|
TOLTERODINE TARTRATE CAP SR 4MG
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
NDC 00009519101
|
| Hospital Charge Code |
3300902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$49.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$44.20
|
| Rate for Payer: First Health Commercial |
$46.80
|
| Rate for Payer: First Health Workers Compensation |
$20.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$46.80
|
| Rate for Payer: GEHA Commercial |
$41.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$46.80
|
| Rate for Payer: Humana ChoiceCare |
$13.52
|
| Rate for Payer: Multiplan All |
$47.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.20
|
| Rate for Payer: OMNI Networks Commercial |
$36.40
|
| Rate for Payer: One Health Plan PPO/POS |
$46.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$49.40
|
| Rate for Payer: Three Rivers Provider Network All |
$39.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$45.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$48.36
|
| Rate for Payer: Zelis Auto |
$20.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$26.00
|
| Rate for Payer: Zelis Worker's Compensation |
$14.20
|
|
|
TOLTERODINE TARTRATE TAB 2MG
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 00904659204
|
| Hospital Charge Code |
3300903
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.37 |
| Max. Negotiated Rate |
$25.65 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$22.95
|
| Rate for Payer: First Health Commercial |
$24.30
|
| Rate for Payer: First Health Workers Compensation |
$10.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$24.30
|
| Rate for Payer: GEHA Commercial |
$18.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$24.30
|
| Rate for Payer: Multiplan All |
$24.57
|
| Rate for Payer: OMNI Networks Commercial |
$18.90
|
| Rate for Payer: One Health Plan PPO/POS |
$24.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$25.65
|
| Rate for Payer: Three Rivers Provider Network All |
$20.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$25.11
|
| Rate for Payer: Zelis Auto |
$10.80
|
| Rate for Payer: Zelis Worker's Compensation |
$7.37
|
|
|
TOLTERODINE TARTRATE TAB 2MG
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 00904659204
|
| Hospital Charge Code |
3300903
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$25.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$22.95
|
| Rate for Payer: First Health Commercial |
$24.30
|
| Rate for Payer: First Health Workers Compensation |
$10.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$24.30
|
| Rate for Payer: GEHA Commercial |
$21.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$24.30
|
| Rate for Payer: Humana ChoiceCare |
$7.02
|
| Rate for Payer: Multiplan All |
$24.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$16.20
|
| Rate for Payer: OMNI Networks Commercial |
$18.90
|
| Rate for Payer: One Health Plan PPO/POS |
$24.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$25.65
|
| Rate for Payer: Three Rivers Provider Network All |
$20.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$23.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$25.11
|
| Rate for Payer: Zelis Auto |
$10.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$13.50
|
| Rate for Payer: Zelis Worker's Compensation |
$7.37
|
|
|
TOLVAPTAN 15MG TAB
|
Facility
|
OP
|
$525.33
|
|
|
Service Code
|
NDC 67877063533
|
| Hospital Charge Code |
3303257
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$131.33 |
| Max. Negotiated Rate |
$499.06 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$315.20
|
| Rate for Payer: Cash Price |
$315.20
|
| Rate for Payer: Cigna Commercial |
$446.53
|
| Rate for Payer: First Health Commercial |
$472.80
|
| Rate for Payer: First Health Workers Compensation |
$202.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$472.80
|
| Rate for Payer: GEHA Commercial |
$420.26
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$472.80
|
| Rate for Payer: Humana ChoiceCare |
$136.59
|
| Rate for Payer: Multiplan All |
$478.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$315.20
|
| Rate for Payer: OMNI Networks Commercial |
$367.73
|
| Rate for Payer: One Health Plan PPO/POS |
$472.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$499.06
|
| Rate for Payer: Three Rivers Provider Network All |
$394.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$462.29
|
| Rate for Payer: United Healthcare Managed Medicaid |
$131.33
|
| Rate for Payer: United Payors & United Providers UP&UP |
