|
DIRECT ADMIT TO OBSERVATION
|
Facility
|
IP
|
$569.00
|
|
|
Service Code
|
CPT G0379
|
| Hospital Charge Code |
9400085
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$155.34 |
| Max. Negotiated Rate |
$540.55 |
| Rate for Payer: Cash Price |
$341.40
|
| Rate for Payer: Cash Price |
$341.40
|
| Rate for Payer: Cigna Commercial |
$483.65
|
| Rate for Payer: First Health Commercial |
$512.10
|
| Rate for Payer: First Health Workers Compensation |
$219.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$512.10
|
| Rate for Payer: GEHA Commercial |
$398.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$512.10
|
| Rate for Payer: Multiplan All |
$517.79
|
| Rate for Payer: OMNI Networks Commercial |
$398.30
|
| Rate for Payer: One Health Plan PPO/POS |
$512.10
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$325.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$540.55
|
| Rate for Payer: Three Rivers Provider Network All |
$426.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$529.17
|
| Rate for Payer: Zelis Auto |
$227.60
|
| Rate for Payer: Zelis Worker's Compensation |
$155.34
|
|
|
DIRECT ADMIT TO OBSERVATION
|
Facility
|
OP
|
$569.00
|
|
|
Service Code
|
CPT G0379
|
| Hospital Charge Code |
9400085
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$68.83 |
| Max. Negotiated Rate |
$1,164.32 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$86.88
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$341.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$86.88
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$68.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$582.16
|
| Rate for Payer: Cash Price |
$341.40
|
| Rate for Payer: Cash Price |
$341.40
|
| Rate for Payer: Cash Price |
$341.40
|
| Rate for Payer: Cigna Commercial |
$483.65
|
| Rate for Payer: First Health Commercial |
$512.10
|
| Rate for Payer: First Health Workers Compensation |
$219.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$512.10
|
| Rate for Payer: GEHA Commercial |
$455.20
|
| Rate for Payer: GEHA Medicare |
$582.16
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$512.10
|
| Rate for Payer: Humana ChoiceCare |
$640.38
|
| Rate for Payer: Humana Medicare Advantage |
$582.16
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$978.03
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$70.23
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$582.16
|
| Rate for Payer: Multiplan All |
$517.79
|
| Rate for Payer: New Mexico Health Connections Medicare |
$989.67
|
| Rate for Payer: OMNI Networks Commercial |
$398.30
|
| Rate for Payer: One Health Plan PPO/POS |
$512.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$81.09
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$325.00
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$582.16
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$540.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,164.32
|
| Rate for Payer: Three Rivers Provider Network All |
$426.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$570.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$70.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$582.16
|
| Rate for Payer: United Payors & United Providers UP&UP |
$529.17
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$582.16
|
| Rate for Payer: Zelis Auto |
$227.60
|
| Rate for Payer: Zelis Medicare |
$494.84
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$698.59
|
| Rate for Payer: Zelis Worker's Compensation |
$155.34
|
|
|
DIVALPROEX 250MG DELAYED RELEASE TAB
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 68084077601
|
| Hospital Charge Code |
3300267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Humana ChoiceCare |
$1.56
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.60
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
DIVALPROEX 250MG DELAYED RELEASE TAB
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 68084077601
|
| Hospital Charge Code |
3300267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
DIVALPROEX ER 250MG 24HR TAB
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 00904636361
|
| Hospital Charge Code |
3300268
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
DIVALPROEX ER 250MG 24HR TAB
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 00904636361
|
| Hospital Charge Code |
3300268
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.25 |
| 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: 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 |
$7.20
|
| 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
|
|
|
DIVALPROEX SPRINKLES 125MG CAP
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00074611411
|
| Hospital Charge Code |
3300266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$4.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
DIVALPROEX SPRINKLES 125MG CAP
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 00074611411
|
| Hospital Charge Code |
3300266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Humana ChoiceCare |
$1.82
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.20
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
d,l-methamphetamine, urine REF714766
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
CPT 80324
|
| Hospital Charge Code |
2200334
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$131.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$82.80
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$117.30
|
| Rate for Payer: First Health Commercial |
$124.20
|
| Rate for Payer: First Health Workers Compensation |
$27.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$124.20
|
| Rate for Payer: GEHA Commercial |
$110.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$124.20
|
| Rate for Payer: Humana ChoiceCare |
$35.88
|
| Rate for Payer: Multiplan All |
$125.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$82.80
|
| Rate for Payer: OMNI Networks Commercial |
