|
TOPIRAMATE 50 MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084034301
|
| Hospital Charge Code |
3302988
|
|
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 50 MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084034301
|
| Hospital Charge Code |
3302988
|
|
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
|
|
|
TOPIRAMATE TAB 25MG
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084034201
|
| Hospital Charge Code |
3300905
|
|
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 TAB 25MG
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084034201
|
| Hospital Charge Code |
3300905
|
|
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
|
|
|
TOPIRAMATE TAB 50MG
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
NDC 51079072720
|
| Hospital Charge Code |
3300906
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.83 |
| Max. Negotiated Rate |
$34.20 |
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$30.60
|
| Rate for Payer: First Health Commercial |
$32.40
|
| Rate for Payer: First Health Workers Compensation |
$13.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$32.40
|
| Rate for Payer: GEHA Commercial |
$25.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$32.40
|
| Rate for Payer: Multiplan All |
$32.76
|
| Rate for Payer: OMNI Networks Commercial |
$25.20
|
| Rate for Payer: One Health Plan PPO/POS |
$32.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$34.20
|
| Rate for Payer: Three Rivers Provider Network All |
$27.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$33.48
|
| Rate for Payer: Zelis Auto |
$14.40
|
| Rate for Payer: Zelis Worker's Compensation |
$9.83
|
|
|
TOPIRAMATE TAB 50MG
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
NDC 51079072720
|
| Hospital Charge Code |
3300906
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$34.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$30.60
|
| Rate for Payer: First Health Commercial |
$32.40
|
| Rate for Payer: First Health Workers Compensation |
$13.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$32.40
|
| Rate for Payer: GEHA Commercial |
$28.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$32.40
|
| Rate for Payer: Humana ChoiceCare |
$9.36
|
| Rate for Payer: Multiplan All |
$32.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$21.60
|
| Rate for Payer: OMNI Networks Commercial |
$25.20
|
| Rate for Payer: One Health Plan PPO/POS |
$32.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$34.20
|
| Rate for Payer: Three Rivers Provider Network All |
$27.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$31.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$33.48
|
| Rate for Payer: Zelis Auto |
$14.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.83
|
|
|
topiramate (topamax) REF716285
|
Facility
|
IP
|
$259.00
|
|
|
Service Code
|
CPT 80201
|
| Hospital Charge Code |
2200312
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$15.76 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$220.15
|
| Rate for Payer: First Health Commercial |
$233.10
|
| Rate for Payer: First Health Workers Compensation |
$22.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$233.10
|
| Rate for Payer: GEHA Commercial |
$181.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$233.10
|
| Rate for Payer: Multiplan All |
$235.69
|
| Rate for Payer: OMNI Networks Commercial |
$181.30
|
| Rate for Payer: One Health Plan PPO/POS |
$233.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$246.05
|
| Rate for Payer: Three Rivers Provider Network All |
$194.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$240.87
|
| Rate for Payer: Zelis Auto |
$103.60
|
| Rate for Payer: Zelis Worker's Compensation |
$15.76
|
|
|
topiramate (topamax) REF716285
|
Facility
|
OP
|
$259.00
|
|
|
Service Code
|
CPT 80201
|
| Hospital Charge Code |
2200312
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$10.13 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$21.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$155.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$21.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.99
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$11.92
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$220.15
|
| Rate for Payer: First Health Commercial |
$233.10
|
| Rate for Payer: First Health Workers Compensation |
$22.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$233.10
|
| Rate for Payer: GEHA Commercial |
$207.20
|
| Rate for Payer: GEHA Medicare |
$11.92
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$233.10
|
| Rate for Payer: Humana ChoiceCare |
$13.11
|
| Rate for Payer: Humana Medicare Advantage |
$11.92
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$20.03
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$17.34
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$11.92
