|
DSTR NROLYTC AGNT PARVERTEB FCT SNGL C/T
|
Facility
|
OP
|
$694.00
|
|
|
Service Code
|
CPT 64633
|
| Hospital Charge Code |
7664633
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$189.46 |
| Max. Negotiated Rate |
$3,708.46 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$755.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$416.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$755.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$598.15
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,854.23
|
| Rate for Payer: Cash Price |
$416.40
|
| Rate for Payer: Cash Price |
$416.40
|
| Rate for Payer: Cigna Commercial |
$589.90
|
| Rate for Payer: First Health Commercial |
$624.60
|
| Rate for Payer: First Health Workers Compensation |
$267.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$624.60
|
| Rate for Payer: GEHA Commercial |
$555.20
|
| Rate for Payer: GEHA Medicare |
$1,854.23
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$624.60
|
| Rate for Payer: Humana ChoiceCare |
$2,039.65
|
| Rate for Payer: Humana Medicare Advantage |
$1,854.23
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$3,115.11
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$610.34
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,854.23
|
| Rate for Payer: Multiplan All |
$631.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,152.19
|
| Rate for Payer: OMNI Networks Commercial |
$485.80
|
| Rate for Payer: One Health Plan PPO/POS |
$624.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$704.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$610.34
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,854.23
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$659.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,708.46
|
| Rate for Payer: Three Rivers Provider Network All |
$520.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,817.15
|
| Rate for Payer: United Healthcare Managed Medicaid |
$610.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,854.23
|
| Rate for Payer: United Payors & United Providers UP&UP |
$645.42
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,854.23
|
| Rate for Payer: Zelis Auto |
$277.60
|
| Rate for Payer: Zelis Medicare |
$1,576.10
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,225.08
|
| Rate for Payer: Zelis Worker's Compensation |
$189.46
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT SNGL C/T
|
Facility
|
OP
|
$694.00
|
|
|
Service Code
|
CPT 64633
|
| Hospital Charge Code |
6164633
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$189.46 |
| Max. Negotiated Rate |
$3,708.46 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$755.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$416.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$755.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$598.15
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,854.23
|
| Rate for Payer: Cash Price |
$416.40
|
| Rate for Payer: Cash Price |
$416.40
|
| Rate for Payer: Cigna Commercial |
$589.90
|
| Rate for Payer: First Health Commercial |
$624.60
|
| Rate for Payer: First Health Workers Compensation |
$267.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$624.60
|
| Rate for Payer: GEHA Commercial |
$555.20
|
| Rate for Payer: GEHA Medicare |
$1,854.23
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$624.60
|
| Rate for Payer: Humana ChoiceCare |
$2,039.65
|
| Rate for Payer: Humana Medicare Advantage |
$1,854.23
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$3,115.11
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$610.34
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,854.23
|
| Rate for Payer: Multiplan All |
$631.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,152.19
|
| Rate for Payer: OMNI Networks Commercial |
$485.80
|
| Rate for Payer: One Health Plan PPO/POS |
$624.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$704.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$610.34
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,854.23
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$659.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,708.46
|
| Rate for Payer: Three Rivers Provider Network All |
$520.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,817.15
|
| Rate for Payer: United Healthcare Managed Medicaid |
$610.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,854.23
|
| Rate for Payer: United Payors & United Providers UP&UP |
$645.42
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,854.23
|
| Rate for Payer: Zelis Auto |
$277.60
|
| Rate for Payer: Zelis Medicare |
$1,576.10
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,225.08
|
| Rate for Payer: Zelis Worker's Compensation |
$189.46
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT SNGL C/T
|
Facility
|
IP
|
$694.00
|
|
|
Service Code
|
CPT 64633
|
| Hospital Charge Code |
7664633
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$189.46 |
| Max. Negotiated Rate |
$659.30 |
| Rate for Payer: Cash Price |
$416.40
|
| Rate for Payer: Cigna Commercial |
$589.90
|
| Rate for Payer: First Health Commercial |
$624.60
|
| Rate for Payer: First Health Workers Compensation |
$267.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$624.60
|
| Rate for Payer: GEHA Commercial |
$485.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$624.60
|
| Rate for Payer: Multiplan All |
$631.54
|
| Rate for Payer: OMNI Networks Commercial |
$485.80
|
| Rate for Payer: One Health Plan PPO/POS |
$624.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$659.30
|
| Rate for Payer: Three Rivers Provider Network All |
$520.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$645.42
|
| Rate for Payer: Zelis Auto |
