|
PROGRAMMER, ICON PATIENT
|
Facility
|
OP
|
$4,385.00
|
|
|
Service Code
|
CPT C1787
|
| Hospital Charge Code |
7002384
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,096.25 |
| Max. Negotiated Rate |
$4,165.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,631.00
|
| Rate for Payer: Cash Price |
$2,631.00
|
| Rate for Payer: Cash Price |
$2,631.00
|
| Rate for Payer: Cigna Commercial |
$3,727.25
|
| Rate for Payer: First Health Commercial |
$3,946.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,946.50
|
| Rate for Payer: GEHA Commercial |
$3,508.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,946.50
|
| Rate for Payer: Humana ChoiceCare |
$1,140.10
|
| Rate for Payer: Multiplan All |
$3,990.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,631.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,069.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,946.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,165.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3,288.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,858.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,096.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,078.05
|
| Rate for Payer: Zelis Auto |
$1,754.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,192.50
|
|
|
PROGRAMMER, ICON PATIENT
|
Facility
|
IP
|
$4,385.00
|
|
|
Service Code
|
CPT C1787
|
| Hospital Charge Code |
7002384
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,754.00 |
| Max. Negotiated Rate |
$4,165.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,508.00
|
| Rate for Payer: Cash Price |
$2,631.00
|
| Rate for Payer: Cash Price |
$2,631.00
|
| Rate for Payer: Cigna Commercial |
$3,727.25
|
| Rate for Payer: First Health Commercial |
$3,946.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,946.50
|
| Rate for Payer: GEHA Commercial |
$3,069.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,946.50
|
| Rate for Payer: Multiplan All |
$3,990.35
|
| Rate for Payer: OMNI Networks Commercial |
$3,069.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,946.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,165.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3,288.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,078.05
|
| Rate for Payer: Zelis Auto |
$1,754.00
|
|
|
PROHANCE 10ML VIAL
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
CPT A9576
|
| Hospital Charge Code |
3301400
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$43.68 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$136.00
|
| Rate for Payer: First Health Commercial |
$144.00
|
| Rate for Payer: First Health Workers Compensation |
$61.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$144.00
|
| Rate for Payer: GEHA Commercial |
$112.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$144.00
|
| Rate for Payer: Multiplan All |
$145.60
|
| Rate for Payer: OMNI Networks Commercial |
$112.00
|
| Rate for Payer: One Health Plan PPO/POS |
$144.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$152.00
|
| Rate for Payer: Three Rivers Provider Network All |
$120.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$148.80
|
| Rate for Payer: Zelis Auto |
$64.00
|
| Rate for Payer: Zelis Worker's Compensation |
$43.68
|
|
|
PROHANCE 10ML VIAL
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
CPT A9576
|
| Hospital Charge Code |
3301400
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$96.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$136.00
|
| Rate for Payer: First Health Commercial |
$144.00
|
| Rate for Payer: First Health Workers Compensation |
$61.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$144.00
|
| Rate for Payer: GEHA Commercial |
$1.56
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$144.00
|
| Rate for Payer: Humana ChoiceCare |
$41.60
|
| Rate for Payer: Multiplan All |
$145.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$96.00
|
| Rate for Payer: OMNI Networks Commercial |
$112.00
|
| Rate for Payer: One Health Plan PPO/POS |
$144.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$152.00
|
| Rate for Payer: Three Rivers Provider Network All |
$120.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$140.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$40.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$148.80
|
| Rate for Payer: Zelis Auto |
$64.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$80.00
|
| Rate for Payer: Zelis Worker's Compensation |
$43.68
|
|
|
PROHANCE 15ML VIAL
|
Facility
|
IP
|
$229.00
|
|
|
Service Code
|
CPT A9576
|
| Hospital Charge Code |
3301786
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$62.52 |
| Max. Negotiated Rate |
$217.55 |
| Rate for Payer: Cash Price |
$137.40
|
| Rate for Payer: Cigna Commercial |
$194.65
|
| Rate for Payer: First Health Commercial |
$206.10
|
| Rate for Payer: First Health Workers Compensation |
$88.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$206.10
|
| Rate for Payer: GEHA Commercial |
$160.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$206.10
|
| Rate for Payer: Multiplan All |
$208.39
|
| Rate for Payer: OMNI Networks Commercial |
$160.30
|
