|
SOFT THUMB CMC SPLINT
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT L3908
|
| Hospital Charge Code |
8230055
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$44.80 |
| Max. Negotiated Rate |
$106.40 |
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$95.20
|
| Rate for Payer: First Health Commercial |
$100.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$100.80
|
| Rate for Payer: GEHA Commercial |
$78.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$100.80
|
| Rate for Payer: Multiplan All |
$101.92
|
| Rate for Payer: OMNI Networks Commercial |
$78.40
|
| Rate for Payer: One Health Plan PPO/POS |
$100.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$106.40
|
| Rate for Payer: Three Rivers Provider Network All |
$84.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$104.16
|
| Rate for Payer: Zelis Auto |
$44.80
|
|
|
soluble transferrin receptor REF143305
|
Facility
|
OP
|
$322.00
|
|
|
Service Code
|
CPT 84238
|
| Hospital Charge Code |
2299534
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$31.08 |
| Max. Negotiated Rate |
$305.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$65.82
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$193.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$65.82
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$52.14
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$36.57
|
| Rate for Payer: Cash Price |
$193.20
|
| Rate for Payer: Cash Price |
$193.20
|
| Rate for Payer: Cigna Commercial |
$273.70
|
| Rate for Payer: First Health Commercial |
$289.80
|
| Rate for Payer: First Health Workers Compensation |
$65.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$289.80
|
| Rate for Payer: GEHA Commercial |
$257.60
|
| Rate for Payer: GEHA Medicare |
$36.57
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$289.80
|
| Rate for Payer: Humana ChoiceCare |
$40.23
|
| Rate for Payer: Humana Medicare Advantage |
$36.57
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$61.44
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$53.20
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$36.57
|
| Rate for Payer: Multiplan All |
$293.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$62.17
|
| Rate for Payer: OMNI Networks Commercial |
$225.40
|
| Rate for Payer: One Health Plan PPO/POS |
$289.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$61.43
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$53.20
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$36.57
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$305.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$73.14
|
| Rate for Payer: Three Rivers Provider Network All |
$241.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$35.84
|
| Rate for Payer: United Healthcare Commercial |
$273.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$53.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.57
|
| Rate for Payer: United Payors & United Providers UP&UP |
$299.46
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$36.57
|
| Rate for Payer: Zelis Auto |
$128.80
|
| Rate for Payer: Zelis Medicare |
$31.08
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$43.88
|
| Rate for Payer: Zelis Worker's Compensation |
$46.45
|
|
|
soluble transferrin receptor REF143305
|
Facility
|
IP
|
$322.00
|
|
|
Service Code
|
CPT 84238
|
| Hospital Charge Code |
2299534
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$46.45 |
| Max. Negotiated Rate |
$305.90 |
| Rate for Payer: Cash Price |
$193.20
|
| Rate for Payer: Cash Price |
$193.20
|
| Rate for Payer: Cigna Commercial |
$273.70
|
| Rate for Payer: First Health Commercial |
$289.80
|
| Rate for Payer: First Health Workers Compensation |
$65.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$289.80
|
| Rate for Payer: GEHA Commercial |
$225.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$289.80
|
| Rate for Payer: Multiplan All |
$293.02
|
| Rate for Payer: OMNI Networks Commercial |
$225.40
|
| Rate for Payer: One Health Plan PPO/POS |
$289.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$305.90
|
| Rate for Payer: Three Rivers Provider Network All |
$241.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$299.46
|
| Rate for Payer: Zelis Auto |
$128.80
|
| Rate for Payer: Zelis Worker's Compensation |
$46.45
|
|
|
SOLUTION LUGOLS IODINE 8ML 5%
|
Facility
|
IP
|
$437.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000022
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$174.80 |
| Max. Negotiated Rate |
$415.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$349.60
|
| Rate for Payer: Cash Price |
$262.20
|
| Rate for Payer: Cash Price |
$262.20
|
| Rate for Payer: Cigna Commercial |
$371.45
|
| Rate for Payer: First Health Commercial |
$393.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$393.30
|
| Rate for Payer: GEHA Commercial |
$305.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$393.30
|
| Rate for Payer: Multiplan All |
$397.67
|
| Rate for Payer: OMNI Networks Commercial |
$305.90
|
| Rate for Payer: One Health Plan PPO/POS |
$393.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$415.15
|
| Rate for Payer: Three Rivers Provider Network All |
$327.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$406.41
|
| Rate for Payer: Zelis Auto |
$174.80
|
|
|
SOLUTION LUGOLS IODINE 8ML 5%
|
Facility
|
OP
|
