|
PPS INITIAL VISIT
|
Facility
|
OP
|
$722.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
8500438
|
|
Hospital Revenue Code
|
521
|
| 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 |
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
|
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
|
|
|
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 |
23500021
|
|
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 INTIAL VISIT
|
Facility
|
IP
|
$722.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
21900179
|
|
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 INTIAL VISIT
|
Facility
|
OP
|
$722.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
21900179
|
|
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 SUBSQT VST
|
Facility
|
IP
|
$448.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
25500006
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$122.30 |
| Max. Negotiated Rate |
$425.60 |
| Rate for Payer: Cash Price |
$268.80
|
| Rate for Payer: Cigna Commercial |
$380.80
|
| Rate for Payer: First Health Commercial |
$403.20
|
| Rate for Payer: First Health Workers Compensation |
$172.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$403.20
|
| Rate for Payer: GEHA Commercial |
$313.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$403.20
|
| Rate for Payer: Multiplan All |
$407.68
|
| Rate for Payer: OMNI Networks Commercial |
$313.60
|
| Rate for Payer: One Health Plan PPO/POS |
$403.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$425.60
|
| Rate for Payer: Three Rivers Provider Network All |
$336.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$416.64
|
| Rate for Payer: Zelis Auto |
$179.20
|
| Rate for Payer: Zelis Worker's Compensation |
$122.30
|
|
|
PPS SUBSQT VST
|
Facility
|
OP
|
$448.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
21900180
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$116.48 |
| Max. Negotiated Rate |
$425.60 |
| 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 |
$268.80
|
| 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 |
$268.80
|
| Rate for Payer: Cash Price |
$268.80
|
| Rate for Payer: Cigna Commercial |
$380.80
|
| Rate for Payer: First Health Commercial |
$403.20
|
| Rate for Payer: First Health Workers Compensation |
$172.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$403.20
|
| Rate for Payer: GEHA Commercial |
$358.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$403.20
|
| Rate for Payer: Humana ChoiceCare |
$116.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$407.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$268.80
|
| Rate for Payer: OMNI Networks Commercial |
$313.60
|
| Rate for Payer: One Health Plan PPO/POS |
$403.20
|
| 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 |
$425.60
|
| Rate for Payer: Three Rivers Provider Network All |
$336.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$394.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$416.64
|
| Rate for Payer: Zelis Auto |
$179.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$224.00
|
| Rate for Payer: Zelis Worker's Compensation |
$122.30
|
|
|
PPS SUBSQT VST
|
Facility
|
OP
|
$448.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
25500006
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$116.48 |
| Max. Negotiated Rate |
$425.60 |
| 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 |
$268.80
|
| 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 |
$268.80
|
| Rate for Payer: Cash Price |
$268.80
|
| Rate for Payer: Cigna Commercial |
$380.80
|
| Rate for Payer: First Health Commercial |
$403.20
|
| Rate for Payer: First Health Workers Compensation |
$172.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$403.20
|
| Rate for Payer: GEHA Commercial |
$358.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$403.20
|
| Rate for Payer: Humana ChoiceCare |
$116.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$407.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$268.80
|
| Rate for Payer: OMNI Networks Commercial |
$313.60
|
| Rate for Payer: One Health Plan PPO/POS |
$403.20
|
| 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 |
$425.60
|
| Rate for Payer: Three Rivers Provider Network All |
$336.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$394.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$416.64
|
| Rate for Payer: Zelis Auto |
$179.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$224.00
|
| Rate for Payer: Zelis Worker's Compensation |
$122.30
|
|
|
PPS SUBSQT VST
|
Facility
|
OP
|
$448.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
9300439
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$116.48 |
| Max. Negotiated Rate |
$425.60 |
| 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 |
$268.80
|
| 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 |
$268.80
|
| Rate for Payer: Cash Price |
$268.80
|
| Rate for Payer: Cigna Commercial |
$380.80
|
| Rate for Payer: First Health Commercial |
$403.20
|
| Rate for Payer: First Health Workers Compensation |
$172.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$403.20
|
| Rate for Payer: GEHA Commercial |
$358.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$403.20
|
| Rate for Payer: Humana ChoiceCare |
$116.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$407.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$268.80
|
| Rate for Payer: OMNI Networks Commercial |
$313.60
|
| Rate for Payer: One Health Plan PPO/POS |
$403.20
|
| 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 |
$425.60
|
| Rate for Payer: Three Rivers Provider Network All |
$336.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$394.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$416.64
|
| Rate for Payer: Zelis Auto |
$179.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$224.00
|
| Rate for Payer: Zelis Worker's Compensation |
$122.30
|
|
|
PPS SUBSQT VST
|
Facility
|
IP
|
$448.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
21500006
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$122.30 |
| Max. Negotiated Rate |
$425.60 |
| Rate for Payer: Cash Price |
$268.80
|
| Rate for Payer: Cigna Commercial |
$380.80
|
