|
CLINIC RAPID STREP
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
CPT 87430
|
| Hospital Charge Code |
7300022
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$14.29 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$30.25
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$45.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$30.25
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$23.97
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$16.81
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: First Health Workers Compensation |
$20.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$68.40
|
| Rate for Payer: GEHA Commercial |
$60.80
|
| Rate for Payer: GEHA Medicare |
$16.81
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$68.40
|
| Rate for Payer: Humana ChoiceCare |
$18.49
|
| Rate for Payer: Humana Medicare Advantage |
$16.81
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$28.24
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$24.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$16.81
|
| Rate for Payer: Multiplan All |
$69.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$28.58
|
| Rate for Payer: OMNI Networks Commercial |
$53.20
|
| Rate for Payer: One Health Plan PPO/POS |
$68.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$28.24
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$24.46
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$16.81
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$72.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$33.62
|
| Rate for Payer: Three Rivers Provider Network All |
$57.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16.47
|
| Rate for Payer: United Healthcare Commercial |
$64.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$24.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.81
|
| Rate for Payer: United Payors & United Providers UP&UP |
$70.68
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$16.81
|
| Rate for Payer: Zelis Auto |
$30.40
|
| Rate for Payer: Zelis Medicare |
$14.29
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.17
|
| Rate for Payer: Zelis Worker's Compensation |
$14.71
|
|
|
CLINIC RAPID STREP
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
CPT 87430
|
| Hospital Charge Code |
7300022
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$14.71 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: First Health Workers Compensation |
$20.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$68.40
|
| Rate for Payer: GEHA Commercial |
$53.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$68.40
|
| Rate for Payer: Multiplan All |
$69.16
|
| Rate for Payer: OMNI Networks Commercial |
$53.20
|
| Rate for Payer: One Health Plan PPO/POS |
$68.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$72.20
|
| Rate for Payer: Three Rivers Provider Network All |
$57.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$70.68
|
| Rate for Payer: Zelis Auto |
$30.40
|
| Rate for Payer: Zelis Worker's Compensation |
$14.71
|
|
|
CLINIC RSV
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
CPT 87420
|
| Hospital Charge Code |
7300028
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$11.82 |
| Max. Negotiated Rate |
$263.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$25.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$166.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$25.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$19.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$13.91
|
| Rate for Payer: Cash Price |
$166.20
|
| Rate for Payer: Cash Price |
$166.20
|
| Rate for Payer: Cigna Commercial |
$235.45
|
| Rate for Payer: First Health Commercial |
$249.30
|
| Rate for Payer: First Health Workers Compensation |
$20.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$249.30
|
| Rate for Payer: GEHA Commercial |
$221.60
|
| Rate for Payer: GEHA Medicare |
$13.91
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$249.30
|
| Rate for Payer: Humana ChoiceCare |
$15.30
|
| Rate for Payer: Humana Medicare Advantage |
$13.91
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$23.37
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$20.24
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$13.91
|
| Rate for Payer: Multiplan All |
$252.07
|
| Rate for Payer: New Mexico Health Connections Medicare |
$23.65
|
| Rate for Payer: OMNI Networks Commercial |
$193.90
|
| Rate for Payer: One Health Plan PPO/POS |
$249.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$23.37
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$20.24
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$13.91
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$263.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$27.82
|
| Rate for Payer: Three Rivers Provider Network All |
$207.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.63
|
| Rate for Payer: United Healthcare Commercial |
$235.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$20.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.91
|
| Rate for Payer: United Payors & United Providers UP&UP |
$257.61
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$13.91
|
| Rate for Payer: Zelis Auto |
$110.80
|
| Rate for Payer: Zelis Medicare |
$11.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$16.69
|
| Rate for Payer: Zelis Worker's Compensation |
$14.71
|
|
|
CLINIC RSV
|
Facility
|
IP
|
$277.00
|
|
|
Service Code
|
CPT 87420
|
| Hospital Charge Code |
7300028
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$14.71 |
| Max. Negotiated Rate |
$263.15 |
| Rate for Payer: Cash Price |
$166.20
|
| Rate for Payer: Cash Price |
$166.20
|
| Rate for Payer: Cigna Commercial |
$235.45
|
| Rate for Payer: First Health Commercial |
$249.30
|
| Rate for Payer: First Health Workers Compensation |
$20.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$249.30
|