| Rate for Payer: One Health Plan PPO/POS |
$206.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$217.55
|
| Rate for Payer: Three Rivers Provider Network All |
$171.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$212.97
|
| Rate for Payer: Zelis Auto |
$91.60
|
| Rate for Payer: Zelis Worker's Compensation |
$62.52
|
|
|
PROHANCE 15ML VIAL
|
Facility
|
OP
|
$229.00
|
|
|
Service Code
|
CPT A9576
|
| Hospital Charge Code |
3301786
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$217.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$137.40
|
| Rate for Payer: Cash Price |
$137.40
|
| Rate for Payer: Cash Price |
$137.40
|
| Rate for Payer: Cigna Commercial |
$194.65
|
| Rate for Payer: First Health Commercial |
$206.10
|
| Rate for Payer: First Health Workers Compensation |
$88.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$206.10
|
| Rate for Payer: GEHA Commercial |
$1.56
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$206.10
|
| Rate for Payer: Humana ChoiceCare |
$59.54
|
| Rate for Payer: Multiplan All |
$208.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$137.40
|
| Rate for Payer: OMNI Networks Commercial |
$160.30
|
| Rate for Payer: One Health Plan PPO/POS |
$206.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$217.55
|
| Rate for Payer: Three Rivers Provider Network All |
$171.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$201.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$57.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$212.97
|
| Rate for Payer: Zelis Auto |
$91.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$114.50
|
| Rate for Payer: Zelis Worker's Compensation |
$62.52
|
|
|
PROHANCE 20ML VIAL
|
Facility
|
OP
|
$281.00
|
|
|
Service Code
|
CPT A9576
|
| Hospital Charge Code |
3301787
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$266.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$168.60
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cigna Commercial |
$238.85
|
| Rate for Payer: First Health Commercial |
$252.90
|
| Rate for Payer: First Health Workers Compensation |
$108.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$252.90
|
| Rate for Payer: GEHA Commercial |
$1.56
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$252.90
|
| Rate for Payer: Humana ChoiceCare |
$73.06
|
| Rate for Payer: Multiplan All |
$255.71
|
| Rate for Payer: New Mexico Health Connections Medicare |
$168.60
|
| Rate for Payer: OMNI Networks Commercial |
$196.70
|
| Rate for Payer: One Health Plan PPO/POS |
$252.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$266.95
|
| Rate for Payer: Three Rivers Provider Network All |
$210.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$247.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$70.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$261.33
|
| Rate for Payer: Zelis Auto |
$112.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$140.50
|
| Rate for Payer: Zelis Worker's Compensation |
$76.71
|
|
|
PROHANCE 20ML VIAL
|
Facility
|
IP
|
$281.00
|
|
|
Service Code
|
CPT A9576
|
| Hospital Charge Code |
3301787
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$76.71 |
| Max. Negotiated Rate |
$266.95 |
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cigna Commercial |
$238.85
|
| Rate for Payer: First Health Commercial |
$252.90
|
| Rate for Payer: First Health Workers Compensation |
$108.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$252.90
|
| Rate for Payer: GEHA Commercial |
$196.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$252.90
|
| Rate for Payer: Multiplan All |
$255.71
|
| Rate for Payer: OMNI Networks Commercial |
$196.70
|
| Rate for Payer: One Health Plan PPO/POS |
$252.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$266.95
|
| Rate for Payer: Three Rivers Provider Network All |
$210.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$261.33
|
| Rate for Payer: Zelis Auto |
$112.40
|
| Rate for Payer: Zelis Worker's Compensation |
$76.71
|
|
|
PROHANCE 5ML VIAL
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
CPT A9576
|
| Hospital Charge Code |
3301459
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$24.30 |
| Max. Negotiated Rate |
$84.55 |
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$75.65
|
| Rate for Payer: First Health Commercial |
$80.10
|
| Rate for Payer: First Health Workers Compensation |
$34.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$80.10
|
| Rate for Payer: GEHA Commercial |
$62.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$80.10
|
| Rate for Payer: Multiplan All |
$80.99
|
| Rate for Payer: OMNI Networks Commercial |
$62.30
|
| Rate for Payer: One Health Plan PPO/POS |
$80.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$84.55
|
| Rate for Payer: Three Rivers Provider Network All |
$66.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$82.77
|
| Rate for Payer: Zelis Auto |
$35.60
|
| Rate for Payer: Zelis Worker's Compensation |
$24.30
|
|
|
PROHANCE 5ML VIAL
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
CPT A9576
|
| Hospital Charge Code |
3301459
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$84.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$75.65