$488.56
|
| Rate for Payer: Zelis Auto |
$210.13
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$262.67
|
| Rate for Payer: Zelis Worker's Compensation |
$143.42
|
|
|
TOLVAPTAN 15MG TAB
|
Facility
|
IP
|
$525.33
|
|
|
Service Code
|
NDC 67877063533
|
| Hospital Charge Code |
3303257
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.42 |
| Max. Negotiated Rate |
$499.06 |
| Rate for Payer: Cash Price |
$315.20
|
| Rate for Payer: Cigna Commercial |
$446.53
|
| Rate for Payer: First Health Commercial |
$472.80
|
| Rate for Payer: First Health Workers Compensation |
$202.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$472.80
|
| Rate for Payer: GEHA Commercial |
$367.73
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$472.80
|
| Rate for Payer: Multiplan All |
$478.05
|
| Rate for Payer: OMNI Networks Commercial |
$367.73
|
| Rate for Payer: One Health Plan PPO/POS |
$472.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$499.06
|
| Rate for Payer: Three Rivers Provider Network All |
$394.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$488.56
|
| Rate for Payer: Zelis Auto |
$210.13
|
| Rate for Payer: Zelis Worker's Compensation |
$143.42
|
|
|
TONGUE AND NECK SURGERY
|
Facility
|
OP
|
$4,533.00
|
|
|
Service Code
|
CPT 41135
|
| Hospital Charge Code |
6141135
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,133.25 |
| Max. Negotiated Rate |
$4,306.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,719.80
|
| Rate for Payer: Cash Price |
$2,719.80
|
| Rate for Payer: Cigna Commercial |
$3,853.05
|
| Rate for Payer: First Health Commercial |
$4,079.70
|
| Rate for Payer: First Health Workers Compensation |
$1,750.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,079.70
|
| Rate for Payer: GEHA Commercial |
$3,626.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,079.70
|
| Rate for Payer: Humana ChoiceCare |
$1,178.58
|
| Rate for Payer: Multiplan All |
$4,125.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,719.80
|
| Rate for Payer: OMNI Networks Commercial |
$3,173.10
|
| Rate for Payer: One Health Plan PPO/POS |
$4,079.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,306.35
|
| Rate for Payer: Three Rivers Provider Network All |
$3,399.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,989.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,133.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,215.69
|
| Rate for Payer: Zelis Auto |
$1,813.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,266.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1,237.51
|
|
|
TONGUE AND NECK SURGERY
|
Facility
|
IP
|
$4,533.00
|
|
|
Service Code
|
CPT 41135
|
| Hospital Charge Code |
6141135
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,237.51 |
| Max. Negotiated Rate |
$4,306.35 |
| Rate for Payer: Cash Price |
$2,719.80
|
| Rate for Payer: Cigna Commercial |
$3,853.05
|
| Rate for Payer: First Health Commercial |
$4,079.70
|
| Rate for Payer: First Health Workers Compensation |
$1,750.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,079.70
|
| Rate for Payer: GEHA Commercial |
$3,173.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,079.70
|
| Rate for Payer: Multiplan All |
$4,125.03
|
| Rate for Payer: OMNI Networks Commercial |
$3,173.10
|
| Rate for Payer: One Health Plan PPO/POS |
$4,079.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,306.35
|
| Rate for Payer: Three Rivers Provider Network All |
$3,399.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,215.69
|
| Rate for Payer: Zelis Auto |
$1,813.20
|
| Rate for Payer: Zelis Worker's Compensation |
$1,237.51
|
|
|
TONGUE BASE VOL REDUCTION
|
Facility
|
IP
|
$959.00
|
|
|
Service Code
|
CPT 41530
|
| Hospital Charge Code |
6141530
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$261.81 |
| Max. Negotiated Rate |
$911.05 |
| Rate for Payer: Cash Price |
$575.40
|
| Rate for Payer: Cigna Commercial |
$815.15
|
| Rate for Payer: First Health Commercial |
$863.10
|
| Rate for Payer: First Health Workers Compensation |
$370.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$863.10
|
| Rate for Payer: GEHA Commercial |
$671.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$863.10
|
| Rate for Payer: Multiplan All |
$872.69
|
| Rate for Payer: OMNI Networks Commercial |
$671.30
|
| Rate for Payer: One Health Plan PPO/POS |
$863.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$911.05
|
| Rate for Payer: Three Rivers Provider Network All |
$719.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$891.87
