|
ETHAMBUTOL HCL 400 MG TAB
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 68850001201
|
| Hospital Charge Code |
3302890
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
ethosuximide REF007443
|
Facility
|
OP
|
$252.00
|
|
|
Service Code
|
CPT 80168
|
| Hospital Charge Code |
22990339
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.89 |
| Max. Negotiated Rate |
$239.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$29.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$151.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$29.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$23.30
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$16.34
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cigna Commercial |
$214.20
|
| Rate for Payer: First Health Commercial |
$226.80
|
| Rate for Payer: First Health Workers Compensation |
$29.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$226.80
|
| Rate for Payer: GEHA Commercial |
$201.60
|
| Rate for Payer: GEHA Medicare |
$16.34
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$226.80
|
| Rate for Payer: Humana ChoiceCare |
$17.97
|
| Rate for Payer: Humana Medicare Advantage |
$16.34
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$27.45
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$23.78
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$16.34
|
| Rate for Payer: Multiplan All |
$229.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.78
|
| Rate for Payer: OMNI Networks Commercial |
$176.40
|
| Rate for Payer: One Health Plan PPO/POS |
$226.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$27.45
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$23.78
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$16.34
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$239.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$32.68
|
| Rate for Payer: Three Rivers Provider Network All |
$189.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16.01
|
| Rate for Payer: United Healthcare Commercial |
$214.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$23.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.34
|
| Rate for Payer: United Payors & United Providers UP&UP |
$234.36
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$16.34
|
| Rate for Payer: Zelis Auto |
$100.80
|
| Rate for Payer: Zelis Medicare |
$13.89
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$19.61
|
| Rate for Payer: Zelis Worker's Compensation |
$21.15
|
|
|
ethosuximide REF007443
|
Facility
|
IP
|
$252.00
|
|
|
Service Code
|
CPT 80168
|
| Hospital Charge Code |
22990339
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.15 |
| Max. Negotiated Rate |
$239.40 |
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cigna Commercial |
$214.20
|
| Rate for Payer: First Health Commercial |
$226.80
|
| Rate for Payer: First Health Workers Compensation |
$29.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$226.80
|
| Rate for Payer: GEHA Commercial |
$176.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$226.80
|
| Rate for Payer: Multiplan All |
$229.32
|
| Rate for Payer: OMNI Networks Commercial |
$176.40
|
| Rate for Payer: One Health Plan PPO/POS |
$226.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$239.40
|
| Rate for Payer: Three Rivers Provider Network All |
$189.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$234.36
|
| Rate for Payer: Zelis Auto |
$100.80
|
| Rate for Payer: Zelis Worker's Compensation |
$21.15
|
|
|
ethylene glycol REF071654
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
CPT 82693
|
| Hospital Charge Code |
2299870
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$22.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$117.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: OMNI Networks Commercial |
$117.60
|
| Rate for Payer: One Health Plan PPO/POS |
$151.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Worker's Compensation |
$16.10
|
|
|
ethylene glycol REF071654
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
CPT 82693
|
| Hospital Charge Code |
2299870
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.66 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$22.35
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$100.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$22.35
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$17.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.90
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$22.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$134.40
|
| Rate for Payer: GEHA Medicare |
$14.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Humana ChoiceCare |
$16.39
|
| Rate for Payer: Humana Medicare Advantage |
$14.90
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$25.03
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$18.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.90
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.33
|
| Rate for Payer: OMNI Networks Commercial |
$117.60
|
| Rate for Payer: One Health Plan PPO/POS |
$151.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$20.86
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$18.07
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.80
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.60
|
| Rate for Payer: United Healthcare Commercial |
$142.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$18.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.90
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.90
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Medicare |
$12.66
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.88
|
| Rate for Payer: Zelis Worker's Compensation |
$16.10
|
|
|
ETODOLAC (LODINE) CAP 200MG
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
NDC 51672401601
|
| Hospital Charge Code |
3302353
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$20.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$13.20
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$18.70
|
| Rate for Payer: First Health Commercial |
$19.80
|
| Rate for Payer: First Health Workers Compensation |
$8.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$19.80
|
| Rate for Payer: GEHA Commercial |
$17.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$19.80
|
| Rate for Payer: Humana ChoiceCare |
$5.72
|
| Rate for Payer: Multiplan All |
$20.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$13.20
|
| Rate for Payer: OMNI Networks Commercial |
$15.40
|
| Rate for Payer: One Health Plan PPO/POS |
$19.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$20.90
|
| Rate for Payer: Three Rivers Provider Network All |
$16.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$19.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$20.46
|
| Rate for Payer: Zelis Auto |
$8.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$11.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6.01
|
|
|
ETODOLAC (LODINE) CAP 200MG
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
NDC 51672401601
|
| Hospital Charge Code |
3302353
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.01 |
| Max. Negotiated Rate |
$20.90 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$18.70
|
| Rate for Payer: First Health Commercial |
$19.80
|
| Rate for Payer: First Health Workers Compensation |
$8.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$19.80
|
| Rate for Payer: GEHA Commercial |
$15.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$19.80
|
| Rate for Payer: Multiplan All |
$20.02
|
| Rate for Payer: OMNI Networks Commercial |
$15.40
|
| Rate for Payer: One Health Plan PPO/POS |
$19.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$20.90
|
| Rate for Payer: Three Rivers Provider Network All |
$16.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$20.46
|
| Rate for Payer: Zelis Auto |
$8.80
|
| Rate for Payer: Zelis Worker's Compensation |
$6.01
|
|
|
ETOMIDATE IV SOLN 2MG/ML-10ML VIAL
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
NDC 00143950601
|
| Hospital Charge Code |
3300316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$21.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$14.56