$96.60
|
| Rate for Payer: One Health Plan PPO/POS |
$124.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$131.10
|
| Rate for Payer: Three Rivers Provider Network All |
$103.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$121.44
|
| Rate for Payer: United Healthcare Commercial |
$117.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$34.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$128.34
|
| Rate for Payer: Zelis Auto |
$55.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$69.00
|
| Rate for Payer: Zelis Worker's Compensation |
$19.29
|
|
|
d,l-methamphetamine, urine REF714766
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
CPT 80324
|
| Hospital Charge Code |
2200334
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$131.10 |
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$117.30
|
| Rate for Payer: First Health Commercial |
$124.20
|
| Rate for Payer: First Health Workers Compensation |
$27.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$124.20
|
| Rate for Payer: GEHA Commercial |
$96.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$124.20
|
| Rate for Payer: Multiplan All |
$125.58
|
| Rate for Payer: OMNI Networks Commercial |
$96.60
|
| Rate for Payer: One Health Plan PPO/POS |
$124.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$131.10
|
| Rate for Payer: Three Rivers Provider Network All |
$103.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$128.34
|
| Rate for Payer: Zelis Auto |
$55.20
|
| Rate for Payer: Zelis Worker's Compensation |
$19.29
|
|
|
DM OP SLF-MGMT TRN SRVC IND-30 MIN
|
Facility
|
IP
|
$153.57
|
|
|
Service Code
|
CPT G0108
|
| Hospital Charge Code |
8500108
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$41.92 |
| Max. Negotiated Rate |
$145.89 |
| Rate for Payer: Cash Price |
$92.14
|
| Rate for Payer: Cigna Commercial |
$130.53
|
| Rate for Payer: First Health Commercial |
$138.21
|
| Rate for Payer: First Health Workers Compensation |
$59.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$138.21
|
| Rate for Payer: GEHA Commercial |
$107.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$138.21
|
| Rate for Payer: Multiplan All |
$139.75
|
| Rate for Payer: OMNI Networks Commercial |
$107.50
|
| Rate for Payer: One Health Plan PPO/POS |
$138.21
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$145.89
|
| Rate for Payer: Three Rivers Provider Network All |
$115.18
|
| Rate for Payer: United Payors & United Providers UP&UP |
$142.82
|
| Rate for Payer: Zelis Auto |
$61.43
|
| Rate for Payer: Zelis Worker's Compensation |
$41.92
|
|
|
DM OP SLF-MGMT TRN SRVC IND-30 MIN
|
Facility
|
IP
|
$162.00
|
|
|
Service Code
|
CPT G0108
|
| Hospital Charge Code |
20500108
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$44.23 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cigna Commercial |
$137.70
|
| Rate for Payer: First Health Commercial |
$145.80
|
| Rate for Payer: First Health Workers Compensation |
$62.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$145.80
|
| Rate for Payer: GEHA Commercial |
$113.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$145.80
|
| Rate for Payer: Multiplan All |
$147.42
|
| Rate for Payer: OMNI Networks Commercial |
$113.40
|
| Rate for Payer: One Health Plan PPO/POS |
$145.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$153.90
|
| Rate for Payer: Three Rivers Provider Network All |
$121.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$150.66
|
| Rate for Payer: Zelis Auto |
$64.80
|
| Rate for Payer: Zelis Worker's Compensation |
$44.23
|
|
|
DM OP SLF-MGMT TRN SRVC IND-30 MIN
|
Facility
|
OP
|
$162.00
|
|
|
Service Code
|
CPT G0108
|
| Hospital Charge Code |
21900184
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.12 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$77.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$97.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$77.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$61.68
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cigna Commercial |
$137.70
|
| Rate for Payer: First Health Commercial |
$145.80
|
| Rate for Payer: First Health Workers Compensation |
$62.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$145.80
|
| Rate for Payer: GEHA Commercial |
$129.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$145.80
|
| Rate for Payer: Humana ChoiceCare |
$42.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$62.94
|
| Rate for Payer: Multiplan All |
$147.42
|
| Rate for Payer: New Mexico Health Connections Medicare |
$97.20
|
| Rate for Payer: OMNI Networks Commercial |
$113.40
|
| Rate for Payer: One Health Plan PPO/POS |
$145.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$72.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$62.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$153.90
|
| Rate for Payer: Three Rivers Provider Network All |
$121.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$142.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$62.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$150.66
|
| Rate for Payer: Zelis Auto |
$64.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.00
|
| Rate for Payer: Zelis Worker's Compensation |
$44.23
|
|
|
DM OP SLF-MGMT TRN SRVC IND-30 MIN
|
Facility
|
OP
|
$153.57
|
|
|
Service Code
|
CPT G0108
|
| Hospital Charge Code |
8500108
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$39.93 |
| Max. Negotiated Rate |
$145.89 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$77.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$92.14
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$77.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$61.68
|
| Rate for Payer: Cash Price |
$92.14
|
| Rate for Payer: Cash Price |
$92.14
|
| Rate for Payer: Cigna Commercial |
$130.53
|
| Rate for Payer: First Health Commercial |
$138.21
|
| Rate for Payer: First Health Workers Compensation |