| Rate for Payer: GEHA Commercial |
$193.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$249.30
|
| Rate for Payer: Multiplan All |
$252.07
|
| Rate for Payer: OMNI Networks Commercial |
$193.90
|
| Rate for Payer: One Health Plan PPO/POS |
$249.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$263.15
|
| Rate for Payer: Three Rivers Provider Network All |
$207.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$257.61
|
| Rate for Payer: Zelis Auto |
$110.80
|
| Rate for Payer: Zelis Worker's Compensation |
$14.71
|
|
|
CLINIC URINALYSIS BY DIPSTICK
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
CPT 81002
|
| Hospital Charge Code |
7300018
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$2.96 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$6.27
|
| 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 |
$6.27
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$4.97
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3.48
|
| 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 |
$4.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$34.20
|
| Rate for Payer: GEHA Commercial |
$30.40
|
| Rate for Payer: GEHA Medicare |
$3.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$34.20
|
| Rate for Payer: Humana ChoiceCare |
$3.83
|
| Rate for Payer: Humana Medicare Advantage |
$3.48
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$5.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3.48
|
| Rate for Payer: Multiplan All |
$34.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5.92
|
| 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 |
$5.85
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$5.07
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3.48
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$36.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6.96
|
| Rate for Payer: Three Rivers Provider Network All |
$28.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.41
|
| Rate for Payer: United Healthcare Commercial |
$32.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.48
|
| Rate for Payer: United Payors & United Providers UP&UP |
$35.34
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3.48
|
| Rate for Payer: Zelis Auto |
$15.20
|
| Rate for Payer: Zelis Medicare |
$2.96
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.18
|
| Rate for Payer: Zelis Worker's Compensation |
$3.12
|
|
|
CLINIC URINALYSIS BY DIPSTICK
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
CPT 81002
|
| Hospital Charge Code |
7300018
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$3.12 |
| 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 |
$4.42
|
| 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 |
$3.12
|
|
|
CLINIC URINE DRUG SCREEN
|
Facility
|
IP
|
$347.00
|
|
|
Service Code
|
CPT 80305
|
| Hospital Charge Code |
7300020
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$329.65 |
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cigna Commercial |
$294.95
|
| Rate for Payer: First Health Commercial |
$312.30
|
| Rate for Payer: First Health Workers Compensation |
$14.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$312.30
|
| Rate for Payer: GEHA Commercial |
$242.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$312.30
|
| Rate for Payer: Multiplan All |
$315.77
|
| Rate for Payer: OMNI Networks Commercial |
$242.90
|
| Rate for Payer: One Health Plan PPO/POS |
$312.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$329.65
|
| Rate for Payer: Three Rivers Provider Network All |
$260.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$322.71
|
| Rate for Payer: Zelis Auto |
$138.80
|
| Rate for Payer: Zelis Worker's Compensation |
$10.16
|
|
|
CLINIC URINE DRUG SCREEN
|
Facility
|
OP
|
$347.00
|
|
|
Service Code
|
CPT 80305
|
| Hospital Charge Code |
7300020
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$329.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$22.68
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$208.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$22.68
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$17.97
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$12.60
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cigna Commercial |
$294.95
|
| Rate for Payer: First Health Commercial |
$312.30
|
| Rate for Payer: First Health Workers Compensation |
$14.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$312.30
|
| Rate for Payer: GEHA Commercial |
$277.60
|
| Rate for Payer: GEHA Medicare |
$12.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$312.30
|
| Rate for Payer: Humana ChoiceCare |
$13.86
|
| Rate for Payer: Humana Medicare Advantage |
$12.60
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$21.17
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$18.33
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$12.60
|
| Rate for Payer: Multiplan All |
$315.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$21.42
|
| Rate for Payer: OMNI Networks Commercial |
$242.90
|
| Rate for Payer: One Health Plan PPO/POS |
$312.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$21.17
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$18.33
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$329.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$25.20
|
| Rate for Payer: Three Rivers Provider Network All |
$260.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.35
|
| Rate for Payer: United Healthcare Commercial |
$294.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$18.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.60
|
| Rate for Payer: United Payors & United Providers UP&UP |
$322.71
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$12.60
|
| Rate for Payer: Zelis Auto |
$138.80
|
| Rate for Payer: Zelis Medicare |
$10.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.12
|
| Rate for Payer: Zelis Worker's Compensation |
$10.16
|
|
|