|
| Rate for Payer: Multiplan All |
$235.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$20.26
|
| Rate for Payer: OMNI Networks Commercial |
$181.30
|
| Rate for Payer: One Health Plan PPO/POS |
$233.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$20.02
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$17.34
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$11.92
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$246.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$23.84
|
| Rate for Payer: Three Rivers Provider Network All |
$194.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11.68
|
| Rate for Payer: United Healthcare Commercial |
$220.15
|
| Rate for Payer: United Healthcare Managed Medicaid |
$17.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.92
|
| Rate for Payer: United Payors & United Providers UP&UP |
$240.87
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$11.92
|
| Rate for Payer: Zelis Auto |
$103.60
|
| Rate for Payer: Zelis Medicare |
$10.13
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$14.30
|
| Rate for Payer: Zelis Worker's Compensation |
$15.76
|
|
|
TORSEMIDE IV SOLN 20MG/2ML
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
CPT J3265
|
| Hospital Charge Code |
3300907
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.02 |
| Max. Negotiated Rate |
$52.25 |
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$46.75
|
| Rate for Payer: First Health Commercial |
$49.50
|
| Rate for Payer: First Health Workers Compensation |
$21.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$49.50
|
| Rate for Payer: GEHA Commercial |
$38.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$49.50
|
| Rate for Payer: Multiplan All |
$50.05
|
| Rate for Payer: OMNI Networks Commercial |
$38.50
|
| Rate for Payer: One Health Plan PPO/POS |
$49.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$52.25
|
| Rate for Payer: Three Rivers Provider Network All |
$41.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$51.15
|
| Rate for Payer: Zelis Auto |
$22.00
|
| Rate for Payer: Zelis Worker's Compensation |
$15.02
|
|
|
TORSEMIDE IV SOLN 20MG/2ML
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
CPT J3265
|
| Hospital Charge Code |
3300907
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.75 |
| Max. Negotiated Rate |
$52.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$46.75
|
| Rate for Payer: First Health Commercial |
$49.50
|
| Rate for Payer: First Health Workers Compensation |
$21.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$49.50
|
| Rate for Payer: GEHA Commercial |
$44.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$49.50
|
| Rate for Payer: Humana ChoiceCare |
$14.30
|
| Rate for Payer: Multiplan All |
$50.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$33.00
|
| Rate for Payer: OMNI Networks Commercial |
$38.50
|
| Rate for Payer: One Health Plan PPO/POS |
$49.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$52.25
|
| Rate for Payer: Three Rivers Provider Network All |
$41.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$48.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$51.15
|
| Rate for Payer: Zelis Auto |
$22.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$27.50
|
| Rate for Payer: Zelis Worker's Compensation |
$15.02
|
|
|
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S);
|
Facility
|
OP
|
$3,103.33
|
|
|
Service Code
|
CPT 58150
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,194.27 |
| Max. Negotiated Rate |
$3,103.33 |
| Rate for Payer: First Health Workers Compensation |
$3,103.33
|
| Rate for Payer: Zelis Worker's Compensation |
$2,194.27
|
|
|
TOTAL HIP ARTHROPLASTY
|
Facility
|
OP
|
$3,468.00
|
|
|
Service Code
|
CPT 27132
|
| Hospital Charge Code |
6127132
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$867.00 |
| Max. Negotiated Rate |
$3,294.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,080.80
|
| Rate for Payer: Cash Price |
$2,080.80
|
| Rate for Payer: Cigna Commercial |
$2,947.80
|
| Rate for Payer: First Health Commercial |
$3,121.20
|
| Rate for Payer: First Health Workers Compensation |
$1,338.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,121.20
|
| Rate for Payer: GEHA Commercial |
$2,774.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,121.20
|
| Rate for Payer: Humana ChoiceCare |
$901.68
|
| Rate for Payer: Multiplan All |
$3,155.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,080.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,427.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,121.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,294.60
|
| Rate for Payer: Three Rivers Provider Network All |
$2,601.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,051.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$867.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,225.24
