|
tpmt enzyme activity REF510750
|
Facility
|
IP
|
$385.00
|
|
|
Service Code
|
CPT 82657
|
| Hospital Charge Code |
2200652
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.90 |
| Max. Negotiated Rate |
$365.75 |
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cigna Commercial |
$327.25
|
| Rate for Payer: First Health Commercial |
$346.50
|
| Rate for Payer: First Health Workers Compensation |
$32.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$346.50
|
| Rate for Payer: GEHA Commercial |
$269.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$346.50
|
| Rate for Payer: Multiplan All |
$350.35
|
| Rate for Payer: OMNI Networks Commercial |
$269.50
|
| Rate for Payer: One Health Plan PPO/POS |
$346.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$365.75
|
| Rate for Payer: Three Rivers Provider Network All |
$288.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$358.05
|
| Rate for Payer: Zelis Auto |
$154.00
|
| Rate for Payer: Zelis Worker's Compensation |
$22.90
|
|
|
tpmt enzyme activity REF510750
|
Facility
|
OP
|
$385.00
|
|
|
Service Code
|
CPT 82657
|
| Hospital Charge Code |
2200652
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.84 |
| Max. Negotiated Rate |
$365.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$39.90
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$231.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$39.90
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$31.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$22.17
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cigna Commercial |
$327.25
|
| Rate for Payer: First Health Commercial |
$346.50
|
| Rate for Payer: First Health Workers Compensation |
$32.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$346.50
|
| Rate for Payer: GEHA Commercial |
$308.00
|
| Rate for Payer: GEHA Medicare |
$22.17
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$346.50
|
| Rate for Payer: Humana ChoiceCare |
$24.39
|
| Rate for Payer: Humana Medicare Advantage |
$22.17
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$37.25
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$32.25
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$22.17
|
| Rate for Payer: Multiplan All |
$350.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$37.69
|
| Rate for Payer: OMNI Networks Commercial |
$269.50
|
| Rate for Payer: One Health Plan PPO/POS |
$346.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$37.24
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$32.25
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$22.17
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$365.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$44.34
|
| Rate for Payer: Three Rivers Provider Network All |
$288.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$21.73
|
| Rate for Payer: United Healthcare Commercial |
$327.25
|
| Rate for Payer: United Healthcare Managed Medicaid |
$32.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.17
|
| Rate for Payer: United Payors & United Providers UP&UP |
$358.05
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$22.17
|
| Rate for Payer: Zelis Auto |
$154.00
|
| Rate for Payer: Zelis Medicare |
$18.84
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$26.60
|
| Rate for Payer: Zelis Worker's Compensation |
$22.90
|
|
|
TPN CENTRAL 5/15+E 2L
|
Facility
|
IP
|
$562.00
|
|
|
Service Code
|
NDC 00338112304
|
| Hospital Charge Code |
3303024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$153.43 |
| Max. Negotiated Rate |
$533.90 |
| Rate for Payer: Cash Price |
$337.20
|
| Rate for Payer: Cigna Commercial |
$477.70
|
| Rate for Payer: First Health Commercial |
$505.80
|
| Rate for Payer: First Health Workers Compensation |
$216.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$505.80
|
| Rate for Payer: GEHA Commercial |
$393.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$505.80
|
| Rate for Payer: Multiplan All |
$511.42
|
| Rate for Payer: OMNI Networks Commercial |
$393.40
|
| Rate for Payer: One Health Plan PPO/POS |
$505.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$533.90
|
| Rate for Payer: Three Rivers Provider Network All |
$421.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$522.66
|
| Rate for Payer: Zelis Auto |
$224.80
|
| Rate for Payer: Zelis Worker's Compensation |
$153.43
|
|
|
TPN CENTRAL 5/15+E 2L
|
Facility
|
OP
|
$562.00
|
|
|
Service Code
|
NDC 00338112304
|
| Hospital Charge Code |
3303024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$140.50 |
| Max. Negotiated Rate |
$533.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$337.20
|
| Rate for Payer: Cash Price |
$337.20
|
| Rate for Payer: Cigna Commercial |
$477.70
|
| Rate for Payer: First Health Commercial |
$505.80
|
| Rate for Payer: First Health Workers Compensation |
