|
BRIEF CHECK IN BY MD/QHP
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
8600018
|
|
Hospital Revenue Code
|
985
|
| Min. Negotiated Rate |
$11.70 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.46
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$36.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Humana ChoiceCare |
$11.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$16.79
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.00
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$19.39
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$16.79
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$39.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.79
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.50
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
9799222
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$31.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Professional
|
Both
|
$41.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
14099223
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$4.69 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$13.03
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$8.31
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$24.60
|
| Rate for Payer: Health Net Federal Services Government |
$34.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$8.31
|
| Rate for Payer: Multiplan All |
$30.75
|
| Rate for Payer: National Preferred Provider Network Commercial |
$38.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.60
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$4.69
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$12.56
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$36.08
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
8499224
|
|
Hospital Revenue Code
|
513
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$31.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
7600021
|
|
Hospital Revenue Code
|
511
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$31.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
8800035
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$11.70 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.46
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$36.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Humana ChoiceCare |
$11.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$16.79
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.00
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$19.39
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$16.79
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$39.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.79
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.50
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Professional
|
Both
|
$41.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
11099222
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$4.69 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$13.03
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$8.31
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$24.60
|
| Rate for Payer: Health Net Federal Services Government |
$34.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$8.31
|
| Rate for Payer: Multiplan All |
$30.75
|
| Rate for Payer: National Preferred Provider Network Commercial |
$38.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.60
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$4.69
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$12.56
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$36.08
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
9399222
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$31.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
20399225
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$31.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
8800035
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$18.00 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$31.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
9200033
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$31.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
21700041
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$31.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
8500016
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$11.70 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.46
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$36.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Humana ChoiceCare |
$11.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$16.79
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.00
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$19.39
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$16.79
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$39.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.79
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.50
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
9400100
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$31.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
21600021
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$11.70 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.46
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$36.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Humana ChoiceCare |
$11.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$16.79
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.00
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$19.39
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$16.79
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$39.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.79
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.50
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Professional
|
Both
|
$41.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
10099222
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$4.69 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$13.03
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$8.31
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$24.60
|
| Rate for Payer: Health Net Federal Services Government |
$34.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$8.31
|
| Rate for Payer: Multiplan All |
$30.75
|
| Rate for Payer: National Preferred Provider Network Commercial |
$38.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.60
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$4.69
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$12.56
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$36.08
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
9799222
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$11.70 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.46
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$36.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Humana ChoiceCare |
$11.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$16.79
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.00
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$19.39
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$16.79
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$39.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.79
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.50
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
8499224
|
|
Hospital Revenue Code
|
513
|
| Min. Negotiated Rate |
$11.70 |
| Max. Negotiated Rate |
$80.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.46
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$36.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Humana ChoiceCare |
$11.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$16.79
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.00
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$19.39
