|
WARFARIN SODIUM 2MG TAB
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 62584098401
|
| Hospital Charge Code |
3300946
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.75 |
| Max. Negotiated Rate |
$14.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$12.75
|
| Rate for Payer: First Health Commercial |
$13.50
|
| Rate for Payer: First Health Workers Compensation |
$5.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$13.50
|
| Rate for Payer: GEHA Commercial |
$12.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$13.50
|
| Rate for Payer: Humana ChoiceCare |
$3.90
|
| Rate for Payer: Multiplan All |
$13.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.00
|
| Rate for Payer: OMNI Networks Commercial |
$10.50
|
| Rate for Payer: One Health Plan PPO/POS |
$13.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$14.25
|
| Rate for Payer: Three Rivers Provider Network All |
$11.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.95
|
| Rate for Payer: Zelis Auto |
$6.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.50
|
| Rate for Payer: Zelis Worker's Compensation |
$4.09
|
|
|
WARFARIN SODIUM 5MG TAB
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00832121601
|
| Hospital Charge Code |
3300947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$14.25 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$12.75
|
| Rate for Payer: First Health Commercial |
$13.50
|
| Rate for Payer: First Health Workers Compensation |
$5.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$13.50
|
| Rate for Payer: GEHA Commercial |
$10.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$13.50
|
| Rate for Payer: Multiplan All |
$13.65
|
| Rate for Payer: OMNI Networks Commercial |
$10.50
|
| Rate for Payer: One Health Plan PPO/POS |
$13.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$14.25
|
| Rate for Payer: Three Rivers Provider Network All |
$11.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.95
|
| Rate for Payer: Zelis Auto |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.09
|
|
|
WARFARIN SODIUM 5MG TAB
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00832121601
|
| Hospital Charge Code |
3300947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.75 |
| Max. Negotiated Rate |
$14.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$12.75
|
| Rate for Payer: First Health Commercial |
$13.50
|
| Rate for Payer: First Health Workers Compensation |
$5.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$13.50
|
| Rate for Payer: GEHA Commercial |
$12.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$13.50
|
| Rate for Payer: Humana ChoiceCare |
$3.90
|
| Rate for Payer: Multiplan All |
$13.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.00
|
| Rate for Payer: OMNI Networks Commercial |
$10.50
|
| Rate for Payer: One Health Plan PPO/POS |
$13.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$14.25
|
| Rate for Payer: Three Rivers Provider Network All |
$11.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.95
|
| Rate for Payer: Zelis Auto |
$6.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.50
|
| Rate for Payer: Zelis Worker's Compensation |
$4.09
|
|
|
WASHER FOR CANCELLOUS SCREW
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008055
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$528.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Humana ChoiceCare |
$171.60
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$396.00
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$580.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$165.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$330.00
|
|
|
WASHER FOR CANCELLOUS SCREW
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008054
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$528.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Humana ChoiceCare |
$171.60
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$396.00
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$580.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$165.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$330.00
|
|
|
WASHER FOR CANCELLOUS SCREW
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008055
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$528.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$462.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
|
|
WASHER FOR CANCELLOUS SCREW
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008053
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$528.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Humana ChoiceCare |
$171.60
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$396.00
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$580.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$165.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$330.00
|
|
|
WASHER FOR CANCELLOUS SCREW
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008053
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$528.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$462.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
|
|
WASHER FOR CANCELLOUS SCREW
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008054
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$528.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$462.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
|
|
WASHER MANOMETRY TUBE #1284
|
Facility
|
IP
|
$741.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001610
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$296.40 |
| Max. Negotiated Rate |
$703.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$592.80
|