$216.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$505.80
|
| Rate for Payer: GEHA Commercial |
$449.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$505.80
|
| Rate for Payer: Humana ChoiceCare |
$146.12
|
| Rate for Payer: Multiplan All |
$511.42
|
| Rate for Payer: New Mexico Health Connections Medicare |
$337.20
|
| Rate for Payer: OMNI Networks Commercial |
$393.40
|
| Rate for Payer: One Health Plan PPO/POS |
$505.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$533.90
|
| Rate for Payer: Three Rivers Provider Network All |
$421.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$494.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$140.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$522.66
|
| Rate for Payer: Zelis Auto |
$224.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$281.00
|
| Rate for Payer: Zelis Worker's Compensation |
$153.43
|
|
|
TPN CENTRAL 5/20+E 2L
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
NDC 00338112504
|
| Hospital Charge Code |
3303006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$132.41 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$339.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
TPN CENTRAL 5/20+E 2L
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
NDC 00338112504
|
| Hospital Charge Code |
3303006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$121.25 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$291.00
|
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$388.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Humana ChoiceCare |
$126.10
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$291.00
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$426.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$121.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$242.50
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
TPN CENTRAL HP 8/14+E 1L
|
Facility
|
OP
|
$469.00
|
|
|
Service Code
|
NDC 00338020206
|
| Hospital Charge Code |
3303023
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.25 |
| Max. Negotiated Rate |
$445.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$281.40
|
| Rate for Payer: Cash Price |
$281.40
|
| Rate for Payer: Cigna Commercial |
$398.65
|
| Rate for Payer: First Health Commercial |
$422.10
|
| Rate for Payer: First Health Workers Compensation |
$181.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$422.10
|
| Rate for Payer: GEHA Commercial |
$375.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$422.10
|
| Rate for Payer: Humana ChoiceCare |
$121.94
|
| Rate for Payer: Multiplan All |
$426.79
|
| Rate for Payer: New Mexico Health Connections Medicare |
$281.40
|
| Rate for Payer: OMNI Networks Commercial |
$328.30
|
| Rate for Payer: One Health Plan PPO/POS |
$422.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$445.55
|
| Rate for Payer: Three Rivers Provider Network All |
$351.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$412.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$117.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$436.17
|
| Rate for Payer: Zelis Auto |
$187.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$234.50
|
| Rate for Payer: Zelis Worker's Compensation |
$128.04
|
|
|
TPN CENTRAL HP 8/14+E 1L
|
Facility
|
IP
|
$469.00
|
|
|
Service Code
|
NDC 00338020206
|
| Hospital Charge Code |
3303023
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$128.04 |
| Max. Negotiated Rate |
$445.55 |
| Rate for Payer: Cash Price |
$281.40
|
| Rate for Payer: Cigna Commercial |
$398.65
|
| Rate for Payer: First Health Commercial |
$422.10
|
| Rate for Payer: First Health Workers Compensation |
$181.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$422.10
|
| Rate for Payer: GEHA Commercial |
$328.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$422.10
|
| Rate for Payer: Multiplan All |
$426.79
|
| Rate for Payer: OMNI Networks Commercial |
$328.30
|
| Rate for Payer: One Health Plan PPO/POS |
$422.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$445.55
|
| Rate for Payer: Three Rivers Provider Network All |
$351.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$436.17
|
| Rate for Payer: Zelis Auto |
$187.60
|
| Rate for Payer: Zelis Worker's Compensation |
$128.04
|
|
|
TPN CENTRAL HP 8/14+E 2L
|
Facility
|
IP
|
$506.00
|
|
|
Service Code
|
NDC 00338020601
|
| Hospital Charge Code |
3303012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$138.14 |
| Max. Negotiated Rate |
$480.70 |
| Rate for Payer: Cash Price |
$303.60
|
| Rate for Payer: Cigna Commercial |
$430.10
|
| Rate for Payer: First Health Commercial |
$455.40
|
| Rate for Payer: First Health Workers Compensation |
$195.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$455.40
|
| Rate for Payer: GEHA Commercial |
$354.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$455.40
|