$437.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000022
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$109.25 |
| Max. Negotiated Rate |
$415.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$262.20
|
| Rate for Payer: Cash Price |
$262.20
|
| Rate for Payer: Cash Price |
$262.20
|
| Rate for Payer: Cigna Commercial |
$371.45
|
| Rate for Payer: First Health Commercial |
$393.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$393.30
|
| Rate for Payer: GEHA Commercial |
$349.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$393.30
|
| Rate for Payer: Humana ChoiceCare |
$113.62
|
| Rate for Payer: Multiplan All |
$397.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$262.20
|
| Rate for Payer: OMNI Networks Commercial |
$305.90
|
| Rate for Payer: One Health Plan PPO/POS |
$393.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$415.15
|
| Rate for Payer: Three Rivers Provider Network All |
$327.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$384.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$109.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$406.41
|
| Rate for Payer: Zelis Auto |
$174.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$218.50
|
|
|
SONY BX SERIES DIGITAL VOICE RECORDER
|
Facility
|
IP
|
$296.00
|
|
| Hospital Charge Code |
90030842
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$80.81 |
| Max. Negotiated Rate |
$281.20 |
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Cigna Commercial |
$251.60
|
| Rate for Payer: First Health Commercial |
$266.40
|
| Rate for Payer: First Health Workers Compensation |
$114.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$266.40
|
| Rate for Payer: GEHA Commercial |
$207.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$266.40
|
| Rate for Payer: Multiplan All |
$269.36
|
| Rate for Payer: OMNI Networks Commercial |
$207.20
|
| Rate for Payer: One Health Plan PPO/POS |
$266.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$281.20
|
| Rate for Payer: Three Rivers Provider Network All |
$222.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$275.28
|
| Rate for Payer: Zelis Auto |
$118.40
|
| Rate for Payer: Zelis Worker's Compensation |
$80.81
|
|
|
SONY BX SERIES DIGITAL VOICE RECORDER
|
Facility
|
OP
|
$296.00
|
|
| Hospital Charge Code |
90030842
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$74.00 |
| Max. Negotiated Rate |
$281.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$177.60
|
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Cigna Commercial |
$251.60
|
| Rate for Payer: First Health Commercial |
$266.40
|
| Rate for Payer: First Health Workers Compensation |
$114.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$266.40
|
| Rate for Payer: GEHA Commercial |
$236.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$266.40
|
| Rate for Payer: Humana ChoiceCare |
$76.96
|
| Rate for Payer: Multiplan All |
$269.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$177.60
|
| Rate for Payer: OMNI Networks Commercial |
$207.20
|
| Rate for Payer: One Health Plan PPO/POS |
$266.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$281.20
|
| Rate for Payer: Three Rivers Provider Network All |
$222.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$260.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$74.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$275.28
|
| Rate for Payer: Zelis Auto |
$118.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$148.00
|
| Rate for Payer: Zelis Worker's Compensation |
$80.81
|
|
|
SOTALOL HCL TAB 80MG
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 60505008000
|
| Hospital Charge Code |
3300860
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Humana ChoiceCare |
$5.46
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.60
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
SOTALOL HCL TAB 80MG
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 60505008000
|
| Hospital Charge Code |
3300860
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
SOTRADECOL 3% 60 MG/2 ML
|
Facility
|
IP
|
$529.00
|
|
|
Service Code
|
NDC 67457016302
|
| Hospital Charge Code |
3302830
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$144.42 |
| Max. Negotiated Rate |
$502.55 |
| Rate for Payer: Cash Price |
$317.40
|
| Rate for Payer: Cigna Commercial |
$449.65
|
| Rate for Payer: First Health Commercial |
$476.10
|
| Rate for Payer: First Health Workers Compensation |
$204.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$476.10
|
| Rate for Payer: GEHA Commercial |
$370.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$476.10
|
| Rate for Payer: Multiplan All |
$481.39
|
| Rate for Payer: OMNI Networks Commercial |
$370.30
|
| Rate for Payer: One Health Plan PPO/POS |
$476.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$502.55
|
| Rate for Payer: Three Rivers Provider Network All |
$396.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$491.97
|
| Rate for Payer: Zelis Auto |
$211.60
|
| Rate for Payer: Zelis Worker's Compensation |
$144.42
|
|
|
SOTRADECOL 3% 60 MG/2 ML
|
Facility
|
OP
|
$529.00
|
|
|
Service Code
|
NDC 67457016302
|
| Hospital Charge Code |
3302830
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$132.25 |
| Max. Negotiated Rate |
$502.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$317.40
|
| Rate for Payer: Cash Price |
$317.40
|
| Rate for Payer: Cigna Commercial |
