|
ECHO GUIDE FOR BIOPSY
|
Facility
|
OP
|
$203.00
|
|
|
Service Code
|
CPT 76942
|
| Hospital Charge Code |
8204015
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$50.75 |
| Max. Negotiated Rate |
$192.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$172.55
|
| Rate for Payer: First Health Commercial |
$182.70
|
| Rate for Payer: First Health Workers Compensation |
$117.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$182.70
|
| Rate for Payer: GEHA Commercial |
$162.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$182.70
|
| Rate for Payer: Humana ChoiceCare |
$52.78
|
| Rate for Payer: Multiplan All |
$184.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$121.80
|
| Rate for Payer: OMNI Networks Commercial |
$142.10
|
| Rate for Payer: One Health Plan PPO/POS |
$182.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$192.85
|
| Rate for Payer: Three Rivers Provider Network All |
$152.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$178.64
|
| Rate for Payer: United Healthcare Commercial |
$172.55
|
| Rate for Payer: United Healthcare Managed Medicaid |
$50.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$188.79
|
| Rate for Payer: Zelis Auto |
$81.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$101.50
|
| Rate for Payer: Zelis Worker's Compensation |
$83.26
|
|
|
ECHO GUIDE FOR BIOPSY
|
Facility
|
IP
|
$203.00
|
|
|
Service Code
|
CPT 76942
|
| Hospital Charge Code |
8900023
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$81.20 |
| Max. Negotiated Rate |
$192.85 |
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$172.55
|
| Rate for Payer: First Health Commercial |
$182.70
|
| Rate for Payer: First Health Workers Compensation |
$117.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$182.70
|
| Rate for Payer: GEHA Commercial |
$142.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$182.70
|
| Rate for Payer: Multiplan All |
$184.73
|
| Rate for Payer: OMNI Networks Commercial |
$142.10
|
| Rate for Payer: One Health Plan PPO/POS |
$182.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$192.85
|
| Rate for Payer: Three Rivers Provider Network All |
$152.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$188.79
|
| Rate for Payer: Zelis Auto |
$81.20
|
| Rate for Payer: Zelis Worker's Compensation |
$83.26
|
|
|
ECHO GUIDE FOR BIOPSY
|
Facility
|
OP
|
$203.00
|
|
|
Service Code
|
CPT 76942
|
| Hospital Charge Code |
8900023
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$50.75 |
| Max. Negotiated Rate |
$192.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$172.55
|
| Rate for Payer: First Health Commercial |
$182.70
|
| Rate for Payer: First Health Workers Compensation |
$117.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$182.70
|
| Rate for Payer: GEHA Commercial |
$162.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$182.70
|
| Rate for Payer: Humana ChoiceCare |
$52.78
|
| Rate for Payer: Multiplan All |
$184.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$121.80
|
| Rate for Payer: OMNI Networks Commercial |
$142.10
|
| Rate for Payer: One Health Plan PPO/POS |
$182.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$192.85
|
| Rate for Payer: Three Rivers Provider Network All |
$152.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$178.64
|
| Rate for Payer: United Healthcare Commercial |
$172.55
|
| Rate for Payer: United Healthcare Managed Medicaid |
$50.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$188.79
|
| Rate for Payer: Zelis Auto |
$81.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$101.50
|
| Rate for Payer: Zelis Worker's Compensation |
$83.26
|
|
|
ECHO GUIDE FOR BIOPSY
|
Facility
|
IP
|
$203.00
|
|
|
Service Code
|
CPT 76942
|
| Hospital Charge Code |
8204015
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$81.20 |
| Max. Negotiated Rate |
$192.85 |
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$172.55
|
| Rate for Payer: First Health Commercial |
$182.70
|
| Rate for Payer: First Health Workers Compensation |
$117.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$182.70
|
| Rate for Payer: GEHA Commercial |
$142.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$182.70
|
| Rate for Payer: Multiplan All |
$184.73
|
| Rate for Payer: OMNI Networks Commercial |
$142.10
|
| Rate for Payer: One Health Plan PPO/POS |
$182.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$192.85
|
| Rate for Payer: Three Rivers Provider Network All |
$152.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$188.79
|
| Rate for Payer: Zelis Auto |
$81.20
|
| Rate for Payer: Zelis Worker's Compensation |
$83.26
|
|
|
ECHO GUIDE FOR BIOPSY
|
Facility
|
OP
|
$203.00
|
|
|
Service Code
|
CPT 76942
|
| Hospital Charge Code |
8800038
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$50.75 |
| Max. Negotiated Rate |
$192.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$172.55
|
| Rate for Payer: First Health Commercial |
$182.70
|
| Rate for Payer: First Health Workers Compensation |
