate for Payer: Zelis Worker's Compensation |
$197.11
|
|
|
PPS INITIAL VISIT
|
Facility
|
IP
|
$722.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
21500005
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$197.11 |
| Max. Negotiated Rate |
$685.90 |
| Rate for Payer: Cash Price |
$433.20
|
| Rate for Payer: Cigna Commercial |
$613.70
|
| Rate for Payer: First Health Commercial |
$649.80
|
| Rate for Payer: First Health Workers Compensation |
$278.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$649.80
|
| Rate for Payer: GEHA Commercial |
$505.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$649.80
|
| Rate for Payer: Multiplan All |
$657.02
|
| Rate for Payer: OMNI Networks Commercial |
$505.40
|
| Rate for Payer: One Health Plan PPO/POS |
$649.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$685.90
|
| Rate for Payer: Three Rivers Provider Network All |
$541.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$671.46
|
| Rate for Payer: Zelis Auto |
$288.80
|
| Rate for Payer: Zelis Worker's Compensation |
$197.11
|
|
|
PPS INITIAL VISIT
|
Facility
|
IP
|
$722.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
21600005
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$197.11 |
| Max. Negotiated Rate |
$685.90 |
| Rate for Payer: Cash Price |
$433.20
|
| Rate for Payer: Cigna Commercial |
$613.70
|
| Rate for Payer: First Health Commercial |
$649.80
|
| Rate for Payer: First Health Workers Compensation |
$278.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$649.80
|
| Rate for Payer: GEHA Commercial |
$505.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$649.80
|
| Rate for Payer: Multiplan All |
$657.02
|
| Rate for Payer: OMNI Networks Commercial |
$505.40
|
| Rate for Payer: One Health Plan PPO/POS |
$649.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$685.90
|
| Rate for Payer: Three Rivers Provider Network All |
$541.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$671.46
|
| Rate for Payer: Zelis Auto |
$288.80
|
| Rate for Payer: Zelis Worker's Compensation |
$197.11
|
|
|
PPS INITIAL VISIT
|
Facility
|
OP
|
$722.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
23500021
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$134.80 |
| Max. Negotiated Rate |
$685.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$433.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$433.20
|
| Rate for Payer: Cash Price |
$433.20
|
| Rate for Payer: Cigna Commercial |
$613.70
|
| Rate for Payer: First Health Commercial |
$649.80
|
| Rate for Payer: First Health Workers Compensation |
$278.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$649.80
|
| Rate for Payer: GEHA Commercial |
$577.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$649.80
|
| Rate for Payer: Humana ChoiceCare |
$187.72
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$657.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$433.20
|
| Rate for Payer: OMNI Networks Commercial |
$505.40
|
| Rate for Payer: One Health Plan PPO/POS |
$649.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$685.90
|
| Rate for Payer: Three Rivers Provider Network All |
$541.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$635.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$671.46
|
| Rate for Payer: Zelis Auto |
$288.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$361.00
|
| Rate for Payer: Zelis Worker's Compensation |
$197.11
|
|