$59.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$138.21
|
| Rate for Payer: GEHA Commercial |
$122.86
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$138.21
|
| Rate for Payer: Humana ChoiceCare |
$39.93
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$62.94
|
| Rate for Payer: Multiplan All |
$139.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$92.14
|
| Rate for Payer: OMNI Networks Commercial |
$107.50
|
| Rate for Payer: One Health Plan PPO/POS |
$138.21
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$72.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$62.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$145.89
|
| Rate for Payer: Three Rivers Provider Network All |
$115.18
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$135.14
|
| Rate for Payer: United Healthcare Managed Medicaid |
$62.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$142.82
|
| Rate for Payer: Zelis Auto |
$61.43
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$76.78
|
| Rate for Payer: Zelis Worker's Compensation |
$41.92
|
|
|
DM OP SLF-MGMT TRN SRVC IND-30 MIN
|
Facility
|
OP
|
$162.00
|
|
|
Service Code
|
CPT G0108
|
| Hospital Charge Code |
21799449
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.12 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$77.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$97.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$77.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$61.68
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cigna Commercial |
$137.70
|
| Rate for Payer: First Health Commercial |
$145.80
|
| Rate for Payer: First Health Workers Compensation |
$62.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$145.80
|
| Rate for Payer: GEHA Commercial |
$129.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$145.80
|
| Rate for Payer: Humana ChoiceCare |
$42.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$62.94
|
| Rate for Payer: Multiplan All |
$147.42
|
| Rate for Payer: New Mexico Health Connections Medicare |
$97.20
|
| Rate for Payer: OMNI Networks Commercial |
$113.40
|
| Rate for Payer: One Health Plan PPO/POS |
$145.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$72.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$62.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$153.90
|
| Rate for Payer: Three Rivers Provider Network All |
$121.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$142.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$62.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$150.66
|
| Rate for Payer: Zelis Auto |
$64.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.00
|
| Rate for Payer: Zelis Worker's Compensation |
$44.23
|
|
|
DM OP SLF-MGMT TRN SRVC IND-30 MIN
|
Facility
|
IP
|
$162.00
|
|
|
Service Code
|
CPT G0108
|
| Hospital Charge Code |
21900184
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$44.23 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cigna Commercial |
$137.70
|
| Rate for Payer: First Health Commercial |
$145.80
|
| Rate for Payer: First Health Workers Compensation |
$62.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$145.80
|
| Rate for Payer: GEHA Commercial |
$113.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$145.80
|
| Rate for Payer: Multiplan All |
$147.42
|
| Rate for Payer: OMNI Networks Commercial |
$113.40
|
| Rate for Payer: One Health Plan PPO/POS |
$145.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$153.90
|
| Rate for Payer: Three Rivers Provider Network All |
$121.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$150.66
|
| Rate for Payer: Zelis Auto |
$64.80
|
| Rate for Payer: Zelis Worker's Compensation |
$44.23
|
|
|
DM OP SLF-MGMT TRN SRVC IND-30 MIN
|
Facility
|
IP
|
$162.00
|
|
|
Service Code
|
CPT G0108
|
| Hospital Charge Code |
21799449
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$44.23 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cigna Commercial |
$137.70
|
| Rate for Payer: First Health Commercial |
$145.80
|
| Rate for Payer: First Health Workers Compensation |
$62.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$145.80
|
| Rate for Payer: GEHA Commercial |
$113.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$145.80
|
| Rate for Payer: Multiplan All |
$147.42
|
| Rate for Payer: OMNI Networks Commercial |
$113.40
|
| Rate for Payer: One Health Plan PPO/POS |
$145.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$153.90
|
| Rate for Payer: Three Rivers Provider Network All |
$121.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$150.66
|
| Rate for Payer: Zelis Auto |
$64.80
|
| Rate for Payer: Zelis Worker's Compensation |
$44.23
|
|
|
DM OP SLF-MGMT TRN SRVC IND-30 MIN
|
Facility
|
OP
|
$162.00
|
|
|
Service Code
|
CPT G0108
|
| Hospital Charge Code |
20500108
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$42.12 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$77.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$97.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$77.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$61.68
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cigna Commercial |
$137.70
|
| Rate for Payer: First Health Commercial |
$145.80
|
| Rate for Payer: First Health Workers Compensation |
$62.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$145.80
|
| Rate for Payer: GEHA Commercial |
$129.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$145.80
|
| Rate for Payer: Humana ChoiceCare |
$42.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$62.94
|
| Rate for Payer: Multiplan All |
$147.42
|
| Rate for Payer: New Mexico Health Connections Medicare |
$97.20
|
| Rate for Payer: OMNI Networks Commercial |
$113.40
|
| Rate for Payer: One Health Plan PPO/POS |
$145.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$72.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$62.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$153.90