CLINIC URINE PREGNANCY TEST
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
CPT 81025
|
| Hospital Charge Code |
7300005
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$6.79 |
| Max. Negotiated Rate |
$120.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$15.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$76.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$15.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$12.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$8.61
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$107.95
|
| Rate for Payer: First Health Commercial |
$114.30
|
| Rate for Payer: First Health Workers Compensation |
$9.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$114.30
|
| Rate for Payer: GEHA Commercial |
$101.60
|
| Rate for Payer: GEHA Medicare |
$8.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$114.30
|
| Rate for Payer: Humana ChoiceCare |
$9.47
|
| Rate for Payer: Humana Medicare Advantage |
$8.61
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$14.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$12.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$8.61
|
| Rate for Payer: Multiplan All |
$115.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$14.64
|
| Rate for Payer: OMNI Networks Commercial |
$88.90
|
| Rate for Payer: One Health Plan PPO/POS |
$114.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$14.46
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$12.53
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$8.61
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$120.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$17.22
|
| Rate for Payer: Three Rivers Provider Network All |
$95.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8.44
|
| Rate for Payer: United Healthcare Commercial |
$107.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.61
|
| Rate for Payer: United Payors & United Providers UP&UP |
$118.11
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$8.61
|
| Rate for Payer: Zelis Auto |
$50.80
|
| Rate for Payer: Zelis Medicare |
$7.32
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.33
|
| Rate for Payer: Zelis Worker's Compensation |
$6.79
|
|
|
CLINIC URINE PREGNANCY TEST
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
CPT 81025
|
| Hospital Charge Code |
7300005
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$6.79 |
| Max. Negotiated Rate |
$120.65 |
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$107.95
|
| Rate for Payer: First Health Commercial |
$114.30
|
| Rate for Payer: First Health Workers Compensation |
$9.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$114.30
|
| Rate for Payer: GEHA Commercial |
$88.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$114.30
|
| Rate for Payer: Multiplan All |
$115.57
|
| Rate for Payer: OMNI Networks Commercial |
$88.90
|
| Rate for Payer: One Health Plan PPO/POS |
$114.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$120.65
|
| Rate for Payer: Three Rivers Provider Network All |
$95.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$118.11
|
| Rate for Payer: Zelis Auto |
$50.80
|
| Rate for Payer: Zelis Worker's Compensation |
$6.79
|
|
|
CLINIC WT PREP
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
CPT 87210
|
| Hospital Charge Code |
73000014
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$5.10 |
| 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 |
$7.22
|
| 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 |
$5.10
|
|
|
CLINIC WT PREP
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
CPT 87210
|
| Hospital Charge Code |
73000014
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$10.47
|
| 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 |
$10.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$8.29
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.82
|
| 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 |
$7.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$34.20
|
| Rate for Payer: GEHA Commercial |
$30.40
|
| Rate for Payer: GEHA Medicare |
$5.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$34.20
|
| Rate for Payer: Humana ChoiceCare |
$6.40
|
| Rate for Payer: Humana Medicare Advantage |
$5.82
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$9.78
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$8.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.82
|
| Rate for Payer: Multiplan All |
$34.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.89
|
| 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 |
$9.77
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$8.46
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.82
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$36.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11.64
|
| Rate for Payer: Three Rivers Provider Network All |
$28.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.70
|
| Rate for Payer: United Healthcare Commercial |
$32.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.82
|
| Rate for Payer: United Payors & United Providers UP&UP |
$35.34
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.82
|
| Rate for Payer: Zelis Auto |
$15.20
|
| Rate for Payer: Zelis Medicare |
$4.95
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.98
|
| Rate for Payer: Zelis Worker's Compensation |
$5.10
|
|
|
CL- INSULIN - REGULAR (HUMAN) INJ 100 UN
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
CPT J1815
|
| Hospital Charge Code |
3350045
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
CL- INSULIN - REGULAR (HUMAN) INJ 100 UN
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
CPT J1815
|
| Hospital Charge Code |
3350045
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$6.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Humana ChoiceCare |
$2.08
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.80
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