|
| Rate for Payer: Zelis Auto |
$383.60
|
| Rate for Payer: Zelis Worker's Compensation |
$261.81
|
|
|
TONGUE BASE VOL REDUCTION
|
Facility
|
OP
|
$959.00
|
|
|
Service Code
|
CPT 41530
|
| Hospital Charge Code |
6141530
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$261.81 |
| Max. Negotiated Rate |
$6,158.84 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,524.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$575.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,524.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,999.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,079.42
|
| Rate for Payer: Cash Price |
$575.40
|
| Rate for Payer: Cash Price |
$575.40
|
| Rate for Payer: Cigna Commercial |
$815.15
|
| Rate for Payer: First Health Commercial |
$863.10
|
| Rate for Payer: First Health Workers Compensation |
$370.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$863.10
|
| Rate for Payer: GEHA Commercial |
$767.20
|
| Rate for Payer: GEHA Medicare |
$3,079.42
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$863.10
|
| Rate for Payer: Humana ChoiceCare |
$3,387.36
|
| Rate for Payer: Humana Medicare Advantage |
$3,079.42
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,173.43
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,040.27
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,079.42
|
| Rate for Payer: Multiplan All |
$872.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,235.01
|
| Rate for Payer: OMNI Networks Commercial |
$671.30
|
| Rate for Payer: One Health Plan PPO/POS |
$863.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,355.78
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,040.27
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,079.42
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$911.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,158.84
|
| Rate for Payer: Three Rivers Provider Network All |
$719.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,017.83
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,040.27
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,079.42
|
| Rate for Payer: United Payors & United Providers UP&UP |
$891.87
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,079.42
|
| Rate for Payer: Zelis Auto |
$383.60
|
| Rate for Payer: Zelis Medicare |
$2,617.51
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,695.30
|
| Rate for Payer: Zelis Worker's Compensation |
$261.81
|
|
|
TONGUE JAW & NECK SURGERY
|
Facility
|
OP
|
$6,304.00
|
|
|
Service Code
|
CPT 41155
|
| Hospital Charge Code |
6141155
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,576.00 |
| Max. Negotiated Rate |
$5,988.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,782.40
|
| Rate for Payer: Cash Price |
$3,782.40
|
| Rate for Payer: Cigna Commercial |
$5,358.40
|
| Rate for Payer: First Health Commercial |
$5,673.60
|
| Rate for Payer: First Health Workers Compensation |
$2,433.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,673.60
|
| Rate for Payer: GEHA Commercial |
$5,043.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,673.60
|
| Rate for Payer: Humana ChoiceCare |
$1,639.04
|
| Rate for Payer: Multiplan All |
$5,736.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,782.40
|
| Rate for Payer: OMNI Networks Commercial |
$4,412.80
|
| Rate for Payer: One Health Plan PPO/POS |
$5,673.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,988.80
|
| Rate for Payer: Three Rivers Provider Network All |
$4,728.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,547.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,576.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,862.72
|
| Rate for Payer: Zelis Auto |
$2,521.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,152.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,720.99
|
|
|
TONGUE JAW & NECK SURGERY
|
Facility
|
IP
|
$6,304.00
|
|
|
Service Code
|
CPT 41155
|
| Hospital Charge Code |
6141155
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,720.99 |
| Max. Negotiated Rate |
$5,988.80 |
| Rate for Payer: Cash Price |
$3,782.40
|
| Rate for Payer: Cigna Commercial |
$5,358.40
|
| Rate for Payer: First Health Commercial |
$5,673.60
|
| Rate for Payer: First Health Workers Compensation |
$2,433.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,673.60
|
| Rate for Payer: GEHA Commercial |
$4,412.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,673.60
|
| Rate for Payer: Multiplan All |
$5,736.64
|
