|
DRILL SKULL FOR DRAINAGE
|
Facility
|
OP
|
$1,926.00
|
|
|
Service Code
|
CPT 61108
|
| Hospital Charge Code |
6161108
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$481.50 |
| Max. Negotiated Rate |
$1,829.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,155.60
|
| Rate for Payer: Cash Price |
$1,155.60
|
| Rate for Payer: Cigna Commercial |
$1,637.10
|
| Rate for Payer: First Health Commercial |
$1,733.40
|
| Rate for Payer: First Health Workers Compensation |
$743.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,733.40
|
| Rate for Payer: GEHA Commercial |
$1,540.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,733.40
|
| Rate for Payer: Humana ChoiceCare |
$500.76
|
| Rate for Payer: Multiplan All |
$1,752.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,155.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,348.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,733.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,829.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,444.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,694.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$481.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,791.18
|
| Rate for Payer: Zelis Auto |
$770.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$963.00
|
| Rate for Payer: Zelis Worker's Compensation |
$525.80
|
|
|
DRILL SKULL FOR DRAINAGE
|
Facility
|
IP
|
$1,926.00
|
|
|
Service Code
|
CPT 61108
|
| Hospital Charge Code |
6161108
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$525.80 |
| Max. Negotiated Rate |
$1,829.70 |
| Rate for Payer: Cash Price |
$1,155.60
|
| Rate for Payer: Cigna Commercial |
$1,637.10
|
| Rate for Payer: First Health Commercial |
$1,733.40
|
| Rate for Payer: First Health Workers Compensation |
$743.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,733.40
|
| Rate for Payer: GEHA Commercial |
$1,348.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,733.40
|
| Rate for Payer: Multiplan All |
$1,752.66
|
| Rate for Payer: OMNI Networks Commercial |
$1,348.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,733.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,829.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,444.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,791.18
|
| Rate for Payer: Zelis Auto |
$770.40
|
| Rate for Payer: Zelis Worker's Compensation |
$525.80
|
|
|
DRNG LYMPH NODE ABSC/LYMPHADENITIS EXTNS
|
Facility
|
OP
|
$1,531.00
|
|
|
Service Code
|
CPT 38305
|
| Hospital Charge Code |
20300067
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$417.96 |
| Max. Negotiated Rate |
$5,546.54 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,962.15
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$918.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,962.15
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,554.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$2,773.27
|
| Rate for Payer: Cash Price |
$918.60
|
| Rate for Payer: Cash Price |
$918.60
|
| Rate for Payer: Cigna Commercial |
$1,301.35
|
| Rate for Payer: First Health Commercial |
$1,377.90
|
| Rate for Payer: First Health Workers Compensation |
$591.12
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,377.90
|
| Rate for Payer: GEHA Commercial |
$1,224.80
|
| Rate for Payer: GEHA Medicare |
$2,773.27
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,377.90
|
| Rate for Payer: Humana ChoiceCare |
$3,050.60
|
| Rate for Payer: Humana Medicare Advantage |
$2,773.27
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$4,659.09
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,586.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$2,773.27
|
| Rate for Payer: Multiplan All |
$1,393.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,714.56
|
| Rate for Payer: OMNI Networks Commercial |
$1,071.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,377.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,831.34
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,586.07
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$2,773.27
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,454.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$5,546.54
|
| Rate for Payer: Three Rivers Provider Network All |
$1,148.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,717.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,586.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,773.27
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,423.83
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$2,773.27
|
| Rate for Payer: Zelis Auto |
$612.40
|
| Rate for Payer: Zelis Medicare |
$2,357.28
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,327.92
|
| Rate for Payer: Zelis Worker's Compensation |
$417.96
|
|
|
DRNG LYMPH NODE ABSC/LYMPHADENITIS EXTNS