|
| Rate for Payer: First Health Commercial |
$80.10
|
| Rate for Payer: First Health Workers Compensation |
$34.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$80.10
|
| Rate for Payer: GEHA Commercial |
$1.56
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$80.10
|
| Rate for Payer: Humana ChoiceCare |
$23.14
|
| Rate for Payer: Multiplan All |
$80.99
|
| Rate for Payer: New Mexico Health Connections Medicare |
$53.40
|
| Rate for Payer: OMNI Networks Commercial |
$62.30
|
| Rate for Payer: One Health Plan PPO/POS |
$80.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$84.55
|
| Rate for Payer: Three Rivers Provider Network All |
$66.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$78.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$22.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$82.77
|
| Rate for Payer: Zelis Auto |
$35.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$44.50
|
| Rate for Payer: Zelis Worker's Compensation |
$24.30
|
|
|
proinsulin REF140533
|
Facility
|
OP
|
$217.00
|
|
|
Service Code
|
CPT 84206
|
| Hospital Charge Code |
2200636
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.64 |
| Max. Negotiated Rate |
$206.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$48.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$48.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$38.06
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$26.69
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$184.45
|
| Rate for Payer: First Health Commercial |
$195.30
|
| Rate for Payer: First Health Workers Compensation |
$30.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$195.30
|
| Rate for Payer: GEHA Commercial |
$173.60
|
| Rate for Payer: GEHA Medicare |
$26.69
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$195.30
|
| Rate for Payer: Humana ChoiceCare |
$29.36
|
| Rate for Payer: Humana Medicare Advantage |
$26.69
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$44.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$38.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$26.69
|
| Rate for Payer: Multiplan All |
$197.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$45.37
|
| Rate for Payer: OMNI Networks Commercial |
$151.90
|
| Rate for Payer: One Health Plan PPO/POS |
$195.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$44.84
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$38.84
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$26.69
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$206.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$53.38
|
| Rate for Payer: Three Rivers Provider Network All |
$162.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$26.16
|
| Rate for Payer: United Healthcare Commercial |
$184.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$38.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.69
|
| Rate for Payer: United Payors & United Providers UP&UP |
$201.81
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$26.69
|
| Rate for Payer: Zelis Auto |
$86.80
|
| Rate for Payer: Zelis Medicare |
$22.69
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$32.03
|
| Rate for Payer: Zelis Worker's Compensation |
$21.64
|
|
|
proinsulin REF140533
|
Facility
|
IP
|
$217.00
|
|
|
Service Code
|
CPT 84206
|
| Hospital Charge Code |
2200636
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.64 |
| Max. Negotiated Rate |
$206.15 |
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$184.45
|
| Rate for Payer: First Health Commercial |
$195.30
|
| Rate for Payer: First Health Workers Compensation |
$30.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$195.30
|
| Rate for Payer: GEHA Commercial |
$151.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$195.30
|
| Rate for Payer: Multiplan All |
$197.47
|
| Rate for Payer: OMNI Networks Commercial |
$151.90
|
| Rate for Payer: One Health Plan PPO/POS |
$195.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$206.15
|
| Rate for Payer: Three Rivers Provider Network All |
$162.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$201.81
|
| Rate for Payer: Zelis Auto |
$86.80
|
| Rate for Payer: Zelis Worker's Compensation |
$21.64
|
|
|
prolactin REF004465
|
Facility
|
IP
|
$313.00
|
|
|
Service Code
|
CPT 84146
|
| Hospital Charge Code |
2234148
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$25.42 |
| Max. Negotiated Rate |
$297.35 |
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$266.05
|
| Rate for Payer: First Health Commercial |
$281.70
|
| Rate for Payer: First Health Workers Compensation |
$35.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$281.70
|
| Rate for Payer: GEHA Commercial |
$219.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$281.70
|
| Rate for Payer: Multiplan All |
$284.83
|
| Rate for Payer: OMNI Networks Commercial |
$219.10
|
| Rate for Payer: One Health Plan PPO/POS |
$281.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$297.35
|
| Rate for Payer: Three Rivers Provider Network All |
$234.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$291.09
|
| Rate for Payer: Zelis Auto |
$125.20
|