| Rate for Payer: OMNI Networks Commercial |
$4,412.80
|
| Rate for Payer: One Health Plan PPO/POS |
$5,673.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,988.80
|
| Rate for Payer: Three Rivers Provider Network All |
$4,728.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,862.72
|
| Rate for Payer: Zelis Auto |
$2,521.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1,720.99
|
|
|
TONGUE MOUTH JAW SURGERY
|
Facility
|
OP
|
$4,596.00
|
|
|
Service Code
|
CPT 41150
|
| Hospital Charge Code |
6141150
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,149.00 |
| Max. Negotiated Rate |
$4,366.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,757.60
|
| Rate for Payer: Cash Price |
$2,757.60
|
| Rate for Payer: Cigna Commercial |
$3,906.60
|
| Rate for Payer: First Health Commercial |
$4,136.40
|
| Rate for Payer: First Health Workers Compensation |
$1,774.52
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,136.40
|
| Rate for Payer: GEHA Commercial |
$3,676.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,136.40
|
| Rate for Payer: Humana ChoiceCare |
$1,194.96
|
| Rate for Payer: Multiplan All |
$4,182.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,757.60
|
| Rate for Payer: OMNI Networks Commercial |
$3,217.20
|
| Rate for Payer: One Health Plan PPO/POS |
$4,136.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,366.20
|
| Rate for Payer: Three Rivers Provider Network All |
$3,447.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,044.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,149.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,274.28
|
| Rate for Payer: Zelis Auto |
$1,838.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,298.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,254.71
|
|
|
TONGUE MOUTH JAW SURGERY
|
Facility
|
IP
|
$4,596.00
|
|
|
Service Code
|
CPT 41150
|
| Hospital Charge Code |
6141150
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,254.71 |
| Max. Negotiated Rate |
$4,366.20 |
| Rate for Payer: Cash Price |
$2,757.60
|
| Rate for Payer: Cigna Commercial |
$3,906.60
|
| Rate for Payer: First Health Commercial |
$4,136.40
|
| Rate for Payer: First Health Workers Compensation |
$1,774.52
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,136.40
|
| Rate for Payer: GEHA Commercial |
$3,217.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,136.40
|
| Rate for Payer: Multiplan All |
$4,182.36
|
| Rate for Payer: OMNI Networks Commercial |
$3,217.20
|
| Rate for Payer: One Health Plan PPO/POS |
$4,136.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,366.20
|
| Rate for Payer: Three Rivers Provider Network All |
$3,447.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,274.28
|
| Rate for Payer: Zelis Auto |
$1,838.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1,254.71
|
|
|
TONGUE MOUTH NECK SURGERY
|
Facility
|
OP
|
$5,012.00
|
|
|
Service Code
|
CPT 41153
|
| Hospital Charge Code |
6141153
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,253.00 |
| Max. Negotiated Rate |
$4,761.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,007.20
|
| Rate for Payer: Cash Price |
$3,007.20
|
| Rate for Payer: Cigna Commercial |
$4,260.20
|
| Rate for Payer: First Health Commercial |
$4,510.80
|
| Rate for Payer: First Health Workers Compensation |
$1,935.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,510.80
|
| Rate for Payer: GEHA Commercial |
$4,009.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,510.80
|
| Rate for Payer: Humana ChoiceCare |
$1,303.12
|
| Rate for Payer: Multiplan All |
$4,560.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,007.20
|
| Rate for Payer: OMNI Networks Commercial |
$3,508.40
|
| Rate for Payer: One Health Plan PPO/POS |
$4,510.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,761.40
|
| Rate for Payer: Three Rivers Provider Network All |
$3,759.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,410.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,253.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,661.16
|
| Rate for Payer: Zelis Auto |
$2,004.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,506.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,368.28
|
|
|
TONGUE MOUTH NECK SURGERY
|
Facility
|
IP
|
$5,012.00
|
|
|
Service Code
|
CPT 41153
|
| Hospital Charge Code |
6141153
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,368.28 |
| Max. Negotiated Rate |
$4,761.40 |
| Rate for Payer: Cash Price |
$3,007.20
|
| Rate for Payer: Cigna Commercial |
$4,260.20
|