| Rate for Payer: First Health Commercial |
$403.20
|
| Rate for Payer: First Health Workers Compensation |
$172.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$403.20
|
| Rate for Payer: GEHA Commercial |
$313.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$403.20
|
| Rate for Payer: Multiplan All |
$407.68
|
| Rate for Payer: OMNI Networks Commercial |
$313.60
|
| Rate for Payer: One Health Plan PPO/POS |
$403.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$425.60
|
| Rate for Payer: Three Rivers Provider Network All |
$336.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$416.64
|
| Rate for Payer: Zelis Auto |
$179.20
|
| Rate for Payer: Zelis Worker's Compensation |
$122.30
|
|
|
PPS SUBSQT VST
|
Facility
|
IP
|
$448.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
9300439
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$122.30 |
| Max. Negotiated Rate |
$425.60 |
| Rate for Payer: Cash Price |
$268.80
|
| Rate for Payer: Cigna Commercial |
$380.80
|
| Rate for Payer: First Health Commercial |
$403.20
|
| Rate for Payer: First Health Workers Compensation |
$172.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$403.20
|
| Rate for Payer: GEHA Commercial |
$313.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$403.20
|
| Rate for Payer: Multiplan All |
$407.68
|
| Rate for Payer: OMNI Networks Commercial |
$313.60
|
| Rate for Payer: One Health Plan PPO/POS |
$403.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$425.60
|
| Rate for Payer: Three Rivers Provider Network All |
$336.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$416.64
|
| Rate for Payer: Zelis Auto |
$179.20
|
| Rate for Payer: Zelis Worker's Compensation |
$122.30
|
|
|
PPS SUBSQT VST
|
Facility
|
IP
|
$448.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
8500439
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$122.30 |
| Max. Negotiated Rate |
$425.60 |
| Rate for Payer: Cash Price |
$268.80
|
| Rate for Payer: Cigna Commercial |
$380.80
|
| Rate for Payer: First Health Commercial |
$403.20
|
| Rate for Payer: First Health Workers Compensation |
$172.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$403.20
|
| Rate for Payer: GEHA Commercial |
$313.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$403.20
|
| Rate for Payer: Multiplan All |
$407.68
|
| Rate for Payer: OMNI Networks Commercial |
$313.60
|
| Rate for Payer: One Health Plan PPO/POS |
$403.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$425.60
|
| Rate for Payer: Three Rivers Provider Network All |
$336.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$416.64
|
| Rate for Payer: Zelis Auto |
$179.20
|
| Rate for Payer: Zelis Worker's Compensation |
$122.30
|
|
|
PPS SUBSQT VST
|
Facility
|
OP
|
$448.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
8500439
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$116.48 |
| Max. Negotiated Rate |
$425.60 |
| 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 |
$268.80
|
| 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 |
$268.80
|
| Rate for Payer: Cash Price |
$268.80
|
| Rate for Payer: Cigna Commercial |
$380.80
|
| Rate for Payer: First Health Commercial |
$403.20
|
| Rate for Payer: First Health Workers Compensation |
$172.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$403.20
|
| Rate for Payer: GEHA Commercial |
$358.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$403.20
|
| Rate for Payer: Humana ChoiceCare |
$116.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$407.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$268.80
|
| Rate for Payer: OMNI Networks Commercial |
$313.60
|
| Rate for Payer: One Health Plan PPO/POS |
$403.20
|
| 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 |
$425.60
|
| Rate for Payer: Three Rivers Provider Network All |
$336.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$394.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$416.64
|
| Rate for Payer: Zelis Auto |
$179.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$224.00
|
| Rate for Payer: Zelis Worker's Compensation |
$122.30
|
|
|
PPS SUBSQT VST
|
Facility
|
IP
|
$448.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
21900180
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$122.30 |
| Max. Negotiated Rate |
$425.60 |
| Rate for Payer: Cash Price |
$268.80
|
| Rate for Payer: Cigna Commercial |
$380.80
|
| Rate for Payer: First Health Commercial |
$403.20
|
| Rate for Payer: First Health Workers Compensation |
$172.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$403.20
|
| Rate for Payer: GEHA Commercial |
$313.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$403.20
|
| Rate for Payer: Multiplan All |
$407.68
|
| Rate for Payer: OMNI Networks Commercial |
$313.60
|
| Rate for Payer: One Health Plan PPO/POS |
$403.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$425.60
|
| Rate for Payer: Three Rivers Provider Network All |
$336.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$416.64
|
| Rate for Payer: Zelis Auto |
$179.20
|
| Rate for Payer: Zelis Worker's Compensation |
$122.30
|
|
|
PPS SUBSQT VST
|
Facility
|
OP
|
$448.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
21500006
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$116.48 |
| Max. Negotiated Rate |
$425.60 |
| 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 |
$268.80
|
| 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 |
$268.80
|
| Rate for Payer: Cash Price |
$268.80
|
| Rate for Payer: Cigna Commercial |
$380.80
|
| Rate for Payer: First Health Commercial |
$403.20
|
| Rate for Payer: First Health Workers Compensation |
$172.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$403.20
|
| Rate for Payer: GEHA Commercial |
$358.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$403.20
|
| Rate for Payer: Humana ChoiceCare |
$116.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$407.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$268.80
|
| Rate for Payer: OMNI Networks Commercial |
$313.60
|
| Rate for Payer: One Health Plan PPO/POS |
$403.20
|
| 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 |
$425.60
|
| Rate for Payer: Three Rivers Provider Network All |