| Rate for Payer: Multiplan All |
$460.46
|
| Rate for Payer: OMNI Networks Commercial |
$354.20
|
| Rate for Payer: One Health Plan PPO/POS |
$455.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$480.70
|
| Rate for Payer: Three Rivers Provider Network All |
$379.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$470.58
|
| Rate for Payer: Zelis Auto |
$202.40
|
| Rate for Payer: Zelis Worker's Compensation |
$138.14
|
|
|
TPN CENTRAL HP 8/14+E 2L
|
Facility
|
OP
|
$506.00
|
|
|
Service Code
|
NDC 00338020601
|
| Hospital Charge Code |
3303012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$126.50 |
| Max. Negotiated Rate |
$480.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$303.60
|
| Rate for Payer: Cash Price |
$303.60
|
| Rate for Payer: Cigna Commercial |
$430.10
|
| Rate for Payer: First Health Commercial |
$455.40
|
| Rate for Payer: First Health Workers Compensation |
$195.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$455.40
|
| Rate for Payer: GEHA Commercial |
$404.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$455.40
|
| Rate for Payer: Humana ChoiceCare |
$131.56
|
| Rate for Payer: Multiplan All |
$460.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$303.60
|
| Rate for Payer: OMNI Networks Commercial |
$354.20
|
| Rate for Payer: One Health Plan PPO/POS |
$455.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$480.70
|
| Rate for Payer: Three Rivers Provider Network All |
$379.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$445.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$126.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$470.58
|
| Rate for Payer: Zelis Auto |
$202.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$253.00
|
| Rate for Payer: Zelis Worker's Compensation |
$138.14
|
|
|
TRACE ELEMENTS 4, INJ 1 ML
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
NDC 00517930225
|
| Hospital Charge Code |
3300911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.50 |
| Max. Negotiated Rate |
$138.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$87.60
|
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cigna Commercial |
$124.10
|
| Rate for Payer: First Health Commercial |
$131.40
|
| Rate for Payer: First Health Workers Compensation |
$56.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$131.40
|
| Rate for Payer: GEHA Commercial |
$116.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$131.40
|
| Rate for Payer: Humana ChoiceCare |
$37.96
|
| Rate for Payer: Multiplan All |
$132.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$87.60
|
| Rate for Payer: OMNI Networks Commercial |
$102.20
|
| Rate for Payer: One Health Plan PPO/POS |
$131.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$138.70
|
| Rate for Payer: Three Rivers Provider Network All |
$109.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$128.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$36.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$135.78
|
| Rate for Payer: Zelis Auto |
$58.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$73.00
|
| Rate for Payer: Zelis Worker's Compensation |
$39.86
|
|
|
TRACE ELEMENTS 4, INJ 1 ML
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
NDC 00517930225
|
| Hospital Charge Code |
3300911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.86 |
| Max. Negotiated Rate |
$138.70 |
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cigna Commercial |
$124.10
|
| Rate for Payer: First Health Commercial |
$131.40
|
| Rate for Payer: First Health Workers Compensation |
$56.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$131.40
|
| Rate for Payer: GEHA Commercial |
$102.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$131.40
|
| Rate for Payer: Multiplan All |
$132.86
|
| Rate for Payer: OMNI Networks Commercial |
$102.20
|
| Rate for Payer: One Health Plan PPO/POS |
$131.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$138.70
|
| Rate for Payer: Three Rivers Provider Network All |
$109.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$135.78
|
| Rate for Payer: Zelis Auto |
$58.40
|
| Rate for Payer: Zelis Worker's Compensation |
$39.86
|
|
|
TRACHEO-ESOPHAGOPLASTY CONG
|
Facility
|
IP
|
$6,498.00
|
|
|
Service Code
|
CPT 43314
|
| Hospital Charge Code |
6143314
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,773.95 |
| Max. Negotiated Rate |
$6,173.10 |
| Rate for Payer: Cash Price |
$3,898.80
|
| Rate for Payer: Cigna Commercial |
$5,523.30
|
| Rate for Payer: First Health Commercial |
$5,848.20
|
| Rate for Payer: First Health Workers Compensation |
$2,508.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,848.20
|
| Rate for Payer: GEHA Commercial |
$4,548.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,848.20
|
| Rate for Payer: Multiplan All |
$5,913.18
|
| Rate for Payer: OMNI Networks Commercial |
$4,548.60
|