|
| Rate for Payer: Three Rivers Provider Network All |
$121.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$142.56
|
| Rate for Payer: United Healthcare Commercial |
$137.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$62.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$150.66
|
| Rate for Payer: Zelis Auto |
$64.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.00
|
| Rate for Payer: Zelis Worker's Compensation |
$44.23
|
|
|
DM SLF-MGMT TRN SRVC GRP- 30 MIN
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT G0109
|
| Hospital Charge Code |
21799450
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$11.70 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$20.93
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$20.93
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.58
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$36.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Humana ChoiceCare |
$11.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$16.91
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.00
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$19.53
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$16.91
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$39.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.91
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.50
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
DM SLF-MGMT TRN SRVC GRP- 30 MIN
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT G0109
|
| Hospital Charge Code |
21799450
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$31.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
DM SLF-MGMT TRN SRVC GRP-30 MIN
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT G0109
|
| Hospital Charge Code |
20500109
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$11.70 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$20.93
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$20.93
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.58
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$36.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Humana ChoiceCare |
$11.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$16.91
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.00
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$19.53
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$16.91
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$39.60
|
| Rate for Payer: United Healthcare Commercial |
$38.25
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.91
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.50
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
DM SLF-MGMT TRN SRVC GRP-30 MIN
|
Facility
|
IP
|
$43.89
|
|
|
Service Code
|
CPT G0109
|
| Hospital Charge Code |
8500109
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$41.70 |
| Rate for Payer: Cash Price |
$26.33
|
| Rate for Payer: Cigna Commercial |
$37.31
|
| Rate for Payer: First Health Commercial |
$39.50
|
| Rate for Payer: First Health Workers Compensation |
$16.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$39.50
|
| Rate for Payer: GEHA Commercial |
$30.72
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$39.50
|
| Rate for Payer: Multiplan All |
$39.94
|
| Rate for Payer: OMNI Networks Commercial |
$30.72
|
| Rate for Payer: One Health Plan PPO/POS |
$39.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$41.70
|
| Rate for Payer: Three Rivers Provider Network All |
$32.92
|
| Rate for Payer: United Payors & United Providers UP&UP |
$40.82
|
| Rate for Payer: Zelis Auto |
$17.56
|
| Rate for Payer: Zelis Worker's Compensation |
$11.98
|
|
|
DM SLF-MGMT TRN SRVC GRP-30 MIN
|
Facility
|
OP
|
$43.89
|
|
|
Service Code
|
CPT G0109
|
| Hospital Charge Code |
8500109
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$11.41 |
| Max. Negotiated Rate |
$41.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$20.93
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$26.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$20.93
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.58
|
| Rate for Payer: Cash Price |
$26.33
|
| Rate for Payer: Cash Price |
$26.33
|
| Rate for Payer: Cigna Commercial |
$37.31
|
| Rate for Payer: First Health Commercial |
$39.50
|
| Rate for Payer: First Health Workers Compensation |
$16.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$39.50
|
| Rate for Payer: GEHA Commercial |
$35.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$39.50
|
| Rate for Payer: Humana ChoiceCare |
$11.41
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$16.91
|
| Rate for Payer: Multiplan All |
$39.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$26.33
|
| Rate for Payer: OMNI Networks Commercial |
$30.72
|
| Rate for Payer: One Health Plan PPO/POS |
$39.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$19.53
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$16.91
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$41.70
|
| Rate for Payer: Three Rivers Provider Network All |
$32.92
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$38.62
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.91
|
| Rate for Payer: United Payors & United Providers UP&UP |
$40.82
|
| Rate for Payer: Zelis Auto |
$17.56
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.95
|
| Rate for Payer: Zelis Worker's Compensation |
$11.98
|
|
|
DM SLF-MGMT TRN SRVC GRP-30 MIN
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT G0109
|
| Hospital Charge Code |
21900109
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$31.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
DM SLF-MGMT TRN SRVC GRP-30 MIN
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT G0109
|
| Hospital Charge Code |
20500109
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$31.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