$449.65
|
| Rate for Payer: First Health Commercial |
$476.10
|
| Rate for Payer: First Health Workers Compensation |
$204.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$476.10
|
| Rate for Payer: GEHA Commercial |
$423.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$476.10
|
| Rate for Payer: Humana ChoiceCare |
$137.54
|
| Rate for Payer: Multiplan All |
$481.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$317.40
|
| Rate for Payer: OMNI Networks Commercial |
$370.30
|
| Rate for Payer: One Health Plan PPO/POS |
$476.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$502.55
|
| Rate for Payer: Three Rivers Provider Network All |
$396.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$465.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$132.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$491.97
|
| Rate for Payer: Zelis Auto |
$211.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$264.50
|
| Rate for Payer: Zelis Worker's Compensation |
$144.42
|
|
|
soybean IgE REF602457
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299199
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
soybean IgE REF602457
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299199
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.22
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: GEHA Medicare |
$5.22
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.22
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.76
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.59
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.22
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10.44
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.12
|
| Rate for Payer: United Healthcare Commercial |
$47.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.22
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Medicare |
$4.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.26
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
SPACER
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
NDC 00085460202
|
| Hospital Charge Code |
3300861
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$42.31 |
| Max. Negotiated Rate |
$147.25 |
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$131.75
|
| Rate for Payer: First Health Commercial |
$139.50
|
| Rate for Payer: First Health Workers Compensation |
$59.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$139.50
|
| Rate for Payer: GEHA Commercial |
$108.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$139.50
|
| Rate for Payer: Multiplan All |
$141.05
|
| Rate for Payer: OMNI Networks Commercial |
$108.50
|
| Rate for Payer: One Health Plan PPO/POS |
$139.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$147.25
|
| Rate for Payer: Three Rivers Provider Network All |
$116.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$144.15
|
| Rate for Payer: Zelis Auto |
$62.00
|
| Rate for Payer: Zelis Worker's Compensation |
$42.31
|
|
|
SPACER
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
NDC 00085460202
|
| Hospital Charge Code |
3300861
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$38.75 |
| Max. Negotiated Rate |
$147.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$131.75
|
| Rate for Payer: First Health Commercial |
$139.50
|
| Rate for Payer: First Health Workers Compensation |
$59.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$139.50
|
| Rate for Payer: GEHA Commercial |
$124.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$139.50
|
| Rate for Payer: Humana ChoiceCare |
$40.30
|
| Rate for Payer: Multiplan All |
$141.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$93.00
|
| Rate for Payer: OMNI Networks Commercial |
$108.50
|
| Rate for Payer: One Health Plan PPO/POS |
$139.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$147.25
|
| Rate for Payer: Three Rivers Provider Network All |
$116.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$136.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$38.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$144.15
|
| Rate for Payer: Zelis Auto |
$62.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$77.50
|
| Rate for Payer: Zelis Worker's Compensation |
$42.31
|
|
|
SP BONE AGRFT MORSEL ADD-ON
|
Facility
|
OP
|
$534.00
|
|
|
Service Code
|
CPT 20937
|
| Hospital Charge Code |
6120937
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$133.50 |
| Max. Negotiated Rate |
$507.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$320.40
|
| Rate for Payer: Cash Price |
$320.40
|
| Rate for Payer: Cigna Commercial |
$453.90
|
| Rate for Payer: First Health Commercial |
$480.60
|
| Rate for Payer: First Health Workers Compensation |
$206.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$480.60
|
| Rate for Payer: GEHA Commercial |
$427.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$480.60
|
| Rate for Payer: Humana ChoiceCare |
$138.84
|
| Rate for Payer: Multiplan All |
$485.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$320.40
|
| Rate for Payer: OMNI Networks Commercial |
$373.80
|
| Rate for Payer: One Health Plan PPO/POS |
$480.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$507.30
|
| Rate for Payer: Three Rivers Provider Network All |
$400.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$469.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$133.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$496.62