|
Facility
|
IP
|
$1,531.00
|
|
|
Service Code
|
CPT 38305
|
| Hospital Charge Code |
20300067
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$417.96 |
| Max. Negotiated Rate |
$1,454.45 |
| Rate for Payer: Cash Price |
$918.60
|
| Rate for Payer: Cigna Commercial |
$1,301.35
|
| Rate for Payer: First Health Commercial |
$1,377.90
|
| Rate for Payer: First Health Workers Compensation |
$591.12
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,377.90
|
| Rate for Payer: GEHA Commercial |
$1,071.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,377.90
|
| Rate for Payer: Multiplan All |
$1,393.21
|
| Rate for Payer: OMNI Networks Commercial |
$1,071.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,377.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,454.45
|
| Rate for Payer: Three Rivers Provider Network All |
$1,148.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,423.83
|
| Rate for Payer: Zelis Auto |
$612.40
|
| Rate for Payer: Zelis Worker's Compensation |
$417.96
|
|
|
DRNG LYMPH NODE ABSC/LYMPHADENITIS SMPL
|
Facility
|
OP
|
$969.00
|
|
|
Service Code
|
CPT 38300
|
| Hospital Charge Code |
20300066
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$264.54 |
| Max. Negotiated Rate |
$5,546.54 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,276.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$581.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,276.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,010.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$2,773.27
|
| Rate for Payer: Cash Price |
$581.40
|
| Rate for Payer: Cash Price |
$581.40
|
| Rate for Payer: Cigna Commercial |
$823.65
|
| Rate for Payer: First Health Commercial |
$872.10
|
| Rate for Payer: First Health Workers Compensation |
$374.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$872.10
|
| Rate for Payer: GEHA Commercial |
$775.20
|
| Rate for Payer: GEHA Medicare |
$2,773.27
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$872.10
|
| Rate for Payer: Humana ChoiceCare |
$3,050.60
|
| Rate for Payer: Humana Medicare Advantage |
$2,773.27
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$4,659.09
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,031.57
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$2,773.27
|
| Rate for Payer: Multiplan All |
$881.79
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,714.56
|
| Rate for Payer: OMNI Networks Commercial |
$678.30
|
| Rate for Payer: One Health Plan PPO/POS |
$872.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,191.09
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,031.57
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$2,773.27
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$920.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$5,546.54
|
| Rate for Payer: Three Rivers Provider Network All |
$726.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,717.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,031.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,773.27
|
| Rate for Payer: United Payors & United Providers UP&UP |
$901.17
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$2,773.27
|
| Rate for Payer: Zelis Auto |
$387.60
|
| Rate for Payer: Zelis Medicare |
$2,357.28
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,327.92
|
| Rate for Payer: Zelis Worker's Compensation |
$264.54
|
|
|
DRNG LYMPH NODE ABSC/LYMPHADENITIS SMPL
|
Facility
|
IP
|
$969.00
|
|
|
Service Code
|
CPT 38300
|
| Hospital Charge Code |
20300066
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$264.54 |
| Max. Negotiated Rate |
$920.55 |
| Rate for Payer: Cash Price |
$581.40
|
| Rate for Payer: Cigna Commercial |
$823.65
|
| Rate for Payer: First Health Commercial |
$872.10
|
| Rate for Payer: First Health Workers Compensation |
$374.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$872.10
|
| Rate for Payer: GEHA Commercial |
$678.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$872.10
|
| Rate for Payer: Multiplan All |
$881.79
|
| Rate for Payer: OMNI Networks Commercial |
$678.30
|
| Rate for Payer: One Health Plan PPO/POS |
$872.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$920.55
|
| Rate for Payer: Three Rivers Provider Network All |
$726.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$901.17
|
| Rate for Payer: Zelis Auto |
$387.60
|
| Rate for Payer: Zelis Worker's Compensation |
$264.54
|
|
|
DRN PANCR PSEUD CYST
|
Facility
|
OP
|
$4,016.00
|
|
| Hospital Charge Code |
2407192
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,004.00 |
| Max. Negotiated Rate |
$3,815.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,409.60
|
| Rate for Payer: Cash Price |
$2,409.60
|
| Rate for Payer: Cigna Commercial |
$3,413.60
|
| Rate for Payer: First Health Commercial |
$3,614.40
|