|
| Rate for Payer: Zelis Auto |
$1,387.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,734.00
|
| Rate for Payer: Zelis Worker's Compensation |
$946.76
|
|
|
TOTAL HIP ARTHROPLASTY
|
Facility
|
IP
|
$2,807.00
|
|
|
Service Code
|
CPT 27130
|
| Hospital Charge Code |
6127130
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$766.31 |
| Max. Negotiated Rate |
$2,666.65 |
| Rate for Payer: Cash Price |
$1,684.20
|
| Rate for Payer: Cigna Commercial |
$2,385.95
|
| Rate for Payer: First Health Commercial |
$2,526.30
|
| Rate for Payer: First Health Workers Compensation |
$1,083.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,526.30
|
| Rate for Payer: GEHA Commercial |
$1,964.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,526.30
|
| Rate for Payer: Multiplan All |
$2,554.37
|
| Rate for Payer: OMNI Networks Commercial |
$1,964.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,526.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,666.65
|
| Rate for Payer: Three Rivers Provider Network All |
$2,105.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,610.51
|
| Rate for Payer: Zelis Auto |
$1,122.80
|
| Rate for Payer: Zelis Worker's Compensation |
$766.31
|
|
|
TOTAL HIP ARTHROPLASTY
|
Facility
|
OP
|
$2,807.00
|
|
|
Service Code
|
CPT 27130
|
| Hospital Charge Code |
6127130
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$766.31 |
| Max. Negotiated Rate |
$24,435.12 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$17,851.06
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,684.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$17,851.06
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$14,141.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$12,217.56
|
| Rate for Payer: Cash Price |
$1,684.20
|
| Rate for Payer: Cash Price |
$1,684.20
|
| Rate for Payer: Cigna Commercial |
$2,385.95
|
| Rate for Payer: First Health Commercial |
$2,526.30
|
| Rate for Payer: First Health Workers Compensation |
$1,083.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,526.30
|
| Rate for Payer: GEHA Commercial |
$2,245.60
|
| Rate for Payer: GEHA Medicare |
$12,217.56
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,526.30
|
| Rate for Payer: Humana ChoiceCare |
$13,439.32
|
| Rate for Payer: Humana Medicare Advantage |
$12,217.56
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$20,525.50
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$14,429.61
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$12,217.56
|
| Rate for Payer: Multiplan All |
$2,554.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$20,769.85
|
| Rate for Payer: OMNI Networks Commercial |
$1,964.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,526.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$16,660.99
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$14,429.61
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$12,217.56
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,666.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$24,435.12
|
| Rate for Payer: Three Rivers Provider Network All |
$2,105.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11,973.21
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14,429.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,217.56
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,610.51
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$12,217.56
|
| Rate for Payer: Zelis Auto |
$1,122.80
|
| Rate for Payer: Zelis Medicare |
$10,384.93
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$14,661.07
|
| Rate for Payer: Zelis Worker's Compensation |
$766.31
|
|
|
TOTAL HIP ARTHROPLASTY
|
Facility
|
IP
|
$3,468.00
|
|
|
Service Code
|
CPT 27132
|
| Hospital Charge Code |
6127132
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$946.76 |
| Max. Negotiated Rate |
$3,294.60 |
| Rate for Payer: Cash Price |
$2,080.80
|
| Rate for Payer: Cigna Commercial |
$2,947.80
|
| Rate for Payer: First Health Commercial |
$3,121.20
|
| Rate for Payer: First Health Workers Compensation |
$1,338.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,121.20
|
| Rate for Payer: GEHA Commercial |
$2,427.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,121.20
|
| Rate for Payer: Multiplan All |
$3,155.88
|
| Rate for Payer: OMNI Networks Commercial |
$2,427.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,121.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,294.60
|
| Rate for Payer: Three Rivers Provider Network All |
$2,601.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,225.24
|
| Rate for Payer: Zelis Auto |
$1,387.20
|
| Rate for Payer: Zelis Worker's Compensation |
$946.76
|
|
|
TOTAL HYSTERECTOMY
|
Facility
|
IP
|
$2,547.00
|
|
|
Service Code
|
CPT 58152
|
| Hospital Charge Code |
6158152
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$695.33 |