| Rate for Payer: Zelis Worker's Compensation |
$25.42
|
|
|
prolactin REF004465
|
Facility
|
OP
|
$313.00
|
|
|
Service Code
|
CPT 84146
|
| Hospital Charge Code |
2234148
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.47 |
| Max. Negotiated Rate |
$297.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$34.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$187.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$34.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$27.64
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$19.38
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$266.05
|
| Rate for Payer: First Health Commercial |
$281.70
|
| Rate for Payer: First Health Workers Compensation |
$35.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$281.70
|
| Rate for Payer: GEHA Commercial |
$250.40
|
| Rate for Payer: GEHA Medicare |
$19.38
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$281.70
|
| Rate for Payer: Humana ChoiceCare |
$21.32
|
| Rate for Payer: Humana Medicare Advantage |
$19.38
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$32.56
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$28.20
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$19.38
|
| Rate for Payer: Multiplan All |
$284.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$32.95
|
| Rate for Payer: OMNI Networks Commercial |
$219.10
|
| Rate for Payer: One Health Plan PPO/POS |
$281.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$32.56
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$28.20
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$19.38
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$297.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$38.76
|
| Rate for Payer: Three Rivers Provider Network All |
$234.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.99
|
| Rate for Payer: United Healthcare Commercial |
$266.05
|
| Rate for Payer: United Healthcare Managed Medicaid |
$28.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.38
|
| Rate for Payer: United Payors & United Providers UP&UP |
$291.09
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$19.38
|
| Rate for Payer: Zelis Auto |
$125.20
|
| Rate for Payer: Zelis Medicare |
$16.47
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$23.26
|
| Rate for Payer: Zelis Worker's Compensation |
$25.42
|
|
|
PROLNGD IP/OB E/M SVC TIME EA ADDL 15
|
Facility
|
IP
|
$80.34
|
|
|
Service Code
|
CPT 99418
|
| Hospital Charge Code |
299418
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$21.93 |
| Max. Negotiated Rate |
$76.32 |
| Rate for Payer: Cash Price |
$48.20
|
| Rate for Payer: Cigna Commercial |
$68.29
|
| Rate for Payer: First Health Commercial |
$72.31
|
| Rate for Payer: First Health Workers Compensation |
$31.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.31
|
| Rate for Payer: GEHA Commercial |
$56.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.31
|
| Rate for Payer: Multiplan All |
$73.11
|
| Rate for Payer: OMNI Networks Commercial |
$56.24
|
| Rate for Payer: One Health Plan PPO/POS |
$72.31
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.32
|
| Rate for Payer: Three Rivers Provider Network All |
$60.26
|
| Rate for Payer: United Payors & United Providers UP&UP |
$74.72
|
| Rate for Payer: Zelis Auto |
$32.14
|
| Rate for Payer: Zelis Worker's Compensation |
$21.93
|
|
|
PROLNGED OFF/OTHER OP E/M SVC BEYND MAX
|
Facility
|
OP
|
$89.75
|
|
|
Service Code
|
CPT G2212
|
| Hospital Charge Code |
852212
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$22.44 |
| Max. Negotiated Rate |
$85.26 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$53.85
|
| Rate for Payer: Cash Price |
$53.85
|
| Rate for Payer: Cigna Commercial |
$76.29
|
| Rate for Payer: First Health Commercial |
$80.78
|
| Rate for Payer: First Health Workers Compensation |
$34.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$80.78
|
| Rate for Payer: GEHA Commercial |
$71.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$80.78
|
| Rate for Payer: Humana ChoiceCare |
$23.34
|
| Rate for Payer: Multiplan All |
$81.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$53.85
|
| Rate for Payer: OMNI Networks Commercial |
$62.83
|
| Rate for Payer: One Health Plan PPO/POS |
$80.78
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$85.26
|
| Rate for Payer: Three Rivers Provider Network All |
$67.31
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$78.98
|
| Rate for Payer: United Healthcare Managed Medicaid |
$22.44
|
| Rate for Payer: United Payors & United Providers UP&UP |
$83.47
|
| Rate for Payer: Zelis Auto |
$35.90
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$44.88
|
| Rate for Payer: Zelis Worker's Compensation |
$24.50
|
|
|
PROLNGED OFF/OTHER OP E/M SVC BEYND MAX
|
Facility
|
IP
|
$89.75
|
|
|
Service Code
|
CPT G2212
|
| Hospital Charge Code |
852212
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$85.26 |
| Rate for Payer: Cash Price |
$53.85
|
| Rate for Payer: Cigna Commercial |
$76.29
|
| Rate for Payer: First Health Commercial |
$80.78
|
| Rate for Payer: First Health Workers Compensation |
$34.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$80.78
|