$277.60
|
| Rate for Payer: Zelis Worker's Compensation |
$189.46
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT SNGL L/S
|
Facility
|
OP
|
$684.00
|
|
|
Service Code
|
CPT 64635
|
| Hospital Charge Code |
6164635
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$186.73 |
| Max. Negotiated Rate |
$3,708.46 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,303.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$410.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,303.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,032.26
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,854.23
|
| Rate for Payer: Cash Price |
$410.40
|
| Rate for Payer: Cash Price |
$410.40
|
| Rate for Payer: Cigna Commercial |
$581.40
|
| Rate for Payer: First Health Commercial |
$615.60
|
| Rate for Payer: First Health Workers Compensation |
$264.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$615.60
|
| Rate for Payer: GEHA Commercial |
$547.20
|
| Rate for Payer: GEHA Medicare |
$1,854.23
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$615.60
|
| Rate for Payer: Humana ChoiceCare |
$2,039.65
|
| Rate for Payer: Humana Medicare Advantage |
$1,854.23
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$3,115.11
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,053.29
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,854.23
|
| Rate for Payer: Multiplan All |
$622.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,152.19
|
| Rate for Payer: OMNI Networks Commercial |
$478.80
|
| Rate for Payer: One Health Plan PPO/POS |
$615.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,216.17
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,053.29
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,854.23
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$649.80
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,708.46
|
| Rate for Payer: Three Rivers Provider Network All |
$513.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,817.15
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,053.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,854.23
|
| Rate for Payer: United Payors & United Providers UP&UP |
$636.12
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,854.23
|
| Rate for Payer: Zelis Auto |
$273.60
|
| Rate for Payer: Zelis Medicare |
$1,576.10
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,225.08
|
| Rate for Payer: Zelis Worker's Compensation |
$186.73
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT SNGL L/S
|
Facility
|
IP
|
$684.00
|
|
|
Service Code
|
CPT 64635
|
| Hospital Charge Code |
6164635
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$186.73 |
| Max. Negotiated Rate |
$649.80 |
| Rate for Payer: Cash Price |
$410.40
|
| Rate for Payer: Cigna Commercial |
$581.40
|
| Rate for Payer: First Health Commercial |
$615.60
|
| Rate for Payer: First Health Workers Compensation |
$264.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$615.60
|
| Rate for Payer: GEHA Commercial |
$478.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$615.60
|
| Rate for Payer: Multiplan All |
$622.44
|
| Rate for Payer: OMNI Networks Commercial |
$478.80
|
| Rate for Payer: One Health Plan PPO/POS |
$615.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$649.80
|
| Rate for Payer: Three Rivers Provider Network All |
$513.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$636.12
|
| Rate for Payer: Zelis Auto |
$273.60
|
| Rate for Payer: Zelis Worker's Compensation |
$186.73
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT SNGL L/S
|
Facility
|
IP
|
$684.00
|
|
|
Service Code
|
CPT 64635
|
| Hospital Charge Code |
7664635
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$186.73 |
| Max. Negotiated Rate |
$649.80 |
| Rate for Payer: Cash Price |
$410.40
|
| Rate for Payer: Cigna Commercial |
$581.40
|
| Rate for Payer: First Health Commercial |
$615.60
|
| Rate for Payer: First Health Workers Compensation |
$264.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$615.60
|
| Rate for Payer: GEHA Commercial |
$478.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$615.60
|
| Rate for Payer: Multiplan All |
$622.44
|
| Rate for Payer: OMNI Networks Commercial |
$478.80
|
| Rate for Payer: One Health Plan PPO/POS |
$615.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$649.80
|
| Rate for Payer: Three Rivers Provider Network All |
$513.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$636.12
|
| Rate for Payer: Zelis Auto |
$273.60
|
| Rate for Payer: Zelis Worker's Compensation |
$186.73
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT SNGL L/S
|
Facility
|
OP
|
$684.00
|
|
|
Service Code
|
CPT 64635
|
| Hospital Charge Code |
7664635
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$186.73 |
| Max. Negotiated Rate |
$3,708.46 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,303.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$410.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,303.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,032.26
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,854.23
|
| Rate for Payer: Cash Price |
$410.40
|
| Rate for Payer: Cash Price |
$410.40
|
| Rate for Payer: Cigna Commercial |
$581.40
|
| Rate for Payer: First Health Commercial |
$615.60
|
| Rate for Payer: First Health Workers Compensation |
$264.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$615.60
|
| Rate for Payer: GEHA Commercial |
$547.20
|
| Rate for Payer: GEHA Medicare |
$1,854.23
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$615.60
|
| Rate for Payer: Humana ChoiceCare |
$2,039.65
|
| Rate for Payer: Humana Medicare Advantage |
$1,854.23
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$3,115.11