| Rate for Payer: One Health Plan PPO/POS |
$5,848.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,173.10
|
| Rate for Payer: Three Rivers Provider Network All |
$4,873.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,043.14
|
| Rate for Payer: Zelis Auto |
$2,599.20
|
| Rate for Payer: Zelis Worker's Compensation |
$1,773.95
|
|
|
TRACHEO-ESOPHAGOPLASTY CONG
|
Facility
|
OP
|
$6,498.00
|
|
|
Service Code
|
CPT 43314
|
| Hospital Charge Code |
6143314
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,624.50 |
| Max. Negotiated Rate |
$6,173.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,898.80
|
| Rate for Payer: Cash Price |
$3,898.80
|
| Rate for Payer: Cigna Commercial |
$5,523.30
|
| Rate for Payer: First Health Commercial |
$5,848.20
|
| Rate for Payer: First Health Workers Compensation |
$2,508.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,848.20
|
| Rate for Payer: GEHA Commercial |
$5,198.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,848.20
|
| Rate for Payer: Humana ChoiceCare |
$1,689.48
|
| Rate for Payer: Multiplan All |
$5,913.18
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,898.80
|
| Rate for Payer: OMNI Networks Commercial |
$4,548.60
|
| Rate for Payer: One Health Plan PPO/POS |
$5,848.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,173.10
|
| Rate for Payer: Three Rivers Provider Network All |
$4,873.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,718.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,624.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,043.14
|
| Rate for Payer: Zelis Auto |
$2,599.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,249.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,773.95
|
|
|
TRACHEOSTOMY CRICOTHYROID EMERGEN
|
Facility
|
OP
|
$2,683.00
|
|
| Hospital Charge Code |
8131605
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$670.75 |
| Max. Negotiated Rate |
$2,548.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,609.80
|
| Rate for Payer: Cash Price |
$1,609.80
|
| Rate for Payer: Cigna Commercial |
$2,280.55
|
| Rate for Payer: First Health Commercial |
$2,414.70
|
| Rate for Payer: First Health Workers Compensation |
$1,035.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,414.70
|
| Rate for Payer: GEHA Commercial |
$2,146.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,414.70
|
| Rate for Payer: Humana ChoiceCare |
$697.58
|
| Rate for Payer: Multiplan All |
$2,441.53
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,609.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,878.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,414.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,548.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2,012.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,361.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$670.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,495.19
|
| Rate for Payer: Zelis Auto |
$1,073.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,341.50
|
| Rate for Payer: Zelis Worker's Compensation |
$732.46
|
|
|
TRACHEOSTOMY CRICOTHYROID EMERGEN
|
Facility
|
IP
|
$2,683.00
|
|
| Hospital Charge Code |
8131605
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$732.46 |
| Max. Negotiated Rate |
$2,548.85 |
| Rate for Payer: Cash Price |
$1,609.80
|
| Rate for Payer: Cigna Commercial |
$2,280.55
|
| Rate for Payer: First Health Commercial |
$2,414.70
|
| Rate for Payer: First Health Workers Compensation |
$1,035.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,414.70
|
| Rate for Payer: GEHA Commercial |
$1,878.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,414.70
|
| Rate for Payer: Multiplan All |
$2,441.53
|
| Rate for Payer: OMNI Networks Commercial |
$1,878.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,414.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,548.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2,012.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,495.19
|
| Rate for Payer: Zelis Auto |
$1,073.20
|
| Rate for Payer: Zelis Worker's Compensation |
$732.46
|
|
|
traMADol HCL 50MG TAB
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 57664037708
|
| Hospital Charge Code |
3300912
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$8.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Humana ChoiceCare |
$2.86
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.60
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
traMADol HCL 50MG TAB
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 57664037708
|
| Hospital Charge Code |
3300912
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$7.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
tramadol REF 071545
|
Facility
|
OP
|
$251.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
2200004
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.84 |