| Rate for Payer: Cash Price |
$444.60
|
| Rate for Payer: Cash Price |
$444.60
|
| Rate for Payer: Cigna Commercial |
$629.85
|
| Rate for Payer: First Health Commercial |
$666.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$666.90
|
| Rate for Payer: GEHA Commercial |
$518.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$666.90
|
| Rate for Payer: Multiplan All |
$674.31
|
| Rate for Payer: OMNI Networks Commercial |
$518.70
|
| Rate for Payer: One Health Plan PPO/POS |
$666.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$703.95
|
| Rate for Payer: Three Rivers Provider Network All |
$555.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$689.13
|
| Rate for Payer: Zelis Auto |
$296.40
|
|
|
WASHER MANOMETRY TUBE #1284
|
Facility
|
OP
|
$741.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001610
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$185.25 |
| Max. Negotiated Rate |
$703.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$444.60
|
| Rate for Payer: Cash Price |
$444.60
|
| Rate for Payer: Cash Price |
$444.60
|
| Rate for Payer: Cigna Commercial |
$629.85
|
| Rate for Payer: First Health Commercial |
$666.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$666.90
|
| Rate for Payer: GEHA Commercial |
$592.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$666.90
|
| Rate for Payer: Humana ChoiceCare |
$192.66
|
| Rate for Payer: Multiplan All |
$674.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$444.60
|
| Rate for Payer: OMNI Networks Commercial |
$518.70
|
| Rate for Payer: One Health Plan PPO/POS |
$666.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$703.95
|
| Rate for Payer: Three Rivers Provider Network All |
$555.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$652.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$185.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$689.13
|
| Rate for Payer: Zelis Auto |
$296.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$370.50
|
|
|
WATER - BACTERIOSTATIC
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 63323092410
|
| Hospital Charge Code |
3300948
|
|
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
|
|
|
WATER - BACTERIOSTATIC
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 63323092410
|
| Hospital Charge Code |
3300948
|
|
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
|
|
|
WBC AUTOMATED
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
CPT 85048
|
| Hospital Charge Code |
2205048
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$4.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$4.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3.62
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$2.54
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$32.30
|
| Rate for Payer: First Health Commercial |
$34.20
|
| Rate for Payer: First Health Workers Compensation |
$5.66
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$34.20
|
| Rate for Payer: GEHA Commercial |
$30.40
|
| Rate for Payer: GEHA Medicare |
$2.54
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$34.20
|
| Rate for Payer: Humana ChoiceCare |
$2.79
|
| Rate for Payer: Humana Medicare Advantage |
$2.54
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$4.27
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$2.54
|
| Rate for Payer: Multiplan All |
$34.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.32
|
| Rate for Payer: OMNI Networks Commercial |
$26.60
|
| Rate for Payer: One Health Plan PPO/POS |
$34.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$4.27
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3.70
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$2.54
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$36.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$5.08
|
| Rate for Payer: Three Rivers Provider Network All |
$28.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.49
|
| Rate for Payer: United Healthcare Commercial |
$32.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.54
|
| Rate for Payer: United Payors & United Providers UP&UP |
$35.34
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$2.54
|
| Rate for Payer: Zelis Auto |
$15.20
|
| Rate for Payer: Zelis Medicare |
$2.16
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.05
|
| Rate for Payer: Zelis Worker's Compensation |
$4.00
|
|
|
WBC AUTOMATED
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
CPT 85048
|
| Hospital Charge Code |
2205048
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$32.30
|
| Rate for Payer: First Health Commercial |
$34.20
|
| Rate for Payer: First Health Workers Compensation |
$5.66
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$34.20
|
| Rate for Payer: GEHA Commercial |
$26.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$34.20
|
| Rate for Payer: Multiplan All |
$34.58
|
| Rate for Payer: OMNI Networks Commercial |
$26.60
|
| Rate for Payer: One Health Plan PPO/POS |
$34.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$36.10
|
| Rate for Payer: Three Rivers Provider Network All |
$28.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$35.34
|
| Rate for Payer: Zelis Auto |
$15.20
|
| Rate for Payer: Zelis Worker's Compensation |
$4.00
|
|
|
WC- Ceftriaxone 1 GM vial
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
3350424
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$8.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
WC- Ceftriaxone 1 GM vial
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
3350424
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$0.47
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Humana ChoiceCare |
$3.12