| Rate for Payer: First Health Commercial |
$4,510.80
|
| Rate for Payer: First Health Workers Compensation |
$1,935.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,510.80
|
| Rate for Payer: GEHA Commercial |
$3,508.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,510.80
|
| Rate for Payer: Multiplan All |
$4,560.92
|
| Rate for Payer: OMNI Networks Commercial |
$3,508.40
|
| Rate for Payer: One Health Plan PPO/POS |
$4,510.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,761.40
|
| Rate for Payer: Three Rivers Provider Network All |
$3,759.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,661.16
|
| Rate for Payer: Zelis Auto |
$2,004.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1,368.28
|
|
|
TONGUE REMOVAL NECK SURGERY
|
Facility
|
IP
|
$5,806.00
|
|
|
Service Code
|
CPT 41145
|
| Hospital Charge Code |
6141145
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,585.04 |
| Max. Negotiated Rate |
$5,515.70 |
| Rate for Payer: Cash Price |
$3,483.60
|
| Rate for Payer: Cigna Commercial |
$4,935.10
|
| Rate for Payer: First Health Commercial |
$5,225.40
|
| Rate for Payer: First Health Workers Compensation |
$2,241.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,225.40
|
| Rate for Payer: GEHA Commercial |
$4,064.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,225.40
|
| Rate for Payer: Multiplan All |
$5,283.46
|
| Rate for Payer: OMNI Networks Commercial |
$4,064.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5,225.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,515.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4,354.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,399.58
|
| Rate for Payer: Zelis Auto |
$2,322.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1,585.04
|
|
|
TONGUE REMOVAL NECK SURGERY
|
Facility
|
OP
|
$5,806.00
|
|
|
Service Code
|
CPT 41145
|
| Hospital Charge Code |
6141145
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,451.50 |
| Max. Negotiated Rate |
$5,515.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,483.60
|
| Rate for Payer: Cash Price |
$3,483.60
|
| Rate for Payer: Cigna Commercial |
$4,935.10
|
| Rate for Payer: First Health Commercial |
$5,225.40
|
| Rate for Payer: First Health Workers Compensation |
$2,241.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,225.40
|
| Rate for Payer: GEHA Commercial |
$4,644.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,225.40
|
| Rate for Payer: Humana ChoiceCare |
$1,509.56
|
| Rate for Payer: Multiplan All |
$5,283.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,483.60
|
| Rate for Payer: OMNI Networks Commercial |
$4,064.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5,225.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,515.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4,354.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,109.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,451.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,399.58
|
| Rate for Payer: Zelis Auto |
$2,322.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,903.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,585.04
|
|
|
TONGUE SUSPENSION
|
Facility
|
IP
|
$1,358.00
|
|
|
Service Code
|
CPT 41512
|
| Hospital Charge Code |
6141512
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$370.73 |
| Max. Negotiated Rate |
$1,290.10 |
| Rate for Payer: Cash Price |
$814.80
|
| Rate for Payer: Cigna Commercial |
$1,154.30
|
| Rate for Payer: First Health Commercial |
$1,222.20
|
| Rate for Payer: First Health Workers Compensation |
$524.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,222.20
|
| Rate for Payer: GEHA Commercial |
$950.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,222.20
|
| Rate for Payer: Multiplan All |
$1,235.78
|
| Rate for Payer: OMNI Networks Commercial |
$950.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,222.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,290.10
|
| Rate for Payer: Three Rivers Provider Network All |
$1,018.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,262.94
|
| Rate for Payer: Zelis Auto |
$543.20
|
| Rate for Payer: Zelis Worker's Compensation |
$370.73
|
|
|
TONGUE SUSPENSION
|
Facility
|
OP
|
$1,358.00
|
|
|
Service Code
|
CPT 41512
|
| Hospital Charge Code |
6141512
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$370.73 |
| Max. Negotiated Rate |
$11,234.32 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$770.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$814.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$770.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$610.32