$117.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$182.70
|
| Rate for Payer: GEHA Commercial |
$162.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$182.70
|
| Rate for Payer: Humana ChoiceCare |
$52.78
|
| Rate for Payer: Multiplan All |
$184.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$121.80
|
| Rate for Payer: OMNI Networks Commercial |
$142.10
|
| Rate for Payer: One Health Plan PPO/POS |
$182.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$192.85
|
| Rate for Payer: Three Rivers Provider Network All |
$152.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$178.64
|
| Rate for Payer: United Healthcare Commercial |
$172.55
|
| Rate for Payer: United Healthcare Managed Medicaid |
$50.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$188.79
|
| Rate for Payer: Zelis Auto |
$81.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$101.50
|
| Rate for Payer: Zelis Worker's Compensation |
$83.26
|
|
|
ECHO TRANSTHORC R-T 2D W/WO LIMITED
|
Facility
|
OP
|
$1,289.50
|
|
|
Service Code
|
CPT 93308
|
| Hospital Charge Code |
2493308
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$195.09 |
| Max. Negotiated Rate |
$1,225.03 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$396.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$773.70
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$396.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$314.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$229.52
|
| Rate for Payer: Cash Price |
$773.70
|
| Rate for Payer: Cash Price |
$773.70
|
| Rate for Payer: Cigna Commercial |
$1,096.08
|
| Rate for Payer: First Health Commercial |
$1,160.55
|
| Rate for Payer: First Health Workers Compensation |
$497.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,160.55
|
| Rate for Payer: GEHA Commercial |
$1,031.60
|
| Rate for Payer: GEHA Medicare |
$229.52
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,160.55
|
| Rate for Payer: Humana ChoiceCare |
$252.47
|
| Rate for Payer: Humana Medicare Advantage |
$229.52
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$385.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$320.57
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$229.52
|
| Rate for Payer: Multiplan All |
$1,173.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$390.18
|
| Rate for Payer: OMNI Networks Commercial |
$902.65
|
| Rate for Payer: One Health Plan PPO/POS |
$1,160.55
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$370.15
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$320.57
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$229.52
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,225.03
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$459.04
|
| Rate for Payer: Three Rivers Provider Network All |
$967.12
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$224.93
|
| Rate for Payer: United Healthcare Commercial |
$1,096.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$320.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$229.52
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,199.23
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$229.52
|
| Rate for Payer: Zelis Auto |
$515.80
|
| Rate for Payer: Zelis Medicare |
$195.09
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$275.42
|
| Rate for Payer: Zelis Worker's Compensation |
$352.03
|
|
|
ECHO TRANSTHORC R-T 2D W/WO LIMITED
|
Facility
|
IP
|
$1,289.50
|
|
|
Service Code
|
CPT 93308
|
| Hospital Charge Code |
2493308
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$352.03 |
| Max. Negotiated Rate |
$1,225.03 |
| Rate for Payer: Cash Price |
$773.70
|
| Rate for Payer: Cigna Commercial |
$1,096.08
|
| Rate for Payer: First Health Commercial |
$1,160.55
|
| Rate for Payer: First Health Workers Compensation |
$497.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,160.55
|
| Rate for Payer: GEHA Commercial |
$902.65
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,160.55
|
| Rate for Payer: Multiplan All |
$1,173.44
|
| Rate for Payer: OMNI Networks Commercial |
$902.65
|
| Rate for Payer: One Health Plan PPO/POS |
$1,160.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,225.03
|
| Rate for Payer: Three Rivers Provider Network All |
$967.12
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,199.23
|
| Rate for Payer: Zelis Auto |
$515.80
|
| Rate for Payer: Zelis Worker's Compensation |
$352.03
|
|
|
ECHO TTHRC R-T 2D W/WOM-MODE COMPL SPEC&
|
Facility
|
IP
|
$606.00
|
|
|
Service Code
|
CPT 93306
|
| Hospital Charge Code |
8699251
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$165.44 |
| Max. Negotiated Rate |
$575.70 |
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$515.10
|
| Rate for Payer: First Health Commercial |
$545.40
|
| Rate for Payer: First Health Workers Compensation |
$233.98
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$545.40
|
| Rate for Payer: GEHA Commercial |
$424.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$545.40