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.20
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
WC- Sodium Chloride 0.9% 1000 mL
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
CPT J7030
|
| Hospital Charge Code |
3350425
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$14.45
|
| Rate for Payer: First Health Commercial |
$15.30
|
| Rate for Payer: First Health Workers Compensation |
$6.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15.30
|
| Rate for Payer: GEHA Commercial |
$11.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15.30
|
| Rate for Payer: Multiplan All |
$15.47
|
| Rate for Payer: OMNI Networks Commercial |
$11.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16.15
|
| Rate for Payer: Three Rivers Provider Network All |
$12.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15.81
|
| Rate for Payer: Zelis Auto |
$6.80
|
| Rate for Payer: Zelis Worker's Compensation |
$4.64
|
|
|
WC- Sodium Chloride 0.9% 1000 mL
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
CPT J7030
|
| Hospital Charge Code |
3350425
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$14.45
|
| Rate for Payer: First Health Commercial |
$15.30
|
| Rate for Payer: First Health Workers Compensation |
$6.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15.30
|
| Rate for Payer: GEHA Commercial |
$2.15
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15.30
|
| Rate for Payer: Humana ChoiceCare |
$4.42
|
| Rate for Payer: Multiplan All |
$15.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10.20
|
| Rate for Payer: OMNI Networks Commercial |
$11.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16.15
|
| Rate for Payer: Three Rivers Provider Network All |
$12.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15.81
|
| Rate for Payer: Zelis Auto |
$6.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.50
|
| Rate for Payer: Zelis Worker's Compensation |
$4.64
|
|
|
WEDGE BIOPSY OF LIVER
|
Facility
|
IP
|
$1,763.00
|
|
|
Service Code
|
CPT 47100
|
| Hospital Charge Code |
6147100
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$481.30 |
| Max. Negotiated Rate |
$1,674.85 |
| Rate for Payer: Cash Price |
$1,057.80
|
| Rate for Payer: Cigna Commercial |
$1,498.55
|
| Rate for Payer: First Health Commercial |
$1,586.70
|
| Rate for Payer: First Health Workers Compensation |
$680.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,586.70
|
| Rate for Payer: GEHA Commercial |
$1,234.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,586.70
|
| Rate for Payer: Multiplan All |
$1,604.33
|
| Rate for Payer: OMNI Networks Commercial |
$1,234.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,586.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,674.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,322.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,639.59
|
| Rate for Payer: Zelis Auto |
$705.20
|
| Rate for Payer: Zelis Worker's Compensation |
$481.30
|
|
|
WEDGE BIOPSY OF LIVER
|
Facility
|
OP
|
$1,763.00
|
|
|
Service Code
|
CPT 47100
|
| Hospital Charge Code |
6147100
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$440.75 |
| Max. Negotiated Rate |
$1,674.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,057.80
|
| Rate for Payer: Cash Price |
$1,057.80
|
| Rate for Payer: Cigna Commercial |
$1,498.55
|
| Rate for Payer: First Health Commercial |
$1,586.70
|
| Rate for Payer: First Health Workers Compensation |
$680.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,586.70
|
| Rate for Payer: GEHA Commercial |
$1,410.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,586.70
|
| Rate for Payer: Humana ChoiceCare |
$458.38
|
| Rate for Payer: Multiplan All |
$1,604.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,057.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,234.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,586.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,674.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,322.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,551.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$440.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,639.59
|
| Rate for Payer: Zelis Auto |
$705.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$881.50
|
| Rate for Payer: Zelis Worker's Compensation |
$481.30
|
|
|
WEDGE EXCISION SKIN NAIL FOLD
|
Facility
|
OP
|
$875.00
|
|
| Hospital Charge Code |
8150043
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$218.75 |
| Max. Negotiated Rate |
$831.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$525.00
|
| Rate for Payer: Cash Price |
$525.00
|
| Rate for Payer: Cigna Commercial |
$743.75
|
| Rate for Payer: First Health Commercial |
$787.50
|
| Rate for Payer: First Health Workers Compensation |
$337.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$787.50
|
| Rate for Payer: GEHA Commercial |
$700.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$787.50
|
| Rate for Payer: Humana ChoiceCare |
$227.50
|
| Rate for Payer: Multiplan All |
$796.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$525.00
|
| Rate for Payer: OMNI Networks Commercial |
$612.50
|
| Rate for Payer: One Health Plan PPO/POS |
$787.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$831.25
|
| Rate for Payer: Three Rivers Provider Network All |
$656.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$770.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$218.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$813.75
|
| Rate for Payer: Zelis Auto |
$350.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$437.50
|
| Rate for Payer: Zelis Worker's Compensation |
$238.88