| Rate for Payer: First Health Workers Compensation |
$1,550.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,614.40
|
| Rate for Payer: GEHA Commercial |
$3,212.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,614.40
|
| Rate for Payer: Humana ChoiceCare |
$1,044.16
|
| Rate for Payer: Multiplan All |
$3,654.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,409.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,811.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,614.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,815.20
|
| Rate for Payer: Three Rivers Provider Network All |
$3,012.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,534.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,004.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,734.88
|
| Rate for Payer: Zelis Auto |
$1,606.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,008.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,096.37
|
|
|
DRN PANCR PSEUD CYST
|
Facility
|
IP
|
$4,016.00
|
|
| Hospital Charge Code |
2407192
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,096.37 |
| Max. Negotiated Rate |
$3,815.20 |
| Rate for Payer: Cash Price |
$2,409.60
|
| Rate for Payer: Cigna Commercial |
$3,413.60
|
| Rate for Payer: First Health Commercial |
$3,614.40
|
| Rate for Payer: First Health Workers Compensation |
$1,550.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,614.40
|
| Rate for Payer: GEHA Commercial |
$2,811.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,614.40
|
| Rate for Payer: Multiplan All |
$3,654.56
|
| Rate for Payer: OMNI Networks Commercial |
$2,811.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,614.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,815.20
|
| Rate for Payer: Three Rivers Provider Network All |
$3,012.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,734.88
|
| Rate for Payer: Zelis Auto |
$1,606.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1,096.37
|
|
|
DRONABINOL 2.5 MG CAP
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 67877056860
|
| Hospital Charge Code |
3302965
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: First Health Commercial |
$12.60
|
| Rate for Payer: First Health Workers Compensation |
$5.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12.60
|
| Rate for Payer: GEHA Commercial |
$9.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12.60
|
| Rate for Payer: Multiplan All |
$12.74
|
| Rate for Payer: OMNI Networks Commercial |
$9.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.02
|
| Rate for Payer: Zelis Auto |
$5.60
|
| Rate for Payer: Zelis Worker's Compensation |
$3.82
|
|
|
DRONABINOL 2.5 MG CAP
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 67877056860
|
| Hospital Charge Code |
3302965
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: First Health Commercial |
$12.60
|
| Rate for Payer: First Health Workers Compensation |
$5.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12.60
|
| Rate for Payer: GEHA Commercial |
$11.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12.60
|
| Rate for Payer: Humana ChoiceCare |
$3.64
|
| Rate for Payer: Multiplan All |
$12.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.40
|
| Rate for Payer: OMNI Networks Commercial |
$9.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.02
|
| Rate for Payer: Zelis Auto |
$5.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.82
|
|
|
DRONABINOL CAP 2.5MG
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 00591359160
|
| Hospital Charge Code |
3300284
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.25 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$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: 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: 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 |
$11.25
|
| 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
|
|
|
DRONABINOL CAP 2.5MG
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 00591359160
|
| Hospital Charge Code |
3300284
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
DRONEDARONE 400 MG TAB
|
Facility
|
IP
|
$103.00
|
|
|
Service Code
|
NDC 00024414260
|
| Hospital Charge Code |
3303039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.12 |
| Max. Negotiated Rate |
$97.85 |
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$87.55
|
| Rate for Payer: First Health Commercial |
$92.70
|
| Rate for Payer: First Health Workers Compensation |
$39.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$92.70
|
| Rate for Payer: GEHA Commercial |
$72.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$92.70
|
| Rate for Payer: Multiplan All |
$93.73
|
| Rate for Payer: OMNI Networks Commercial |
$72.10
|
| Rate for Payer: One Health Plan PPO/POS |
$92.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$97.85