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,053.29
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,854.23
|
| Rate for Payer: Multiplan All |
$622.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,152.19
|
| Rate for Payer: OMNI Networks Commercial |
$478.80
|
| Rate for Payer: One Health Plan PPO/POS |
$615.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,216.17
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,053.29
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,854.23
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$649.80
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,708.46
|
| Rate for Payer: Three Rivers Provider Network All |
$513.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,817.15
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,053.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,854.23
|
| Rate for Payer: United Payors & United Providers UP&UP |
$636.12
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,854.23
|
| Rate for Payer: Zelis Auto |
$273.60
|
| Rate for Payer: Zelis Medicare |
$1,576.10
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,225.08
|
| Rate for Payer: Zelis Worker's Compensation |
$186.73
|
|
|
DTAP-HIB-IP VACCINE, IM
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
21600335
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$34.25 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$82.20
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$116.45
|
| Rate for Payer: First Health Commercial |
$123.30
|
| Rate for Payer: First Health Workers Compensation |
$52.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$123.30
|
| Rate for Payer: GEHA Commercial |
$109.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$123.30
|
| Rate for Payer: Humana ChoiceCare |
$35.62
|
| Rate for Payer: Multiplan All |
$124.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$82.20
|
| Rate for Payer: OMNI Networks Commercial |
$95.90
|
| Rate for Payer: One Health Plan PPO/POS |
$123.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$130.15
|
| Rate for Payer: Three Rivers Provider Network All |
$102.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$120.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$34.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$127.41
|
| Rate for Payer: Zelis Auto |
$54.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$68.50
|
| Rate for Payer: Zelis Worker's Compensation |
$37.40
|
|
|
DTAP-HIB-IP VACCINE, IM
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
8590698
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.25 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$82.20
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$116.45
|
| Rate for Payer: First Health Commercial |
$123.30
|
| Rate for Payer: First Health Workers Compensation |
$52.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$123.30
|
| Rate for Payer: GEHA Commercial |
$109.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$123.30
|
| Rate for Payer: Humana ChoiceCare |
$35.62
|
| Rate for Payer: Multiplan All |
$124.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$82.20
|
| Rate for Payer: OMNI Networks Commercial |
$95.90
|
| Rate for Payer: One Health Plan PPO/POS |
$123.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$130.15
|
| Rate for Payer: Three Rivers Provider Network All |
$102.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$120.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$34.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$127.41
|
| Rate for Payer: Zelis Auto |
$54.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$68.50
|
| Rate for Payer: Zelis Worker's Compensation |
$37.40
|
|
|
DTAP-HIB-IP VACCINE, IM
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
8590698
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.40 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$116.45
|
| Rate for Payer: First Health Commercial |
$123.30
|
| Rate for Payer: First Health Workers Compensation |
$52.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$123.30
|
| Rate for Payer: GEHA Commercial |
$95.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$123.30
|
| Rate for Payer: Multiplan All |
$124.67
|
| Rate for Payer: OMNI Networks Commercial |
$95.90
|
| Rate for Payer: One Health Plan PPO/POS |
$123.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$130.15
|
| Rate for Payer: Three Rivers Provider Network All |
$102.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$127.41
|
| Rate for Payer: Zelis Auto |
$54.80
|
| Rate for Payer: Zelis Worker's Compensation |
$37.40
|
|
|
DTAP-HIB-IP VACCINE, IM
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
21600335
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$37.40 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$116.45
|
| Rate for Payer: First Health Commercial |
$123.30
|
| Rate for Payer: First Health Workers Compensation |
$52.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$123.30
|
| Rate for Payer: GEHA Commercial |
$95.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$123.30
|
| Rate for Payer: Multiplan All |
$124.67
|
| Rate for Payer: OMNI Networks Commercial |
$95.90
|
| Rate for Payer: One Health Plan PPO/POS |
$123.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$130.15
|
| Rate for Payer: Three Rivers Provider Network All |
$102.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$127.41
|
| Rate for Payer: Zelis Auto |
$54.80
|
| Rate for Payer: Zelis Worker's Compensation |
$37.40
|
|
|
DTAP VACCINE, < 7 YRS, IM
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
8590700
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.47 |