CL- IODOSORB GEL
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
NDC 40565012256
|
| Hospital Charge Code |
3350018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$176.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$111.60
|
| Rate for Payer: Cash Price |
$111.60
|
| Rate for Payer: Cigna Commercial |
$158.10
|
| Rate for Payer: First Health Commercial |
$167.40
|
| Rate for Payer: First Health Workers Compensation |
$71.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$167.40
|
| Rate for Payer: GEHA Commercial |
$148.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$167.40
|
| Rate for Payer: Humana ChoiceCare |
$48.36
|
| Rate for Payer: Multiplan All |
$169.26
|
| Rate for Payer: New Mexico Health Connections Medicare |
$111.60
|
| Rate for Payer: OMNI Networks Commercial |
$130.20
|
| Rate for Payer: One Health Plan PPO/POS |
$167.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$176.70
|
| Rate for Payer: Three Rivers Provider Network All |
$139.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$163.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$46.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$172.98
|
| Rate for Payer: Zelis Auto |
$74.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$93.00
|
| Rate for Payer: Zelis Worker's Compensation |
$50.78
|
|
|
CL- IODOSORB GEL
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
NDC 40565012256
|
| Hospital Charge Code |
3350018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.78 |
| Max. Negotiated Rate |
$176.70 |
| Rate for Payer: Cash Price |
$111.60
|
| Rate for Payer: Cigna Commercial |
$158.10
|
| Rate for Payer: First Health Commercial |
$167.40
|
| Rate for Payer: First Health Workers Compensation |
$71.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$167.40
|
| Rate for Payer: GEHA Commercial |
$130.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$167.40
|
| Rate for Payer: Multiplan All |
$169.26
|
| Rate for Payer: OMNI Networks Commercial |
$130.20
|
| Rate for Payer: One Health Plan PPO/POS |
$167.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$176.70
|
| Rate for Payer: Three Rivers Provider Network All |
$139.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$172.98
|
| Rate for Payer: Zelis Auto |
$74.40
|
| Rate for Payer: Zelis Worker's Compensation |
$50.78
|
|
|
CL- IPRATROPIUM-ALBUTEROL NEBU 3ML
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
CPT J7620
|
| Hospital Charge Code |
3350047
|
|
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
|
|
|
CL- IPRATROPIUM-ALBUTEROL NEBU 3ML
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
CPT J7620
|
| Hospital Charge Code |
3350047
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| 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: 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 |
$0.22
|
| 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
|
|
|
CL- IPRATROPIUM BROMIDE INHAL 0.02%
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
CPT J7644
|
| Hospital Charge Code |
3350046
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| 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: 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 |
$0.43
|
| 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
|
|
|
CL- IPRATROPIUM BROMIDE INHAL 0.02%
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
CPT J7644
|
| Hospital Charge Code |
3350046
|
|
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
|
|
|
CL- IRINOTECAN 20 MG
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
CPT J9206
|
| Hospital Charge Code |
3350317
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$6.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
CL- IRINOTECAN 20 MG
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
CPT J9206
|
| Hospital Charge Code |
3350317
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.93 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$1.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Humana ChoiceCare |
$2.34
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5.40
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.50
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
CL- IV NS 1000ML (SODIUM CHLORIDE 0.9%)
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
CPT J7030
|
| Hospital Charge Code |
3350142
|
|
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
|
|
|
CL- IV NS 1000ML (SODIUM CHLORIDE 0.9%)
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
CPT J7030
|
| Hospital Charge Code |
3350142
|
|
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
|
|
|
CL- JUVEDERM ULTRA PLUS XC- 1ML VIAL
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3350199
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$142.00 |
| Max. Negotiated Rate |
$539.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$340.80
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$482.80
|
| Rate for Payer: First Health Commercial |
$511.20
|
| Rate for Payer: First Health Workers Compensation |
$219.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$511.20
|
| Rate for Payer: GEHA Commercial |
$454.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$511.20
|
| Rate for Payer: Humana ChoiceCare |
$147.68
|
| Rate for Payer: Multiplan All |
$516.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$340.80
|
| Rate for Payer: OMNI Networks Commercial |
$397.60
|
| Rate for Payer: One Health Plan PPO/POS |
$511.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$539.60
|
| Rate for Payer: Three Rivers Provider Network All |
$426.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$499.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$142.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$528.24
|
| Rate for Payer: Zelis Auto |
$227.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$284.00
|
| Rate for Payer: Zelis Worker's Compensation |
$155.06
|
|