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$80.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$39.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.79
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.50
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
9599224
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$11.70 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.46
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$36.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Humana ChoiceCare |
$11.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$16.79
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.00
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$19.39
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$16.79
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$39.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.79
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.50
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
BRIEF CHECK IN BY MD/QHP
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT G2012
|
| Hospital Charge Code |
25500021
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$11.70 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.46
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$36.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Humana ChoiceCare |
$11.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$16.79
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.00
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$19.39
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$16.79
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$39.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.79
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.50
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
BRIMONIDINE 0.15% OPHTH SOLN
|
Facility
|
IP
|
$690.00
|
|
|
Service Code
|
NDC 61314014405
|
| Hospital Charge Code |
3300111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$188.37 |
| Max. Negotiated Rate |
$655.50 |
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cigna Commercial |
$586.50
|
| Rate for Payer: First Health Commercial |
$621.00
|
| Rate for Payer: First Health Workers Compensation |
$266.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$621.00
|
| Rate for Payer: GEHA Commercial |
$483.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$621.00
|
| Rate for Payer: Multiplan All |
$627.90
|
| Rate for Payer: OMNI Networks Commercial |
$483.00
|
| Rate for Payer: One Health Plan PPO/POS |
$621.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$655.50
|
| Rate for Payer: Three Rivers Provider Network All |
$517.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$641.70
|
| Rate for Payer: Zelis Auto |
$276.00
|
| Rate for Payer: Zelis Worker's Compensation |
$188.37
|
|
|
BRIMONIDINE 0.15% OPHTH SOLN
|
Facility
|
OP
|
$690.00
|
|
|
Service Code
|
NDC 61314014405
|
| Hospital Charge Code |
3300111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$172.50 |
| Max. Negotiated Rate |
$655.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$414.00
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cigna Commercial |
$586.50
|
| Rate for Payer: First Health Commercial |
$621.00
|
| Rate for Payer: First Health Workers Compensation |
$266.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$621.00
|
| Rate for Payer: GEHA Commercial |
$552.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$621.00
|
| Rate for Payer: Humana ChoiceCare |
$179.40
|
| Rate for Payer: Multiplan All |
$627.90
|
| Rate for Payer: New Mexico Health Connections Medicare |
$414.00
|
| Rate for Payer: OMNI Networks Commercial |
$483.00
|
| Rate for Payer: One Health Plan PPO/POS |
$621.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$655.50
|
| Rate for Payer: Three Rivers Provider Network All |
$517.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$607.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$172.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$641.70
|
| Rate for Payer: Zelis Auto |
$276.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$345.00
|
| Rate for Payer: Zelis Worker's Compensation |
$188.37
|
|
|
BRIMONIDINE 0.15% OPTH SOLN
|
Facility
|
IP
|
$822.00
|
|
|
Service Code
|
NDC 61314014405
|
| Hospital Charge Code |
3302940
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$224.41 |
| Max. Negotiated Rate |
$780.90 |
| Rate for Payer: Cash Price |
$493.20
|
| Rate for Payer: Cigna Commercial |
$698.70
|
| Rate for Payer: First Health Commercial |
$739.80
|
| Rate for Payer: First Health Workers Compensation |
$317.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$739.80
|
| Rate for Payer: GEHA Commercial |
$575.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$739.80
|
| Rate for Payer: Multiplan All |
$748.02
|
| Rate for Payer: OMNI Networks Commercial |
$575.40
|
| Rate for Payer: One Health Plan PPO/POS |
$739.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$780.90
|
| Rate for Payer: Three Rivers Provider Network All |
$616.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$764.46
|
| Rate for Payer: Zelis Auto |
$328.80
|
| Rate for Payer: Zelis Worker's Compensation |
$224.41
|
|
|
BRIMONIDINE 0.15% OPTH SOLN
|
Facility
|
OP
|
$822.00
|
|
|
Service Code
|
NDC 61314014405
|
| Hospital Charge Code |
3302940
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$205.50 |
| Max. Negotiated Rate |
$780.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$493.20
|
| Rate for Payer: Cash Price |
$493.20
|
| Rate for Payer: Cigna Commercial |
$698.70
|
| Rate for Payer: First Health Commercial |
$739.80
|
| Rate for Payer: First Health Workers Compensation |
$317.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$739.80
|
| Rate for Payer: GEHA Commercial |
$657.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$739.80
|
| Rate for Payer: Humana ChoiceCare |
$213.72
|
| Rate for Payer: Multiplan All |
$748.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$493.20
|
| Rate for Payer: OMNI Networks Commercial |
$575.40
|
| Rate for Payer: One Health Plan PPO/POS |
$739.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$780.90
|
| Rate for Payer: Three Rivers Provider Network All |
$616.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$723.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$205.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$764.46
|
| Rate for Payer: Zelis Auto |
$328.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$411.00
|
| Rate for Payer: Zelis Worker's Compensation |
$224.41
|
|
|
BRIMONIDINE 0.1% OPHTHALMIC
|
Facility
|
OP
|
$736.00
|
|
|
Service Code
|
NDC 00023932105
|
| Hospital Charge Code |
3301828
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$184.00 |
| Max. Negotiated Rate |
$699.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$441.60
|
| Rate for Payer: Cash Price |
$441.60
|
| Rate for Payer: Cigna Commercial |
$625.60
|
| Rate for Payer: First Health Commercial |
$662.40
|
| Rate for Payer: First Health Workers Compensation |
$284.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$662.40
|
| Rate for Payer: GEHA Commercial |
$588.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$662.40
|
| Rate for Payer: Humana ChoiceCare |
$191.36
|
| Rate for Payer: Multiplan All |
$669.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$441.60
|
| Rate for Payer: OMNI Networks Commercial |
$515.20
|
| Rate for Payer: One Health Plan PPO/POS |
$662.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$699.20
|
| Rate for Payer: Three Rivers Provider Network All |
$552.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$647.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$184.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$684.48
|
| Rate for Payer: Zelis Auto |
$294.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$368.00
|
| Rate for Payer: Zelis Worker's Compensation |
$200.93
|
|