| Max. Negotiated Rate |
$50.35 |
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$45.05
|
| Rate for Payer: First Health Commercial |
$47.70
|
| Rate for Payer: First Health Workers Compensation |
$20.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$47.70
|
| Rate for Payer: GEHA Commercial |
$37.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$47.70
|
| Rate for Payer: Multiplan All |
$48.23
|
| Rate for Payer: OMNI Networks Commercial |
$37.10
|
| Rate for Payer: One Health Plan PPO/POS |
$47.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$50.35
|
| Rate for Payer: Three Rivers Provider Network All |
$39.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$49.29
|
| Rate for Payer: Zelis Auto |
$21.20
|
| Rate for Payer: Zelis Worker's Compensation |
$14.47
|
|
|
DTAP VACCINE, < 7 YRS, IM
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
8590700
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$50.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$45.05
|
| Rate for Payer: First Health Commercial |
$47.70
|
| Rate for Payer: First Health Workers Compensation |
$20.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$47.70
|
| Rate for Payer: GEHA Commercial |
$42.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$47.70
|
| Rate for Payer: Humana ChoiceCare |
$13.78
|
| Rate for Payer: Multiplan All |
$48.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.80
|
| Rate for Payer: OMNI Networks Commercial |
$37.10
|
| Rate for Payer: One Health Plan PPO/POS |
$47.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$50.35
|
| Rate for Payer: Three Rivers Provider Network All |
$39.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$46.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$49.29
|
| Rate for Payer: Zelis Auto |
$21.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$26.50
|
| Rate for Payer: Zelis Worker's Compensation |
$14.47
|
|
|
DTPA-TC99M PER DOSE
|
Facility
|
IP
|
$491.00
|
|
|
Service Code
|
CPT A9567
|
| Hospital Charge Code |
2410064
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$134.04 |
| Max. Negotiated Rate |
$466.45 |
| Rate for Payer: Cash Price |
$294.60
|
| Rate for Payer: Cigna Commercial |
$417.35
|
| Rate for Payer: First Health Commercial |
$441.90
|
| Rate for Payer: First Health Workers Compensation |
$189.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$441.90
|
| Rate for Payer: GEHA Commercial |
$343.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$441.90
|
| Rate for Payer: Multiplan All |
$446.81
|
| Rate for Payer: OMNI Networks Commercial |
$343.70
|
| Rate for Payer: One Health Plan PPO/POS |
$441.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$466.45
|
| Rate for Payer: Three Rivers Provider Network All |
$368.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$456.63
|
| Rate for Payer: Zelis Auto |
$196.40
|
| Rate for Payer: Zelis Worker's Compensation |
$134.04
|
|
|
DTPA-TC99M PER DOSE
|
Facility
|
OP
|
$491.00
|
|
|
Service Code
|
CPT A9567
|
| Hospital Charge Code |
2410064
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$122.75 |
| Max. Negotiated Rate |
$466.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$294.60
|
| Rate for Payer: Cash Price |
$294.60
|
| Rate for Payer: Cigna Commercial |
$417.35
|
| Rate for Payer: First Health Commercial |
$441.90
|
| Rate for Payer: First Health Workers Compensation |
$189.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$441.90
|
| Rate for Payer: GEHA Commercial |
$392.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$441.90
|
| Rate for Payer: Humana ChoiceCare |
$127.66
|
| Rate for Payer: Multiplan All |
$446.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$294.60
|
| Rate for Payer: OMNI Networks Commercial |
$343.70
|
| Rate for Payer: One Health Plan PPO/POS |
$441.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$466.45
|
| Rate for Payer: Three Rivers Provider Network All |
$368.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$432.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$122.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$456.63
|
| Rate for Payer: Zelis Auto |
$196.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$245.50
|
| Rate for Payer: Zelis Worker's Compensation |
$134.04
|
|
|
DT VACCINE < 7, IM
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT 90702
|
| Hospital Charge Code |
8590702
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.92 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$43.35
|
| Rate for Payer: First Health Commercial |
$45.90
|
| Rate for Payer: First Health Workers Compensation |
$19.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.90
|
| Rate for Payer: GEHA Commercial |
$35.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.90
|
| Rate for Payer: Multiplan All |
$46.41
|
| Rate for Payer: OMNI Networks Commercial |
$35.70
|
| Rate for Payer: One Health Plan PPO/POS |
$45.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$48.45
|
| Rate for Payer: Three Rivers Provider Network All |
$38.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$47.43
|
| Rate for Payer: Zelis Auto |
$20.40
|
| Rate for Payer: Zelis Worker's Compensation |
$13.92
|
|
|
DT VACCINE < 7, IM
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
CPT 90702
|
| Hospital Charge Code |
21600337
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$43.35
|
| Rate for Payer: First Health Commercial |
$45.90
|
| Rate for Payer: First Health Workers Compensation |
$19.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.90
|
| Rate for Payer: GEHA Commercial |
$40.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.90
|
| Rate for Payer: Humana ChoiceCare |
$13.26
|