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5,617.16
|
| Rate for Payer: Cash Price |
$814.80
|
| Rate for Payer: Cash Price |
$814.80
|
| Rate for Payer: Cigna Commercial |
$1,154.30
|
| Rate for Payer: First Health Commercial |
$1,222.20
|
| Rate for Payer: First Health Workers Compensation |
$524.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,222.20
|
| Rate for Payer: GEHA Commercial |
$1,086.40
|
| Rate for Payer: GEHA Medicare |
$5,617.16
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,222.20
|
| Rate for Payer: Humana ChoiceCare |
$6,178.88
|
| Rate for Payer: Humana Medicare Advantage |
$5,617.16
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$9,436.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$622.75
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5,617.16
|
| Rate for Payer: Multiplan All |
$1,235.78
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9,549.17
|
| Rate for Payer: OMNI Networks Commercial |
$950.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,222.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$719.05
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$622.75
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5,617.16
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,290.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11,234.32
|
| Rate for Payer: Three Rivers Provider Network All |
$1,018.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,504.82
|
| Rate for Payer: United Healthcare Managed Medicaid |
$622.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,617.16
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,262.94
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5,617.16
|
| Rate for Payer: Zelis Auto |
$543.20
|
| Rate for Payer: Zelis Medicare |
$4,774.59
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,740.59
|
| Rate for Payer: Zelis Worker's Compensation |
$370.73
|
|
|
TONGUE TIE
|
Facility
|
OP
|
$612.00
|
|
|
Service Code
|
CPT 41010
|
| Hospital Charge Code |
8300066
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$167.08 |
| Max. Negotiated Rate |
$2,813.06 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$770.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$367.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$770.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$610.32
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,406.53
|
| Rate for Payer: Cash Price |
$367.20
|
| Rate for Payer: Cash Price |
$367.20
|
| Rate for Payer: Cigna Commercial |
$520.20
|
| Rate for Payer: First Health Commercial |
$550.80
|
| Rate for Payer: First Health Workers Compensation |
$236.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$550.80
|
| Rate for Payer: GEHA Commercial |
$489.60
|
| Rate for Payer: GEHA Medicare |
$1,406.53
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$550.80
|
| Rate for Payer: Humana ChoiceCare |
$1,547.18
|
| Rate for Payer: Humana Medicare Advantage |
$1,406.53
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,362.97
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$622.75
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,406.53
|
| Rate for Payer: Multiplan All |
$556.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,391.10
|
| Rate for Payer: OMNI Networks Commercial |
$428.40
|
| Rate for Payer: One Health Plan PPO/POS |
$550.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$719.05
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$622.75
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,406.53
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$581.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$2,813.06
|
| Rate for Payer: Three Rivers Provider Network All |
$459.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,378.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$622.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,406.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$569.16
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,406.53
|
| Rate for Payer: Zelis Auto |
$244.80
|
| Rate for Payer: Zelis Medicare |
$1,195.55
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,687.84
|
| Rate for Payer: Zelis Worker's Compensation |
$167.08
|
|
|
TONGUE TIE
|
Facility
|
IP
|
$612.00
|
|
|
Service Code
|
CPT 41010
|
| Hospital Charge Code |
8300066
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$167.08 |