$336.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$394.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$416.64
|
| Rate for Payer: Zelis Auto |
$179.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$224.00
|
| Rate for Payer: Zelis Worker's Compensation |
$122.30
|
|
|
PPS SUBSQT VST
|
Facility
|
IP
|
$448.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
23500022
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$122.30 |
| Max. Negotiated Rate |
$425.60 |
| Rate for Payer: Cash Price |
$268.80
|
| Rate for Payer: Cigna Commercial |
$380.80
|
| Rate for Payer: First Health Commercial |
$403.20
|
| Rate for Payer: First Health Workers Compensation |
$172.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$403.20
|
| Rate for Payer: GEHA Commercial |
$313.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$403.20
|
| Rate for Payer: Multiplan All |
$407.68
|
| Rate for Payer: OMNI Networks Commercial |
$313.60
|
| Rate for Payer: One Health Plan PPO/POS |
$403.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$425.60
|
| Rate for Payer: Three Rivers Provider Network All |
$336.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$416.64
|
| Rate for Payer: Zelis Auto |
$179.20
|
| Rate for Payer: Zelis Worker's Compensation |
$122.30
|
|
|
PPS SUBSQT VST
|
Facility
|
OP
|
$448.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
23500022
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$116.48 |
| Max. Negotiated Rate |
$425.60 |
| 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 |
$268.80
|
| 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 |
$268.80
|
| Rate for Payer: Cash Price |
$268.80
|
| Rate for Payer: Cigna Commercial |
$380.80
|
| Rate for Payer: First Health Commercial |
$403.20
|
| Rate for Payer: First Health Workers Compensation |
$172.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$403.20
|
| Rate for Payer: GEHA Commercial |
$358.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$403.20
|
| Rate for Payer: Humana ChoiceCare |
$116.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$407.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$268.80
|
| Rate for Payer: OMNI Networks Commercial |
$313.60
|
| Rate for Payer: One Health Plan PPO/POS |
$403.20
|
| 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 |
$425.60
|
| Rate for Payer: Three Rivers Provider Network All |
$336.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$394.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$416.64
|
| Rate for Payer: Zelis Auto |
$179.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$224.00
|
| Rate for Payer: Zelis Worker's Compensation |
$122.30
|
|
|
PPS SUBSQT VST
|
Facility
|
OP
|
$448.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
21600006
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$116.48 |
| Max. Negotiated Rate |
$425.60 |
| 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 |
$268.80
|
| 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 |
$268.80
|
| Rate for Payer: Cash Price |
$268.80
|
| Rate for Payer: Cigna Commercial |
$380.80
|
| Rate for Payer: First Health Commercial |
$403.20
|
| Rate for Payer: First Health Workers Compensation |
$172.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$403.20
|
| Rate for Payer: GEHA Commercial |
$358.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$403.20
|
| Rate for Payer: Humana ChoiceCare |
$116.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$407.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$268.80
|
| Rate for Payer: OMNI Networks Commercial |
$313.60
|
| Rate for Payer: One Health Plan PPO/POS |
$403.20
|
| 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 |
$425.60
|
| Rate for Payer: Three Rivers Provider Network All |
$336.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$394.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$416.64
|
| Rate for Payer: Zelis Auto |
$179.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$224.00
|
| Rate for Payer: Zelis Worker's Compensation |
$122.30
|
|
|
PPS SUBSQT VST
|
Facility
|
IP
|
$448.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
21600006
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$122.30 |
| Max. Negotiated Rate |
$425.60 |
| Rate for Payer: Cash Price |
$268.80
|
| Rate for Payer: Cigna Commercial |
$380.80
|
| Rate for Payer: First Health Commercial |
$403.20
|
| Rate for Payer: First Health Workers Compensation |
$172.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$403.20
|
| Rate for Payer: GEHA Commercial |
$313.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$403.20
|
| Rate for Payer: Multiplan All |
$407.68
|
| Rate for Payer: OMNI Networks Commercial |
$313.60
|
| Rate for Payer: One Health Plan PPO/POS |
$403.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$425.60
|
| Rate for Payer: Three Rivers Provider Network All |
$336.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$416.64
|
| Rate for Payer: Zelis Auto |
$179.20
|
| Rate for Payer: Zelis Worker's Compensation |
$122.30
|
|
|
PRAMIPEXOLE 0.125 MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 13668009190
|
| Hospital Charge Code |
3302956
|
|
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
|
|
|
PRAMIPEXOLE 0.125 MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 13668009190
|
| Hospital Charge Code |
3302956
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| 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 |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| 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: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
PRAMIPEXOLE 0.5 MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 13668009390
|
| Hospital Charge Code |
3303195
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| 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 |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| 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: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
PRAMIPEXOLE 0.5 MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 13668009390
|
| Hospital Charge Code |
3303195
|
|
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
|
|