|
| Rate for Payer: Multiplan All |
$551.46
|
| Rate for Payer: OMNI Networks Commercial |
$424.20
|
| Rate for Payer: One Health Plan PPO/POS |
$545.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$575.70
|
| Rate for Payer: Three Rivers Provider Network All |
$454.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$563.58
|
| Rate for Payer: Zelis Auto |
$242.40
|
| Rate for Payer: Zelis Worker's Compensation |
$165.44
|
|
|
ECHO TTHRC R-T 2D W/WOM-MODE COMPL SPEC&
|
Facility
|
OP
|
$606.00
|
|
|
Service Code
|
CPT 93306
|
| Hospital Charge Code |
8699251
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$165.44 |
| Max. Negotiated Rate |
$1,041.26 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$676.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$363.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$676.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$535.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$520.63
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$515.10
|
| Rate for Payer: First Health Commercial |
$545.40
|
| Rate for Payer: First Health Workers Compensation |
$233.98
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$545.40
|
| Rate for Payer: GEHA Commercial |
$484.80
|
| Rate for Payer: GEHA Medicare |
$520.63
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$545.40
|
| Rate for Payer: Humana ChoiceCare |
$572.69
|
| Rate for Payer: Humana Medicare Advantage |
$520.63
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$874.66
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$546.80
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$520.63
|
| Rate for Payer: Multiplan All |
$551.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$885.07
|
| Rate for Payer: OMNI Networks Commercial |
$424.20
|
| Rate for Payer: One Health Plan PPO/POS |
$545.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$631.36
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$546.80
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$520.63
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$575.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,041.26
|
| Rate for Payer: Three Rivers Provider Network All |
$454.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$510.22
|
| Rate for Payer: United Healthcare Commercial |
$515.10
|
| Rate for Payer: United Healthcare Managed Medicaid |
$546.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$520.63
|
| Rate for Payer: United Payors & United Providers UP&UP |
$563.58
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$520.63
|
| Rate for Payer: Zelis Auto |
$242.40
|
| Rate for Payer: Zelis Medicare |
$442.54
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$624.76
|
| Rate for Payer: Zelis Worker's Compensation |
$165.44
|
|
|
ECOG IMPLTD BRN NPGT <30 D
|
Facility
|
OP
|
$519.00
|
|
|
Service Code
|
CPT 95836
|
| Hospital Charge Code |
6195836
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$30.10 |
| Max. Negotiated Rate |
$493.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$55.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$311.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$55.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$44.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$35.41
|
| Rate for Payer: Cash Price |
$311.40
|
| Rate for Payer: Cash Price |
$311.40
|
| Rate for Payer: Cigna Commercial |
$441.15
|
| Rate for Payer: First Health Commercial |
$467.10
|
| Rate for Payer: First Health Workers Compensation |
$200.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$467.10
|
| Rate for Payer: GEHA Commercial |
$415.20
|
| Rate for Payer: GEHA Medicare |
$35.41
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$467.10
|
| Rate for Payer: Humana ChoiceCare |
$38.95
|
| Rate for Payer: Humana Medicare Advantage |
$35.41
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$59.49
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$45.06
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$35.41
|
| Rate for Payer: Multiplan All |
$472.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$60.20
|
| Rate for Payer: OMNI Networks Commercial |
$363.30
|
| Rate for Payer: One Health Plan PPO/POS |
$467.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$52.02
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$45.06
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$35.41
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$493.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$70.82
|
| Rate for Payer: Three Rivers Provider Network All |
$389.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$34.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$45.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.41
|
| Rate for Payer: United Payors & United Providers UP&UP |
$482.67
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$35.41
|
| Rate for Payer: Zelis Auto |
$207.60
|
| Rate for Payer: Zelis Medicare |
$30.10