|
|
|
WEDGE EXCISION SKIN NAIL FOLD
|
Facility
|
IP
|
$448.74
|
|
|
Service Code
|
CPT 11765
|
| Hospital Charge Code |
7211765
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$122.51 |
| Max. Negotiated Rate |
$426.30 |
| Rate for Payer: Cash Price |
$269.24
|
| Rate for Payer: Cigna Commercial |
$381.43
|
| Rate for Payer: First Health Commercial |
$403.87
|
| Rate for Payer: First Health Workers Compensation |
$173.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$403.87
|
| Rate for Payer: GEHA Commercial |
$314.12
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$403.87
|
| Rate for Payer: Multiplan All |
$408.35
|
| Rate for Payer: OMNI Networks Commercial |
$314.12
|
| Rate for Payer: One Health Plan PPO/POS |
$403.87
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$426.30
|
| Rate for Payer: Three Rivers Provider Network All |
$336.56
|
| Rate for Payer: United Payors & United Providers UP&UP |
$417.33
|
| Rate for Payer: Zelis Auto |
$179.50
|
| Rate for Payer: Zelis Worker's Compensation |
$122.51
|
|
|
WEDGE EXCISION SKIN NAIL FOLD
|
Facility
|
OP
|
$448.74
|
|
|
Service Code
|
CPT 11765
|
| Hospital Charge Code |
7211765
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$70.39 |
| Max. Negotiated Rate |
$758.74 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$88.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$269.24
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$88.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$70.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$379.37
|
| Rate for Payer: Cash Price |
$269.24
|
| Rate for Payer: Cash Price |
$269.24
|
| Rate for Payer: Cigna Commercial |
$381.43
|
| Rate for Payer: First Health Commercial |
$403.87
|
| Rate for Payer: First Health Workers Compensation |
$173.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$403.87
|
| Rate for Payer: GEHA Commercial |
$358.99
|
| Rate for Payer: GEHA Medicare |
$379.37
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$403.87
|
| Rate for Payer: Humana ChoiceCare |
$417.31
|
| Rate for Payer: Humana Medicare Advantage |
$379.37
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$637.34
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$71.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$379.37
|
| Rate for Payer: Multiplan All |
$408.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$644.93
|
| Rate for Payer: OMNI Networks Commercial |
$314.12
|
| Rate for Payer: One Health Plan PPO/POS |
$403.87
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$82.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$71.83
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$379.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$426.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$758.74
|
| Rate for Payer: Three Rivers Provider Network All |
$336.56
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$371.78
|
| Rate for Payer: United Healthcare Managed Medicaid |
$71.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$379.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$417.33
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$379.37
|
| Rate for Payer: Zelis Auto |
$179.50
|
| Rate for Payer: Zelis Medicare |
$322.46
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$455.24
|
| Rate for Payer: Zelis Worker's Compensation |
$122.51
|
|
|
WEDGE EXCISION SKIN NAIL FOLD
|
Facility
|
OP
|
$283.00
|
|
|
Service Code
|
CPT 11765
|
| Hospital Charge Code |
21600085
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$70.39 |
| Max. Negotiated Rate |
$758.74 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$88.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$169.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$88.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$70.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$379.37
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cigna Commercial |
$240.55
|
| Rate for Payer: First Health Commercial |
$254.70
|
| Rate for Payer: First Health Workers Compensation |
$109.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$254.70
|
| Rate for Payer: GEHA Commercial |
$226.40
|
| Rate for Payer: GEHA Medicare |
$379.37
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$254.70
|
| Rate for Payer: Humana ChoiceCare |
$417.31
|
| Rate for Payer: Humana Medicare Advantage |
$379.37
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$637.34
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$71.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$379.37
|
| Rate for Payer: Multiplan All |
$257.53
|
| Rate for Payer: New Mexico Health Connections Medicare |
$644.93
|
| Rate for Payer: OMNI Networks Commercial |
$198.10
|
| Rate for Payer: One Health Plan PPO/POS |
$254.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$82.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$71.83
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$379.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$268.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$758.74
|
| Rate for Payer: Three Rivers Provider Network All |
$212.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$371.78
|
| Rate for Payer: United Healthcare Managed Medicaid |
$71.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$379.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$263.19
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$379.37
|
| Rate for Payer: Zelis Auto |
$113.20
|
| Rate for Payer: Zelis Medicare |
$322.46
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$455.24
|
| Rate for Payer: Zelis Worker's Compensation |
$77.26
|
|