| Max. Negotiated Rate |
$2,419.65 |
| Rate for Payer: Cash Price |
$1,528.20
|
| Rate for Payer: Cigna Commercial |
$2,164.95
|
| Rate for Payer: First Health Commercial |
$2,292.30
|
| Rate for Payer: First Health Workers Compensation |
$983.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,292.30
|
| Rate for Payer: GEHA Commercial |
$1,782.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,292.30
|
| Rate for Payer: Multiplan All |
$2,317.77
|
| Rate for Payer: OMNI Networks Commercial |
$1,782.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,292.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,419.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,910.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,368.71
|
| Rate for Payer: Zelis Auto |
$1,018.80
|
| Rate for Payer: Zelis Worker's Compensation |
$695.33
|
|
|
TOTAL HYSTERECTOMY
|
Facility
|
IP
|
$3,012.21
|
|
|
Service Code
|
CPT 58150
|
| Hospital Charge Code |
6158150
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$822.33 |
| Max. Negotiated Rate |
$2,861.60 |
| Rate for Payer: Cash Price |
$1,807.33
|
| Rate for Payer: Cigna Commercial |
$2,560.38
|
| Rate for Payer: First Health Commercial |
$2,710.99
|
| Rate for Payer: First Health Workers Compensation |
$1,163.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,710.99
|
| Rate for Payer: GEHA Commercial |
$2,108.55
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,710.99
|
| Rate for Payer: Multiplan All |
$2,741.11
|
| Rate for Payer: OMNI Networks Commercial |
$2,108.55
|
| Rate for Payer: One Health Plan PPO/POS |
$2,710.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,861.60
|
| Rate for Payer: Three Rivers Provider Network All |
$2,259.16
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,801.36
|
| Rate for Payer: Zelis Auto |
$1,204.88
|
| Rate for Payer: Zelis Worker's Compensation |
$822.33
|
|
|
TOTAL HYSTERECTOMY
|
Facility
|
OP
|
$2,547.00
|
|
|
Service Code
|
CPT 58152
|
| Hospital Charge Code |
6158152
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$636.75 |
| Max. Negotiated Rate |
$2,419.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,528.20
|
| Rate for Payer: Cash Price |
$1,528.20
|
| Rate for Payer: Cigna Commercial |
$2,164.95
|
| Rate for Payer: First Health Commercial |
$2,292.30
|
| Rate for Payer: First Health Workers Compensation |
$983.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,292.30
|
| Rate for Payer: GEHA Commercial |
$2,037.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,292.30
|
| Rate for Payer: Humana ChoiceCare |
$662.22
|
| Rate for Payer: Multiplan All |
$2,317.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,528.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,782.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,292.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,419.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,910.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,241.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$636.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,368.71
|
| Rate for Payer: Zelis Auto |
$1,018.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,273.50
|
| Rate for Payer: Zelis Worker's Compensation |
$695.33
|
|
|
TOTAL HYSTERECTOMY
|
Facility
|
OP
|
$3,012.21
|
|
|
Service Code
|
CPT 58150
|
| Hospital Charge Code |
6158150
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$753.05 |
| Max. Negotiated Rate |
$2,861.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,807.33
|
| Rate for Payer: Cash Price |
$1,807.33
|
| Rate for Payer: Cigna Commercial |
$2,560.38
|
| Rate for Payer: First Health Commercial |
$2,710.99
|
| Rate for Payer: First Health Workers Compensation |
$1,163.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,710.99
|
| Rate for Payer: GEHA Commercial |
$2,409.77
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,710.99
|
| Rate for Payer: Humana ChoiceCare |
$783.17
|
| Rate for Payer: Multiplan All |
$2,741.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,807.33
|
| Rate for Payer: OMNI Networks Commercial |
$2,108.55
|
| Rate for Payer: One Health Plan PPO/POS |
$2,710.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,861.60
|
| Rate for Payer: Three Rivers Provider Network All |
$2,259.16
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,650.74
|
| Rate for Payer: United Healthcare Managed Medicaid |
$753.05
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,801.36
|
| Rate for Payer: Zelis Auto |
$1,204.88
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,506.11
|
| Rate for Payer: Zelis Worker's Compensation |
$822.33
|
|
|
TOTAL KNEE ARTHROPLASTY
|
Facility
|
IP
|
$2,806.00
|
|
|
Service Code
|
CPT 27447
|
| Hospital Charge Code |
6127447
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$766.04 |
| Max. Negotiated Rate |