| Max. Negotiated Rate |
$581.40 |
| Rate for Payer: Cash Price |
$367.20
|
| Rate for Payer: Cigna Commercial |
$520.20
|
| Rate for Payer: First Health Commercial |
$550.80
|
| Rate for Payer: First Health Workers Compensation |
$236.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$550.80
|
| Rate for Payer: GEHA Commercial |
$428.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$550.80
|
| Rate for Payer: Multiplan All |
$556.92
|
| Rate for Payer: OMNI Networks Commercial |
$428.40
|
| Rate for Payer: One Health Plan PPO/POS |
$550.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$581.40
|
| Rate for Payer: Three Rivers Provider Network All |
$459.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$569.16
|
| Rate for Payer: Zelis Auto |
$244.80
|
| Rate for Payer: Zelis Worker's Compensation |
$167.08
|
|
|
TONGUE TO LIP SURGERY
|
Facility
|
IP
|
$856.00
|
|
|
Service Code
|
CPT 41510
|
| Hospital Charge Code |
6141510
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$233.69 |
| Max. Negotiated Rate |
$813.20 |
| Rate for Payer: Cash Price |
$513.60
|
| Rate for Payer: Cigna Commercial |
$727.60
|
| Rate for Payer: First Health Commercial |
$770.40
|
| Rate for Payer: First Health Workers Compensation |
$330.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$770.40
|
| Rate for Payer: GEHA Commercial |
$599.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$770.40
|
| Rate for Payer: Multiplan All |
$778.96
|
| Rate for Payer: OMNI Networks Commercial |
$599.20
|
| Rate for Payer: One Health Plan PPO/POS |
$770.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$813.20
|
| Rate for Payer: Three Rivers Provider Network All |
$642.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$796.08
|
| Rate for Payer: Zelis Auto |
$342.40
|
| Rate for Payer: Zelis Worker's Compensation |
$233.69
|
|
|
TONGUE TO LIP SURGERY
|
Facility
|
OP
|
$856.00
|
|
|
Service Code
|
CPT 41510
|
| Hospital Charge Code |
6141510
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$233.69 |
| Max. Negotiated Rate |
$6,158.84 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,737.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$513.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,737.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,376.73
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,079.42
|
| Rate for Payer: Cash Price |
$513.60
|
| Rate for Payer: Cash Price |
$513.60
|
| Rate for Payer: Cigna Commercial |
$727.60
|
| Rate for Payer: First Health Commercial |
$770.40
|
| Rate for Payer: First Health Workers Compensation |
$330.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$770.40
|
| Rate for Payer: GEHA Commercial |
$684.80
|
| Rate for Payer: GEHA Medicare |
$3,079.42
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$770.40
|
| Rate for Payer: Humana ChoiceCare |
$3,387.36
|
| Rate for Payer: Humana Medicare Advantage |
$3,079.42
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,173.43
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,404.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,079.42
|
| Rate for Payer: Multiplan All |
$778.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,235.01
|
| Rate for Payer: OMNI Networks Commercial |
$599.20
|
| Rate for Payer: One Health Plan PPO/POS |
$770.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,622.00
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,404.77
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,079.42
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$813.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,158.84
|
| Rate for Payer: Three Rivers Provider Network All |
$642.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,017.83
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,404.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,079.42
|
| Rate for Payer: United Payors & United Providers UP&UP |
$796.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,079.42
|
| Rate for Payer: Zelis Auto |
$342.40
|
| Rate for Payer: Zelis Medicare |
$2,617.51
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,695.30
|
| Rate for Payer: Zelis Worker's Compensation |
$233.69
|
|
|
TOPIRAMATE 100 MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084034401
|
| Hospital Charge Code |
3300904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
TOPIRAMATE 100 MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084034401
|
| Hospital Charge Code |
3300904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