| Rate for Payer: GEHA Commercial |
$62.83
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$80.78
|
| Rate for Payer: Multiplan All |
$81.67
|
| Rate for Payer: OMNI Networks Commercial |
$62.83
|
| Rate for Payer: One Health Plan PPO/POS |
$80.78
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$85.26
|
| Rate for Payer: Three Rivers Provider Network All |
$67.31
|
| Rate for Payer: United Payors & United Providers UP&UP |
$83.47
|
| Rate for Payer: Zelis Auto |
$35.90
|
| Rate for Payer: Zelis Worker's Compensation |
$24.50
|
|
|
PROLONGED HOSP IP OR OBS EVAL EA ADDL 15
|
Facility
|
OP
|
$93.36
|
|
|
Service Code
|
CPT G0316
|
| Hospital Charge Code |
1000316
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$23.34 |
| Max. Negotiated Rate |
$88.69 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$56.02
|
| Rate for Payer: Cash Price |
$56.02
|
| Rate for Payer: Cigna Commercial |
$79.36
|
| Rate for Payer: First Health Commercial |
$84.02
|
| Rate for Payer: First Health Workers Compensation |
$36.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$84.02
|
| Rate for Payer: GEHA Commercial |
$74.69
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$84.02
|
| Rate for Payer: Humana ChoiceCare |
$24.27
|
| Rate for Payer: Multiplan All |
$84.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$56.02
|
| Rate for Payer: OMNI Networks Commercial |
$65.35
|
| Rate for Payer: One Health Plan PPO/POS |
$84.02
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$88.69
|
| Rate for Payer: Three Rivers Provider Network All |
$70.02
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$82.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$23.34
|
| Rate for Payer: United Payors & United Providers UP&UP |
$86.82
|
| Rate for Payer: Zelis Auto |
$37.34
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$46.68
|
| Rate for Payer: Zelis Worker's Compensation |
$25.49
|
|
|
PROLONGED HOSP IP OR OBS EVAL EA ADDL 15
|
Facility
|
IP
|
$93.36
|
|
|
Service Code
|
CPT G0316
|
| Hospital Charge Code |
1000316
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$25.49 |
| Max. Negotiated Rate |
$88.69 |
| Rate for Payer: Cash Price |
$56.02
|
| Rate for Payer: Cigna Commercial |
$79.36
|
| Rate for Payer: First Health Commercial |
$84.02
|
| Rate for Payer: First Health Workers Compensation |
$36.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$84.02
|
| Rate for Payer: GEHA Commercial |
$65.35
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$84.02
|
| Rate for Payer: Multiplan All |
$84.96
|
| Rate for Payer: OMNI Networks Commercial |
$65.35
|
| Rate for Payer: One Health Plan PPO/POS |
$84.02
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$88.69
|
| Rate for Payer: Three Rivers Provider Network All |
$70.02
|
| Rate for Payer: United Payors & United Providers UP&UP |
$86.82
|
| Rate for Payer: Zelis Auto |
$37.34
|
| Rate for Payer: Zelis Worker's Compensation |
$25.49
|
|
|
PROMETHAZINE 25 MG/ML INJ.
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
CPT J2550
|
| Hospital Charge Code |
3300763
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$7.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
PROMETHAZINE 25 MG/ML INJ.
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
CPT J2550
|
| Hospital Charge Code |
3300763
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$3.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Humana ChoiceCare |
$2.60
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.00
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
PROMETHAZINE 6.25 MG/5 ML SYRUP
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 17856060805
|
| Hospital Charge Code |
3301146
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Humana ChoiceCare |
$1.56
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.60
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
PROMETHAZINE 6.25 MG/5 ML SYRUP
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 17856060805
|
| Hospital Charge Code |
3301146
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
PROMETHAZINE HCL 12.5 MG RECTAL SUPPOS
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
NDC 00713053612
|
| Hospital Charge Code |
3300764
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
PROMETHAZINE HCL 12.5 MG RECTAL SUPPOS
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
NDC 00713053612
|
| Hospital Charge Code |
3300764
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.00 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$64.80
|
| 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 |
$86.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$97.20
|
| Rate for Payer: Humana ChoiceCare |
$28.08
|
| Rate for Payer: Multiplan All |
$98.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$64.80
|
| 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: TriWest Veterans Administration/VAPC3 |
$95.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$27.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$100.44
|
| Rate for Payer: Zelis Auto |
$43.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$54.00
|
| Rate for Payer: Zelis Worker's Compensation |
$29.48
|
|