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$42.49
|
| Rate for Payer: Zelis Worker's Compensation |
$141.69
|
|
|
ECOG IMPLTD BRN NPGT <30 D
|
Facility
|
OP
|
$519.00
|
|
|
Service Code
|
CPT 95836
|
| Hospital Charge Code |
21700042
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.10 |
| Max. Negotiated Rate |
$493.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$55.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$311.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$55.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$44.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$35.41
|
| Rate for Payer: Cash Price |
$311.40
|
| Rate for Payer: Cash Price |
$311.40
|
| Rate for Payer: Cigna Commercial |
$441.15
|
| Rate for Payer: First Health Commercial |
$467.10
|
| Rate for Payer: First Health Workers Compensation |
$200.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$467.10
|
| Rate for Payer: GEHA Commercial |
$415.20
|
| Rate for Payer: GEHA Medicare |
$35.41
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$467.10
|
| Rate for Payer: Humana ChoiceCare |
$38.95
|
| Rate for Payer: Humana Medicare Advantage |
$35.41
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$59.49
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$45.06
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$35.41
|
| Rate for Payer: Multiplan All |
$472.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$60.20
|
| Rate for Payer: OMNI Networks Commercial |
$363.30
|
| Rate for Payer: One Health Plan PPO/POS |
$467.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$52.02
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$45.06
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$35.41
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$493.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$70.82
|
| Rate for Payer: Three Rivers Provider Network All |
$389.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$34.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$45.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.41
|
| Rate for Payer: United Payors & United Providers UP&UP |
$482.67
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$35.41
|
| Rate for Payer: Zelis Auto |
$207.60
|
| Rate for Payer: Zelis Medicare |
$30.10
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$42.49
|
| Rate for Payer: Zelis Worker's Compensation |
$141.69
|
|
|
ECOG IMPLTD BRN NPGT <30 D
|
Facility
|
IP
|
$519.00
|
|
|
Service Code
|
CPT 95836
|
| Hospital Charge Code |
6195836
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$141.69 |
| Max. Negotiated Rate |
$493.05 |
| Rate for Payer: Cash Price |
$311.40
|
| Rate for Payer: Cigna Commercial |
$441.15
|
| Rate for Payer: First Health Commercial |
$467.10
|
| Rate for Payer: First Health Workers Compensation |
$200.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$467.10
|
| Rate for Payer: GEHA Commercial |
$363.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$467.10
|
| Rate for Payer: Multiplan All |
$472.29
|
| Rate for Payer: OMNI Networks Commercial |
$363.30
|
| Rate for Payer: One Health Plan PPO/POS |
$467.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$493.05
|
| Rate for Payer: Three Rivers Provider Network All |
$389.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$482.67
|
| Rate for Payer: Zelis Auto |
$207.60
|
| Rate for Payer: Zelis Worker's Compensation |
$141.69
|
|
|
ECOG IMPLTD BRN NPGT <30 D
|
Facility
|
IP
|
$519.00
|
|
|
Service Code
|
CPT 95836
|
| Hospital Charge Code |
21700042
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$141.69 |
| Max. Negotiated Rate |
$493.05 |
| Rate for Payer: Cash Price |
$311.40
|
| Rate for Payer: Cigna Commercial |
$441.15
|
| Rate for Payer: First Health Commercial |
$467.10
|
| Rate for Payer: First Health Workers Compensation |
$200.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$467.10
|
| Rate for Payer: GEHA Commercial |
$363.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$467.10
|
| Rate for Payer: Multiplan All |
$472.29
|
| Rate for Payer: OMNI Networks Commercial |
$363.30
|
| Rate for Payer: One Health Plan PPO/POS |
$467.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$493.05
|
| Rate for Payer: Three Rivers Provider Network All |
$389.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$482.67
|
| Rate for Payer: Zelis Auto |
$207.60
|
| Rate for Payer: Zelis Worker's Compensation |
$141.69
|
|
|
ECOG IMPLTD BRN NPGT <30 D
|
Facility
|
IP
|
$519.00
|
|
|
Service Code
|
CPT 95836
|
| Hospital Charge Code |
21999313
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$141.69 |
| Max. Negotiated Rate |
$493.05 |
| Rate for Payer: Cash Price |
$311.40
|
| Rate for Payer: Cigna Commercial |
$441.15
|
| Rate for Payer: First Health Commercial |
$467.10
|
| Rate for Payer: First Health Workers Compensation |
$200.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$467.10
|
| Rate for Payer: GEHA Commercial |