| Max. Negotiated Rate |
$238.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$33.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$150.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$33.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$26.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$18.64
|
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cigna Commercial |
$213.35
|
| Rate for Payer: First Health Commercial |
$225.90
|
| Rate for Payer: First Health Workers Compensation |
$31.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$225.90
|
| Rate for Payer: GEHA Commercial |
$200.80
|
| Rate for Payer: GEHA Medicare |
$18.64
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$225.90
|
| Rate for Payer: Humana ChoiceCare |
$20.50
|
| Rate for Payer: Humana Medicare Advantage |
$18.64
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$31.32
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$27.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$18.64
|
| Rate for Payer: Multiplan All |
$228.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.69
|
| Rate for Payer: OMNI Networks Commercial |
$175.70
|
| Rate for Payer: One Health Plan PPO/POS |
$225.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$31.32
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$27.12
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$18.64
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$238.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$37.28
|
| Rate for Payer: Three Rivers Provider Network All |
$188.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.27
|
| Rate for Payer: United Healthcare Commercial |
$213.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$27.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: United Payors & United Providers UP&UP |
$233.43
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$18.64
|
| Rate for Payer: Zelis Auto |
$100.40
|
| Rate for Payer: Zelis Medicare |
$15.84
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.37
|
| Rate for Payer: Zelis Worker's Compensation |
$22.12
|
|
|
tramadol REF 071545
|
Facility
|
IP
|
$251.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
2200004
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$22.12 |
| Max. Negotiated Rate |
$238.45 |
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cigna Commercial |
$213.35
|
| Rate for Payer: First Health Commercial |
$225.90
|
| Rate for Payer: First Health Workers Compensation |
$31.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$225.90
|
| Rate for Payer: GEHA Commercial |
$175.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$225.90
|
| Rate for Payer: Multiplan All |
$228.41
|
| Rate for Payer: OMNI Networks Commercial |
$175.70
|
| Rate for Payer: One Health Plan PPO/POS |
$225.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$238.45
|
| Rate for Payer: Three Rivers Provider Network All |
$188.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$233.43
|
| Rate for Payer: Zelis Auto |
$100.40
|
| Rate for Payer: Zelis Worker's Compensation |
$22.12
|
|
|
TRANEXAMIC ACID 1 GM/10 ML INJ SDV
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300913
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.29 |
| Max. Negotiated Rate |
$63.65 |
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$56.95
|
| Rate for Payer: First Health Commercial |
$60.30
|
| Rate for Payer: First Health Workers Compensation |
$25.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$60.30
|
| Rate for Payer: GEHA Commercial |
$46.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$60.30
|
| Rate for Payer: Multiplan All |
$60.97
|
| Rate for Payer: OMNI Networks Commercial |
$46.90
|
| Rate for Payer: One Health Plan PPO/POS |
$60.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$63.65
|
| Rate for Payer: Three Rivers Provider Network All |
$50.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$62.31
|
| Rate for Payer: Zelis Auto |
$26.80
|
| Rate for Payer: Zelis Worker's Compensation |
$18.29
|
|
|
TRANEXAMIC ACID 1 GM/10 ML INJ SDV
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300913
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.75 |
| Max. Negotiated Rate |
$63.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$40.20
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$56.95
|
| Rate for Payer: First Health Commercial |
$60.30
|
| Rate for Payer: First Health Workers Compensation |
$25.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$60.30
|
| Rate for Payer: GEHA Commercial |
$53.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$60.30
|
| Rate for Payer: Humana ChoiceCare |
$17.42
|
| Rate for Payer: Multiplan All |
$60.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$40.20
|
| Rate for Payer: OMNI Networks Commercial |
$46.90
|