|
| Rate for Payer: Zelis Auto |
$213.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$267.00
|
| Rate for Payer: Zelis Worker's Compensation |
$145.78
|
|
|
SP BONE AGRFT MORSEL ADD-ON
|
Facility
|
IP
|
$534.00
|
|
|
Service Code
|
CPT 20937
|
| Hospital Charge Code |
6120937
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$145.78 |
| Max. Negotiated Rate |
$507.30 |
| Rate for Payer: Cash Price |
$320.40
|
| Rate for Payer: Cigna Commercial |
$453.90
|
| Rate for Payer: First Health Commercial |
$480.60
|
| Rate for Payer: First Health Workers Compensation |
$206.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$480.60
|
| Rate for Payer: GEHA Commercial |
$373.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$480.60
|
| Rate for Payer: Multiplan All |
$485.94
|
| Rate for Payer: OMNI Networks Commercial |
$373.80
|
| Rate for Payer: One Health Plan PPO/POS |
$480.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$507.30
|
| Rate for Payer: Three Rivers Provider Network All |
$400.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$496.62
|
| Rate for Payer: Zelis Auto |
$213.60
|
| Rate for Payer: Zelis Worker's Compensation |
$145.78
|
|
|
SP BONE AGRFT STRUCT ADD-ON
|
Facility
|
OP
|
$593.00
|
|
|
Service Code
|
CPT 20938
|
| Hospital Charge Code |
6120938
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$148.25 |
| Max. Negotiated Rate |
$563.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$355.80
|
| Rate for Payer: Cash Price |
$355.80
|
| Rate for Payer: Cigna Commercial |
$504.05
|
| Rate for Payer: First Health Commercial |
$533.70
|
| Rate for Payer: First Health Workers Compensation |
$228.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$533.70
|
| Rate for Payer: GEHA Commercial |
$474.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$533.70
|
| Rate for Payer: Humana ChoiceCare |
$154.18
|
| Rate for Payer: Multiplan All |
$539.63
|
| Rate for Payer: New Mexico Health Connections Medicare |
$355.80
|
| Rate for Payer: OMNI Networks Commercial |
$415.10
|
| Rate for Payer: One Health Plan PPO/POS |
$533.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$563.35
|
| Rate for Payer: Three Rivers Provider Network All |
$444.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$521.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$148.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$551.49
|
| Rate for Payer: Zelis Auto |
$237.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$296.50
|
| Rate for Payer: Zelis Worker's Compensation |
$161.89
|
|
|
SP BONE AGRFT STRUCT ADD-ON
|
Facility
|
IP
|
$593.00
|
|
|
Service Code
|
CPT 20938
|
| Hospital Charge Code |
6120938
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$161.89 |
| Max. Negotiated Rate |
$563.35 |
| Rate for Payer: Cash Price |
$355.80
|
| Rate for Payer: Cigna Commercial |
$504.05
|
| Rate for Payer: First Health Commercial |
$533.70
|
| Rate for Payer: First Health Workers Compensation |
$228.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$533.70
|
| Rate for Payer: GEHA Commercial |
$415.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$533.70
|
| Rate for Payer: Multiplan All |
$539.63
|
| Rate for Payer: OMNI Networks Commercial |
$415.10
|
| Rate for Payer: One Health Plan PPO/POS |
$533.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$563.35
|
| Rate for Payer: Three Rivers Provider Network All |
$444.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$551.49
|
| Rate for Payer: Zelis Auto |
$237.20
|
| Rate for Payer: Zelis Worker's Compensation |
$161.89
|
|
|
SP BONE ALGRFT STRUCT ADD-ON
|
Facility
|
OP
|
$362.00
|
|
|
Service Code
|
CPT 20931
|
| Hospital Charge Code |
6120931
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$90.50 |
| Max. Negotiated Rate |
$343.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$217.20
|
| Rate for Payer: Cash Price |
$217.20
|
| Rate for Payer: Cigna Commercial |
$307.70
|
| Rate for Payer: First Health Commercial |
$325.80
|
| Rate for Payer: First Health Workers Compensation |
$139.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$325.80
|
| Rate for Payer: GEHA Commercial |
$289.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$325.80
|
| Rate for Payer: Humana ChoiceCare |
$94.12
|
| Rate for Payer: Multiplan All |
$329.42
|
| Rate for Payer: New Mexico Health Connections Medicare |
$217.20
|
| Rate for Payer: OMNI Networks Commercial |
$253.40
|
| Rate for Payer: One Health Plan PPO/POS |
$325.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$343.90
|
| Rate for Payer: Three Rivers Provider Network All |
$271.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$318.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$90.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$336.66
|
| Rate for Payer: Zelis Auto |
$144.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$181.00
|
| Rate for Payer: Zelis Worker's Compensation |
$98.83
|
|
|
SP BONE ALGRFT STRUCT ADD-ON
|
Facility
|
IP
|
$362.00
|
|
|
Service Code
|
CPT 20931
|
| Hospital Charge Code |
6120931
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$98.83 |
| Max. Negotiated Rate |
$343.90 |
| Rate for Payer: Cash Price |
$217.20
|
| Rate for Payer: Cigna Commercial |
$307.70
|
| Rate for Payer: First Health Commercial |
$325.80
|
| Rate for Payer: First Health Workers Compensation |