|
| Rate for Payer: Three Rivers Provider Network All |
$77.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$95.79
|
| Rate for Payer: Zelis Auto |
$41.20
|
| Rate for Payer: Zelis Worker's Compensation |
$28.12
|
|
|
DRONEDARONE 400 MG TAB
|
Facility
|
OP
|
$103.00
|
|
|
Service Code
|
NDC 00024414260
|
| Hospital Charge Code |
3303039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.75 |
| Max. Negotiated Rate |
$97.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$61.80
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$87.55
|
| Rate for Payer: First Health Commercial |
$92.70
|
| Rate for Payer: First Health Workers Compensation |
$39.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$92.70
|
| Rate for Payer: GEHA Commercial |
$82.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$92.70
|
| Rate for Payer: Humana ChoiceCare |
$26.78
|
| Rate for Payer: Multiplan All |
$93.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$61.80
|
| Rate for Payer: OMNI Networks Commercial |
$72.10
|
| Rate for Payer: One Health Plan PPO/POS |
$92.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$97.85
|
| Rate for Payer: Three Rivers Provider Network All |
$77.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$90.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$25.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$95.79
|
| Rate for Payer: Zelis Auto |
$41.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$51.50
|
| Rate for Payer: Zelis Worker's Compensation |
$28.12
|
|
|
DRONEDARONE HCL TAB 400MG
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
NDC 00024414210
|
| Hospital Charge Code |
3300285
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$39.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$35.70
|
| Rate for Payer: First Health Commercial |
$37.80
|
| Rate for Payer: First Health Workers Compensation |
$16.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$37.80
|
| Rate for Payer: GEHA Commercial |
$33.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$37.80
|
| Rate for Payer: Humana ChoiceCare |
$10.92
|
| Rate for Payer: Multiplan All |
$38.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.20
|
| Rate for Payer: OMNI Networks Commercial |
$29.40
|
| Rate for Payer: One Health Plan PPO/POS |
$37.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$39.90
|
| Rate for Payer: Three Rivers Provider Network All |
$31.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$36.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$39.06
|
| Rate for Payer: Zelis Auto |
$16.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.00
|
| Rate for Payer: Zelis Worker's Compensation |
$11.47
|
|
|
DRONEDARONE HCL TAB 400MG
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
NDC 00024414210
|
| Hospital Charge Code |
3300285
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.47 |
| Max. Negotiated Rate |
$39.90 |
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$35.70
|
| Rate for Payer: First Health Commercial |
$37.80
|
| Rate for Payer: First Health Workers Compensation |
$16.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$37.80
|
| Rate for Payer: GEHA Commercial |
$29.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$37.80
|
| Rate for Payer: Multiplan All |
$38.22
|
| Rate for Payer: OMNI Networks Commercial |
$29.40
|
| Rate for Payer: One Health Plan PPO/POS |
$37.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$39.90
|
| Rate for Payer: Three Rivers Provider Network All |
$31.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$39.06
|
| Rate for Payer: Zelis Auto |
$16.80
|
| Rate for Payer: Zelis Worker's Compensation |
$11.47
|
|
|
DROPERIDOL 5 MG/2 ML INJ
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
CPT J1790
|
| Hospital Charge Code |
3303058
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.02 |
| Max. Negotiated Rate |
$62.70 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$56.10
|
| Rate for Payer: First Health Commercial |
$59.40
|
| Rate for Payer: First Health Workers Compensation |
$25.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$59.40
|
| Rate for Payer: GEHA Commercial |
$46.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$59.40
|
| Rate for Payer: Multiplan All |
$60.06
|
| Rate for Payer: OMNI Networks Commercial |
$46.20
|
| Rate for Payer: One Health Plan PPO/POS |
$59.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$62.70
|
| Rate for Payer: Three Rivers Provider Network All |
$49.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$61.38
|
| Rate for Payer: Zelis Auto |
$26.40
|
| Rate for Payer: Zelis Worker's Compensation |
$18.02
|
|
|
DROPERIDOL 5 MG/2 ML INJ
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
CPT J1790
|
| Hospital Charge Code |
3303058
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.39 |