$363.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$467.10
|
| Rate for Payer: Multiplan All |
$472.29
|
| Rate for Payer: OMNI Networks Commercial |
$363.30
|
| Rate for Payer: One Health Plan PPO/POS |
$467.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$493.05
|
| Rate for Payer: Three Rivers Provider Network All |
$389.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$482.67
|
| Rate for Payer: Zelis Auto |
$207.60
|
| Rate for Payer: Zelis Worker's Compensation |
$141.69
|
|
|
ECOG IMPLTD BRN NPGT <30 D
|
Facility
|
OP
|
$519.00
|
|
|
Service Code
|
CPT 95836
|
| Hospital Charge Code |
21999313
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.10 |
| Max. Negotiated Rate |
$493.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$55.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$311.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$55.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$44.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$35.41
|
| Rate for Payer: Cash Price |
$311.40
|
| Rate for Payer: Cash Price |
$311.40
|
| Rate for Payer: Cigna Commercial |
$441.15
|
| Rate for Payer: First Health Commercial |
$467.10
|
| Rate for Payer: First Health Workers Compensation |
$200.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$467.10
|
| Rate for Payer: GEHA Commercial |
$415.20
|
| Rate for Payer: GEHA Medicare |
$35.41
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$467.10
|
| Rate for Payer: Humana ChoiceCare |
$38.95
|
| Rate for Payer: Humana Medicare Advantage |
$35.41
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$59.49
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$45.06
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$35.41
|
| Rate for Payer: Multiplan All |
$472.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$60.20
|
| Rate for Payer: OMNI Networks Commercial |
$363.30
|
| Rate for Payer: One Health Plan PPO/POS |
$467.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$52.02
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$45.06
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$35.41
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$493.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$70.82
|
| Rate for Payer: Three Rivers Provider Network All |
$389.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$34.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$45.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.41
|
| Rate for Payer: United Payors & United Providers UP&UP |
$482.67
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$35.41
|
| Rate for Payer: Zelis Auto |
$207.60
|
| Rate for Payer: Zelis Medicare |
$30.10
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$42.49
|
| Rate for Payer: Zelis Worker's Compensation |
$141.69
|
|
|
ED CARDIAC
|
Facility
|
IP
|
$1,250.00
|
|
|
Service Code
|
CPT 93308
|
| Hospital Charge Code |
8180001
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$341.25 |
| Max. Negotiated Rate |
$1,187.50 |
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,062.50
|
| Rate for Payer: First Health Commercial |
$1,125.00
|
| Rate for Payer: First Health Workers Compensation |
$482.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,125.00
|
| Rate for Payer: GEHA Commercial |
$875.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,125.00
|
| Rate for Payer: Multiplan All |
$1,137.50
|
| Rate for Payer: OMNI Networks Commercial |
$875.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,125.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,187.50
|
| Rate for Payer: Three Rivers Provider Network All |
$937.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,162.50
|
| Rate for Payer: Zelis Auto |
$500.00
|
| Rate for Payer: Zelis Worker's Compensation |
$341.25
|
|
|
ED CARDIAC
|
Facility
|
OP
|
$1,250.00
|
|
|
Service Code
|
CPT 93308
|
| Hospital Charge Code |
8180001
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$195.09 |
| Max. Negotiated Rate |
$1,187.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$396.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$750.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$396.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$314.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$229.52
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,062.50
|
| Rate for Payer: First Health Commercial |
$1,125.00
|
| Rate for Payer: First Health Workers Compensation |
$482.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,125.00
|
| Rate for Payer: GEHA Commercial |
$1,000.00
|
| Rate for Payer: GEHA Medicare |
$229.52
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,125.00
|
| Rate for Payer: Humana ChoiceCare |
$252.47
|
| Rate for Payer: Humana Medicare Advantage |
$229.52
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$385.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$320.57
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$229.52
|
| Rate for Payer: Multiplan All |