| Rate for Payer: Multiplan All |
$46.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.60
|
| Rate for Payer: OMNI Networks Commercial |
$35.70
|
| Rate for Payer: One Health Plan PPO/POS |
$45.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$48.45
|
| Rate for Payer: Three Rivers Provider Network All |
$38.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$44.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$47.43
|
| Rate for Payer: Zelis Auto |
$20.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$25.50
|
| Rate for Payer: Zelis Worker's Compensation |
$13.92
|
|
|
DT VACCINE < 7, IM
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT 90702
|
| Hospital Charge Code |
21600337
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$13.92 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$43.35
|
| Rate for Payer: First Health Commercial |
$45.90
|
| Rate for Payer: First Health Workers Compensation |
$19.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.90
|
| Rate for Payer: GEHA Commercial |
$35.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.90
|
| Rate for Payer: Multiplan All |
$46.41
|
| Rate for Payer: OMNI Networks Commercial |
$35.70
|
| Rate for Payer: One Health Plan PPO/POS |
$45.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$48.45
|
| Rate for Payer: Three Rivers Provider Network All |
$38.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$47.43
|
| Rate for Payer: Zelis Auto |
$20.40
|
| Rate for Payer: Zelis Worker's Compensation |
$13.92
|
|
|
DT VACCINE < 7, IM
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
CPT 90702
|
| Hospital Charge Code |
8590702
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$43.35
|
| Rate for Payer: First Health Commercial |
$45.90
|
| Rate for Payer: First Health Workers Compensation |
$19.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.90
|
| Rate for Payer: GEHA Commercial |
$40.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.90
|
| Rate for Payer: Humana ChoiceCare |
$13.26
|
| Rate for Payer: Multiplan All |
$46.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.60
|
| Rate for Payer: OMNI Networks Commercial |
$35.70
|
| Rate for Payer: One Health Plan PPO/POS |
$45.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$48.45
|
| Rate for Payer: Three Rivers Provider Network All |
$38.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$44.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$47.43
|
| Rate for Payer: Zelis Auto |
$20.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$25.50
|
| Rate for Payer: Zelis Worker's Compensation |
$13.92
|
|
|
DULoxetine HCL 20MG CAP
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904704304
|
| Hospital Charge Code |
3300286
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
DULoxetine HCL 20MG CAP
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904704304
|
| Hospital Charge Code |
3300286
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
DULoxetine HCL 30MG CAP
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 68084068301
|
| Hospital Charge Code |
3300287
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
DULoxetine HCL 30MG CAP
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 68084068301
|
| Hospital Charge Code |
3300287
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
DUODENAL EXCLUSION
|
Facility
|
OP
|
$3,775.00
|
|
|
Service Code
|
CPT 48547
|
| Hospital Charge Code |
6148547
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$943.75 |
| Max. Negotiated Rate |
$3,586.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,265.00
|
| Rate for Payer: Cash Price |
$2,265.00
|
| Rate for Payer: Cigna Commercial |
$3,208.75
|
| Rate for Payer: First Health Commercial |
$3,397.50
|
| Rate for Payer: First Health Workers Compensation |
$1,457.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,397.50
|
| Rate for Payer: GEHA Commercial |
$3,020.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,397.50
|
| Rate for Payer: Humana ChoiceCare |
$981.50
|
| Rate for Payer: Multiplan All |
$3,435.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,265.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,642.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,397.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,586.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,831.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,322.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$943.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,510.75
|
| Rate for Payer: Zelis Auto |
$1,510.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,887.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1,030.58
|
|
|
DUODENAL EXCLUSION
|
Facility
|
IP
|
$3,775.00
|
|
|
Service Code
|
CPT 48547
|
| Hospital Charge Code |
6148547
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,030.58 |
| Max. Negotiated Rate |
$3,586.25 |
| Rate for Payer: Cash Price |
$2,265.00
|
| Rate for Payer: Cigna Commercial |
$3,208.75
|
| Rate for Payer: First Health Commercial |
$3,397.50
|
| Rate for Payer: First Health Workers Compensation |
$1,457.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,397.50
|
| Rate for Payer: GEHA Commercial |
$2,642.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,397.50
|
| Rate for Payer: Multiplan All |
$3,435.25
|
| Rate for Payer: OMNI Networks Commercial |
$2,642.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,397.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,586.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,831.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,510.75
|
| Rate for Payer: Zelis Auto |
$1,510.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,030.58
|
|