| Max. Negotiated Rate |
$62.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$56.10
|
| Rate for Payer: First Health Commercial |
$59.40
|
| Rate for Payer: First Health Workers Compensation |
$25.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$59.40
|
| Rate for Payer: GEHA Commercial |
$8.39
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$59.40
|
| Rate for Payer: Humana ChoiceCare |
$17.16
|
| Rate for Payer: Multiplan All |
$60.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$39.60
|
| Rate for Payer: OMNI Networks Commercial |
$46.20
|
| Rate for Payer: One Health Plan PPO/POS |
$59.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$62.70
|
| Rate for Payer: Three Rivers Provider Network All |
$49.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$58.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$61.38
|
| Rate for Payer: Zelis Auto |
$26.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.02
|
|
|
DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LA
|
Facility
|
IP
|
$416.00
|
|
|
Service Code
|
CPT 16030
|
| Hospital Charge Code |
6116030
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$113.57 |
| Max. Negotiated Rate |
$395.20 |
| Rate for Payer: Cash Price |
$249.60
|
| Rate for Payer: Cigna Commercial |
$353.60
|
| Rate for Payer: First Health Commercial |
$374.40
|
| Rate for Payer: First Health Workers Compensation |
$160.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$374.40
|
| Rate for Payer: GEHA Commercial |
$291.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$374.40
|
| Rate for Payer: Multiplan All |
$378.56
|
| Rate for Payer: OMNI Networks Commercial |
$291.20
|
| Rate for Payer: One Health Plan PPO/POS |
$374.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$395.20
|
| Rate for Payer: Three Rivers Provider Network All |
$312.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$386.88
|
| Rate for Payer: Zelis Auto |
$166.40
|
| Rate for Payer: Zelis Worker's Compensation |
$113.57
|
|
|
DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LA
|
Facility
|
OP
|
$1,205.00
|
|
|
Service Code
|
CPT 16030
|
| Hospital Charge Code |
1900017
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$123.45 |
| Max. Negotiated Rate |
$1,144.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$155.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$723.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$155.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$123.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$387.14
|
| Rate for Payer: Cash Price |
$723.00
|
| Rate for Payer: Cash Price |
$723.00
|
| Rate for Payer: Cigna Commercial |
$1,024.25
|
| Rate for Payer: First Health Commercial |
$1,084.50
|
| Rate for Payer: First Health Workers Compensation |
$465.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,084.50
|
| Rate for Payer: GEHA Commercial |
$964.00
|
| Rate for Payer: GEHA Medicare |
$387.14
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,084.50
|
| Rate for Payer: Humana ChoiceCare |
$425.85
|
| Rate for Payer: Humana Medicare Advantage |
$387.14
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$650.40
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$125.97
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$387.14
|
| Rate for Payer: Multiplan All |
$1,096.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$658.14
|
| Rate for Payer: OMNI Networks Commercial |
$843.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,084.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$145.45
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$125.97
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$387.14
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,144.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$774.28
|
| Rate for Payer: Three Rivers Provider Network All |
$903.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$379.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$125.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$387.14
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,120.65
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$387.14
|
| Rate for Payer: Zelis Auto |
$482.00
|
| Rate for Payer: Zelis Medicare |
$329.07
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$464.57
|
| Rate for Payer: Zelis Worker's Compensation |
$328.96
|
|
|
DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LA
|
Facility
|
IP
|
$875.00
|
|
| Hospital Charge Code |
8150039
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$238.88 |
| Max. Negotiated Rate |
$831.25 |
| 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 |
$612.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$787.50
|
| Rate for Payer: Multiplan All |
$796.25
|