$1,137.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$390.18
|
| Rate for Payer: OMNI Networks Commercial |
$875.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,125.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$370.15
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$320.57
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$229.52
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,187.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$459.04
|
| Rate for Payer: Three Rivers Provider Network All |
$937.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$224.93
|
| Rate for Payer: United Healthcare Managed Medicaid |
$320.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$229.52
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,162.50
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$229.52
|
| Rate for Payer: Zelis Auto |
$500.00
|
| Rate for Payer: Zelis Medicare |
$195.09
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$275.42
|
| Rate for Payer: Zelis Worker's Compensation |
$341.25
|
|
|
ED- DC ACETAMIN W/COD 300-30MG TAB
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 00406048462
|
| Hospital Charge Code |
3302870
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$9.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Humana ChoiceCare |
$3.12
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.20
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
ED- DC ACETAMIN W/COD 300-30MG TAB
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 00406048462
|
| Hospital Charge Code |
3302870
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$8.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
ED- DC AZITHROMYCIN 300 MG/15 ML SUSP
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
NDC 00093202723
|
| Hospital Charge Code |
3302878
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.84 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$68.00
|
| Rate for Payer: First Health Commercial |
$72.00
|
| Rate for Payer: First Health Workers Compensation |
$30.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.00
|
| Rate for Payer: GEHA Commercial |
$56.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.00
|
| Rate for Payer: Multiplan All |
$72.80
|
| Rate for Payer: OMNI Networks Commercial |
$56.00
|
| Rate for Payer: One Health Plan PPO/POS |
$72.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.00
|
| Rate for Payer: Three Rivers Provider Network All |
$60.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$74.40
|
| Rate for Payer: Zelis Auto |
$32.00
|
| Rate for Payer: Zelis Worker's Compensation |
$21.84
|
|
|
ED- DC AZITHROMYCIN 300 MG/15 ML SUSP
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
NDC 00093202723
|
| Hospital Charge Code |
3302878
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$68.00
|
| Rate for Payer: First Health Commercial |
$72.00
|
| Rate for Payer: First Health Workers Compensation |
$30.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.00
|
| Rate for Payer: GEHA Commercial |
$64.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.00
|
| Rate for Payer: Humana ChoiceCare |
$20.80
|
| Rate for Payer: Multiplan All |
$72.80
|
| Rate for Payer: New Mexico Health Connections Medicare |
$48.00
|
| Rate for Payer: OMNI Networks Commercial |
$56.00
|
| Rate for Payer: One Health Plan PPO/POS |
$72.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.00
|
| Rate for Payer: Three Rivers Provider Network All |
$60.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$70.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$20.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$74.40
|
| Rate for Payer: Zelis Auto |
$32.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$40.00
|
| Rate for Payer: Zelis Worker's Compensation |
$21.84
|
|
|
ED- DC CYCLOBENZAPRINE HCL TAB 10MG
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 69097084607
|
| Hospital Charge Code |
3302873
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$9.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Humana ChoiceCare |
$3.12
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.20
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
ED- DC CYCLOBENZAPRINE HCL TAB 10MG
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 69097084607
|
| Hospital Charge Code |
3302873
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$8.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
ED- DC DIAZEPAM TAB 5MG
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
3302879
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$8.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
ED- DC DIAZEPAM TAB 5MG
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
3302879
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$9.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Humana ChoiceCare |
$3.12
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.20
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