$2,665.70 |
| Rate for Payer: Cash Price |
$1,683.60
|
| Rate for Payer: Cigna Commercial |
$2,385.10
|
| Rate for Payer: First Health Commercial |
$2,525.40
|
| Rate for Payer: First Health Workers Compensation |
$1,083.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,525.40
|
| Rate for Payer: GEHA Commercial |
$1,964.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,525.40
|
| Rate for Payer: Multiplan All |
$2,553.46
|
| Rate for Payer: OMNI Networks Commercial |
$1,964.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,525.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,665.70
|
| Rate for Payer: Three Rivers Provider Network All |
$2,104.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,609.58
|
| Rate for Payer: Zelis Auto |
$1,122.40
|
| Rate for Payer: Zelis Worker's Compensation |
$766.04
|
|
|
TOTAL KNEE ARTHROPLASTY
|
Facility
|
OP
|
$2,806.00
|
|
|
Service Code
|
CPT 27447
|
| Hospital Charge Code |
6127447
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$766.04 |
| Max. Negotiated Rate |
$24,435.12 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$14,728.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,683.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$14,728.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$11,668.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$12,217.56
|
| Rate for Payer: Cash Price |
$1,683.60
|
| Rate for Payer: Cash Price |
$1,683.60
|
| Rate for Payer: Cigna Commercial |
$2,385.10
|
| Rate for Payer: First Health Commercial |
$2,525.40
|
| Rate for Payer: First Health Workers Compensation |
$1,083.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,525.40
|
| Rate for Payer: GEHA Commercial |
$2,244.80
|
| Rate for Payer: GEHA Medicare |
$12,217.56
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,525.40
|
| Rate for Payer: Humana ChoiceCare |
$13,439.32
|
| Rate for Payer: Humana Medicare Advantage |
$12,217.56
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$20,525.50
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$11,905.82
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$12,217.56
|
| Rate for Payer: Multiplan All |
$2,553.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$20,769.85
|
| Rate for Payer: OMNI Networks Commercial |
$1,964.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,525.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$13,746.92
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$11,905.82
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$12,217.56
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,665.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$24,435.12
|
| Rate for Payer: Three Rivers Provider Network All |
$2,104.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11,973.21
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11,905.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,217.56
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,609.58
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$12,217.56
|
| Rate for Payer: Zelis Auto |
$1,122.40
|
| Rate for Payer: Zelis Medicare |
$10,384.93
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$14,661.07
|
| Rate for Payer: Zelis Worker's Compensation |
$766.04
|
|
|
TOTAL PSA(RL)
|
Facility
|
OP
|
$197.00
|
|
|
Service Code
|
CPT 84154
|
| Hospital Charge Code |
2299074
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.63 |
| Max. Negotiated Rate |
$187.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$33.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$118.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$33.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$26.23
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$18.39
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$167.45
|
| Rate for Payer: First Health Commercial |
$177.30
|
| Rate for Payer: First Health Workers Compensation |
$27.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$177.30
|
| Rate for Payer: GEHA Commercial |
$157.60
|
| Rate for Payer: GEHA Medicare |
$18.39
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$177.30
|
| Rate for Payer: Humana ChoiceCare |
$20.23
|
| Rate for Payer: Humana Medicare Advantage |
$18.39
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$30.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$26.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$18.39
|
| Rate for Payer: Multiplan All |
$179.27
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.26
|
| Rate for Payer: OMNI Networks Commercial |
$137.90
|
| Rate for Payer: One Health Plan PPO/POS |
$177.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$30.90
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$26.76
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$18.39
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$187.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$36.78