$139.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$325.80
|
| Rate for Payer: GEHA Commercial |
$253.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$325.80
|
| Rate for Payer: Multiplan All |
$329.42
|
| Rate for Payer: OMNI Networks Commercial |
$253.40
|
| Rate for Payer: One Health Plan PPO/POS |
$325.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$343.90
|
| Rate for Payer: Three Rivers Provider Network All |
$271.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$336.66
|
| Rate for Payer: Zelis Auto |
$144.80
|
| Rate for Payer: Zelis Worker's Compensation |
$98.83
|
|
|
SPCLTY ABSORB DRESS 16SQ/< NO ADHES
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
CPT A6251
|
| Hospital Charge Code |
8506251
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$4.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$15.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$4.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3.30
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$21.25
|
| Rate for Payer: First Health Commercial |
$22.50
|
| Rate for Payer: First Health Workers Compensation |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22.50
|
| Rate for Payer: GEHA Commercial |
$20.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22.50
|
| Rate for Payer: Humana ChoiceCare |
$6.50
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3.37
|
| Rate for Payer: Multiplan All |
$22.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$15.00
|
| Rate for Payer: OMNI Networks Commercial |
$17.50
|
| Rate for Payer: One Health Plan PPO/POS |
$22.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$3.89
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$23.75
|
| Rate for Payer: Three Rivers Provider Network All |
$18.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$22.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23.25
|
| Rate for Payer: Zelis Auto |
$10.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12.50
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
|
SPCLTY ABSORB DRESS 16SQ/< NO ADHES
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
CPT A6251
|
| Hospital Charge Code |
7206251
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$4.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$15.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$4.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3.30
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$21.25
|
| Rate for Payer: First Health Commercial |
$22.50
|
| Rate for Payer: First Health Workers Compensation |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22.50
|
| Rate for Payer: GEHA Commercial |
$20.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22.50
|
| Rate for Payer: Humana ChoiceCare |
$6.50
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3.37
|
| Rate for Payer: Multiplan All |
$22.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$15.00
|
| Rate for Payer: OMNI Networks Commercial |
$17.50
|
| Rate for Payer: One Health Plan PPO/POS |
$22.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$3.89
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$23.75
|
| Rate for Payer: Three Rivers Provider Network All |
$18.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$22.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23.25
|
| Rate for Payer: Zelis Auto |
$10.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12.50
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
|
SPCLTY ABSORB DRESS 16SQ/< NO ADHES
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
CPT A6251
|
| Hospital Charge Code |
8506251
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.83 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$21.25
|
| Rate for Payer: First Health Commercial |
$22.50
|
| Rate for Payer: First Health Workers Compensation |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22.50
|
| Rate for Payer: GEHA Commercial |
$17.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22.50
|
| Rate for Payer: Multiplan All |
$22.75
|
| Rate for Payer: OMNI Networks Commercial |
$17.50
|
| Rate for Payer: One Health Plan PPO/POS |
$22.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$23.75
|
| Rate for Payer: Three Rivers Provider Network All |
$18.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23.25
|
| Rate for Payer: Zelis Auto |
$10.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
|
SPCLTY ABSORB DRESS 16SQ/< NO ADHES
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
CPT A6251
|
| Hospital Charge Code |
7206251
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$6.83 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$21.25
|
| Rate for Payer: First Health Commercial |
$22.50
|
| Rate for Payer: First Health Workers Compensation |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22.50
|
| Rate for Payer: GEHA Commercial |
$17.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22.50
|
| Rate for Payer: Multiplan All |
$22.75
|
| Rate for Payer: OMNI Networks Commercial |
$17.50
|
| Rate for Payer: One Health Plan PPO/POS |
$22.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$23.75
|
| Rate for Payer: Three Rivers Provider Network All |
$18.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23.25
|
| Rate for Payer: Zelis Auto |
$10.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