| 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: United Payors & United Providers UP&UP |
$813.75
|
| Rate for Payer: Zelis Auto |
$350.00
|
| Rate for Payer: Zelis Worker's Compensation |
$238.88
|
|
|
DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LA
|
Facility
|
OP
|
$875.00
|
|
| Hospital Charge Code |
8150039
|
|
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
|
|
|
DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LA
|
Facility
|
IP
|
$576.00
|
|
|
Service Code
|
CPT 16030
|
| Hospital Charge Code |
21600203
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$157.25 |
| Max. Negotiated Rate |
$547.20 |
| Rate for Payer: Cash Price |
$345.60
|
| Rate for Payer: Cigna Commercial |
$489.60
|
| Rate for Payer: First Health Commercial |
$518.40
|
| Rate for Payer: First Health Workers Compensation |
$222.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$518.40
|
| Rate for Payer: GEHA Commercial |
$403.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$518.40
|
| Rate for Payer: Multiplan All |
$524.16
|
| Rate for Payer: OMNI Networks Commercial |
$403.20
|
| Rate for Payer: One Health Plan PPO/POS |
$518.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$547.20
|
| Rate for Payer: Three Rivers Provider Network All |
$432.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$535.68
|
| Rate for Payer: Zelis Auto |
$230.40
|
| Rate for Payer: Zelis Worker's Compensation |
$157.25
|
|
|
DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LA
|
Facility
|
OP
|
$416.00
|
|
|
Service Code
|
CPT 16030
|
| Hospital Charge Code |
6116030
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$113.57 |
| Max. Negotiated Rate |
$774.28 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$155.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$249.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$155.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$123.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$387.14
|
| Rate for Payer: Cash Price |
$249.60
|
| Rate for Payer: Cash Price |
$249.60
|
| Rate for Payer: Cigna Commercial |
$353.60
|
| Rate for Payer: First Health Commercial |
$374.40
|
| Rate for Payer: First Health Workers Compensation |
$160.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$374.40
|
| Rate for Payer: GEHA Commercial |
$332.80
|
| Rate for Payer: GEHA Medicare |
$387.14
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$374.40
|
| Rate for Payer: Humana ChoiceCare |
$425.85
|
| Rate for Payer: Humana Medicare Advantage |
$387.14
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$650.40
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$125.97
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$387.14
|
| Rate for Payer: Multiplan All |
$378.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$658.14
|
| Rate for Payer: OMNI Networks Commercial |
$291.20
|
| Rate for Payer: One Health Plan PPO/POS |
$374.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$145.45
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$125.97
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$387.14
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$395.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$774.28
|
| Rate for Payer: Three Rivers Provider Network All |
$312.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$379.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$125.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$387.14
|
| Rate for Payer: United Payors & United Providers UP&UP |
$386.88
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$387.14
|
| Rate for Payer: Zelis Auto |
$166.40
|
| Rate for Payer: Zelis Medicare |
$329.07
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$464.57
|
| Rate for Payer: Zelis Worker's Compensation |
$113.57
|
|
|
DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LA
|
Facility
|
IP
|
$1,205.00
|
|
|
Service Code
|
CPT 16030
|
| Hospital Charge Code |
1900017
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$328.96 |
| Max. Negotiated Rate |
$1,144.75 |
| Rate for Payer: Cash Price |
$723.00
|
| Rate for Payer: Cigna Commercial |
$1,024.25
|
| Rate for Payer: First Health Commercial |
$1,084.50
|
| Rate for Payer: First Health Workers Compensation |
$465.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,084.50
|
| Rate for Payer: GEHA Commercial |
$843.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,084.50
|
| Rate for Payer: Multiplan All |
$1,096.55
|
| Rate for Payer: OMNI Networks Commercial |
$843.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,084.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,144.75
|
| Rate for Payer: Three Rivers Provider Network All |
$903.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,120.65
|
| Rate for Payer: Zelis Auto |
$482.00
|
| Rate for Payer: Zelis Worker's Compensation |
$328.96
|
|