| Rate for Payer: One Health Plan PPO/POS |
$60.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$63.65
|
| Rate for Payer: Three Rivers Provider Network All |
$50.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$58.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$62.31
|
| Rate for Payer: Zelis Auto |
$26.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.50
|
| Rate for Payer: Zelis Worker's Compensation |
$18.29
|
|
|
TRANSABDOM AMNIOINFUS W/US
|
Facility
|
IP
|
$793.00
|
|
|
Service Code
|
CPT 59070
|
| Hospital Charge Code |
6159070
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$216.49 |
| Max. Negotiated Rate |
$753.35 |
| Rate for Payer: Cash Price |
$475.80
|
| Rate for Payer: Cigna Commercial |
$674.05
|
| Rate for Payer: First Health Commercial |
$713.70
|
| Rate for Payer: First Health Workers Compensation |
$306.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$713.70
|
| Rate for Payer: GEHA Commercial |
$555.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$713.70
|
| Rate for Payer: Multiplan All |
$721.63
|
| Rate for Payer: OMNI Networks Commercial |
$555.10
|
| Rate for Payer: One Health Plan PPO/POS |
$713.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$753.35
|
| Rate for Payer: Three Rivers Provider Network All |
$594.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$737.49
|
| Rate for Payer: Zelis Auto |
$317.20
|
| Rate for Payer: Zelis Worker's Compensation |
$216.49
|
|
|
TRANSABDOM AMNIOINFUS W/US
|
Facility
|
OP
|
$793.00
|
|
|
Service Code
|
CPT 59070
|
| Hospital Charge Code |
6159070
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$122.37 |
| Max. Negotiated Rate |
$753.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$154.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$475.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$154.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$122.37
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$288.84
|
| Rate for Payer: Cash Price |
$475.80
|
| Rate for Payer: Cash Price |
$475.80
|
| Rate for Payer: Cigna Commercial |
$674.05
|
| Rate for Payer: First Health Commercial |
$713.70
|
| Rate for Payer: First Health Workers Compensation |
$306.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$713.70
|
| Rate for Payer: GEHA Commercial |
$634.40
|
| Rate for Payer: GEHA Medicare |
$288.84
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$713.70
|
| Rate for Payer: Humana ChoiceCare |
$317.72
|
| Rate for Payer: Humana Medicare Advantage |
$288.84
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$485.25
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$124.86
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$288.84
|
| Rate for Payer: Multiplan All |
$721.63
|
| Rate for Payer: New Mexico Health Connections Medicare |
$491.03
|
| Rate for Payer: OMNI Networks Commercial |
$555.10
|
| Rate for Payer: One Health Plan PPO/POS |
$713.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$144.17
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$124.86
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$288.84
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$753.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$577.68
|
| Rate for Payer: Three Rivers Provider Network All |
$594.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$283.06
|
| Rate for Payer: United Healthcare Managed Medicaid |
$124.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$288.84
|
| Rate for Payer: United Payors & United Providers UP&UP |
$737.49
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$288.84
|
| Rate for Payer: Zelis Auto |
$317.20
|
| Rate for Payer: Zelis Medicare |
$245.51
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$346.61
|
| Rate for Payer: Zelis Worker's Compensation |
$216.49
|
|
|
TRANSAB ESOPH HIAT HERN RPR
|
Facility
|
IP
|
$2,671.00
|
|
|
Service Code
|
CPT 43333
|
| Hospital Charge Code |
6143333
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$729.18 |
| Max. Negotiated Rate |
$2,537.45 |
| Rate for Payer: Cash Price |
$1,602.60
|
| Rate for Payer: Cigna Commercial |
$2,270.35
|
| Rate for Payer: First Health Commercial |
$2,403.90
|
| Rate for Payer: First Health Workers Compensation |
$1,031.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,403.90
|
| Rate for Payer: GEHA Commercial |
$1,869.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,403.90
|
| Rate for Payer: Multiplan All |
$2,430.61
|
| Rate for Payer: OMNI Networks Commercial |
$1,869.70
|
| Rate for Payer: One Health Plan PPO/POS |
$2,403.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,537.45
|
| Rate for Payer: Three Rivers Provider Network All |
$2,003.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,484.03
|
| Rate for Payer: Zelis Auto |
$1,068.40
|
| Rate for Payer: Zelis Worker's Compensation |
$729.18
|
|