|
| Rate for Payer: Three Rivers Provider Network All |
$147.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.02
|
| Rate for Payer: United Healthcare Commercial |
$167.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.39
|
| Rate for Payer: United Payors & United Providers UP&UP |
$183.21
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$18.39
|
| Rate for Payer: Zelis Auto |
$78.80
|
| Rate for Payer: Zelis Medicare |
$15.63
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.07
|
| Rate for Payer: Zelis Worker's Compensation |
$19.77
|
|
|
TOTAL PSA(RL)
|
Facility
|
IP
|
$197.00
|
|
|
Service Code
|
CPT 84154
|
| Hospital Charge Code |
2299074
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.77 |
| Max. Negotiated Rate |
$187.15 |
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$167.45
|
| Rate for Payer: First Health Commercial |
$177.30
|
| Rate for Payer: First Health Workers Compensation |
$27.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$177.30
|
| Rate for Payer: GEHA Commercial |
$137.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$177.30
|
| Rate for Payer: Multiplan All |
$179.27
|
| Rate for Payer: OMNI Networks Commercial |
$137.90
|
| Rate for Payer: One Health Plan PPO/POS |
$177.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$187.15
|
| Rate for Payer: Three Rivers Provider Network All |
$147.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$183.21
|
| Rate for Payer: Zelis Auto |
$78.80
|
| Rate for Payer: Zelis Worker's Compensation |
$19.77
|
|
|
toxoplasma gondii ab IgG REF006478
|
Facility
|
OP
|
$148.00
|
|
|
Service Code
|
CPT 86777
|
| Hospital Charge Code |
22990850
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.23 |
| Max. Negotiated Rate |
$140.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$25.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$88.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$25.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$20.52
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.39
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$125.80
|
| Rate for Payer: First Health Commercial |
$133.20
|
| Rate for Payer: First Health Workers Compensation |
$21.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$133.20
|
| Rate for Payer: GEHA Commercial |
$118.40
|
| Rate for Payer: GEHA Medicare |
$14.39
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$133.20
|
| Rate for Payer: Humana ChoiceCare |
$15.83
|
| Rate for Payer: Humana Medicare Advantage |
$14.39
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$24.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$20.94
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.39
|
| Rate for Payer: Multiplan All |
$134.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.46
|
| Rate for Payer: OMNI Networks Commercial |
$103.60
|
| Rate for Payer: One Health Plan PPO/POS |
$133.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$24.18
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$20.94
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.39
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$140.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$28.78
|
| Rate for Payer: Three Rivers Provider Network All |
$111.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.10
|
| Rate for Payer: United Healthcare Commercial |
$125.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$20.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.39
|
| Rate for Payer: United Payors & United Providers UP&UP |
$137.64
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.39
|
| Rate for Payer: Zelis Auto |
$59.20
|
| Rate for Payer: Zelis Medicare |
$12.23
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.27
|
| Rate for Payer: Zelis Worker's Compensation |
$15.53
|
|
|
toxoplasma gondii ab IgG REF006478
|
Facility
|
IP
|
$148.00
|
|
|
Service Code
|
CPT 86777
|
| Hospital Charge Code |
22990850
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$15.53 |
| Max. Negotiated Rate |
$140.60 |
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$125.80
|
| Rate for Payer: First Health Commercial |
$133.20
|
| Rate for Payer: First Health Workers Compensation |
$21.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$133.20
|
| Rate for Payer: GEHA Commercial |
$103.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$133.20
|
| Rate for Payer: Multiplan All |
$134.68
|
| Rate for Payer: OMNI Networks Commercial |
$103.60
|
| Rate for Payer: One Health Plan PPO/POS |
$133.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$140.60
|
| Rate for Payer: Three Rivers Provider Network All |
$111.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$137.64
|
| Rate for Payer: Zelis Auto |
$59.20
|
| Rate for Payer: Zelis Worker's Compensation |
$15.53
|
|