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$33.60
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$49.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$28.00
|
| Rate for Payer: Zelis Worker's Compensation |
$15.29
|
|
|
ETOMIDATE IV SOLN 2MG/ML-10ML VIAL
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
NDC 00143950601
|
| Hospital Charge Code |
3300316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$21.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Worker's Compensation |
$15.29
|
|
|
ETOMIDATE IV SOLN 2 MG/ ML 20 ML VIAL
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
NDC 55150022220
|
| Hospital Charge Code |
3302867
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$25.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
ETOMIDATE IV SOLN 2 MG/ ML 20 ML VIAL
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
NDC 55150022220
|
| Hospital Charge Code |
3302867
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.25 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22.20
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$29.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Humana ChoiceCare |
$9.62
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.20
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$32.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$18.50
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
eucalyptus, IgE REF602930
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2200817
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.22
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: GEHA Medicare |
$5.22
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.22
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.76
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.59
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.22
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10.44
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.12
|
| Rate for Payer: United Healthcare Commercial |
$47.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.22
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Medicare |
$4.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.26
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
eucalyptus, IgE REF602930
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2200817
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
EVACUATION SUBUNGUAL HEMATOMA
|
Facility
|
IP
|
$296.00
|
|
| Hospital Charge Code |
8150045
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$80.81 |
| Max. Negotiated Rate |
$281.20 |
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Cigna Commercial |
$251.60
|
| Rate for Payer: First Health Commercial |
$266.40
|
| Rate for Payer: First Health Workers Compensation |
$114.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$266.40
|
| Rate for Payer: GEHA Commercial |
$207.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$266.40
|
| Rate for Payer: Multiplan All |
$269.36
|
| Rate for Payer: OMNI Networks Commercial |
$207.20
|
| Rate for Payer: One Health Plan PPO/POS |
$266.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$281.20
|
| Rate for Payer: Three Rivers Provider Network All |
$222.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$275.28
|
| Rate for Payer: Zelis Auto |
$118.40
|
| Rate for Payer: Zelis Worker's Compensation |
$80.81
|
|
|
EVACUATION SUBUNGUAL HEMATOMA
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
CPT 11740
|
| Hospital Charge Code |
20300022
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$41.50 |
| Max. Negotiated Rate |
$244.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$78.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$91.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$78.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$62.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$122.40
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$129.20
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: First Health Workers Compensation |
$58.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$136.80
|
| Rate for Payer: GEHA Commercial |
$121.60
|
| Rate for Payer: GEHA Medicare |
$122.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$136.80
|
| Rate for Payer: Humana ChoiceCare |
$134.64
|
| Rate for Payer: Humana Medicare Advantage |
$122.40
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$205.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$63.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$122.40
|
| Rate for Payer: Multiplan All |
$138.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$208.08
|
| Rate for Payer: OMNI Networks Commercial |
$106.40
|
| Rate for Payer: One Health Plan PPO/POS |
$136.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$73.29
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$63.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$122.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$144.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$244.80
|
| Rate for Payer: Three Rivers Provider Network All |
$114.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$119.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$63.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.40
|
| Rate for Payer: United Payors & United Providers UP&UP |
$141.36
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$122.40
|
| Rate for Payer: Zelis Auto |
$60.80
|
| Rate for Payer: Zelis Medicare |
$104.04
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$146.88
|
| Rate for Payer: Zelis Worker's Compensation |
$41.50
|
|
|
EVACUATION SUBUNGUAL HEMATOMA
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
CPT 11740
|
| Hospital Charge Code |
8300016
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$41.50 |
| Max. Negotiated Rate |
$244.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$78.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$91.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$78.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$62.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$122.40
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$129.20
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: First Health Workers Compensation |
$58.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$136.80
|
| Rate for Payer: GEHA Commercial |
$121.60
|
| Rate for Payer: GEHA Medicare |
$122.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$136.80
|
| Rate for Payer: Humana ChoiceCare |
$134.64
|
| Rate for Payer: Humana Medicare Advantage |
$122.40
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$205.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$63.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$122.40
|
| Rate for Payer: Multiplan All |
$138.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$208.08
|
| Rate for Payer: OMNI Networks Commercial |
$106.40
|
| Rate for Payer: One Health Plan PPO/POS |
$136.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$73.29
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$63.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$122.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$144.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$244.80
|
| Rate for Payer: Three Rivers Provider Network All |
$114.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$119.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$63.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.40
|
| Rate for Payer: United Payors & United Providers UP&UP |
$141.36
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$122.40
|
| Rate for Payer: Zelis Auto |
$60.80
|
| Rate for Payer: Zelis Medicare |
$104.04
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$146.88
|
| Rate for Payer: Zelis Worker's Compensation |
$41.50
|
|
|
EVACUATION SUBUNGUAL HEMATOMA
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
CPT 11740
|
| Hospital Charge Code |
8300016
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$41.50 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$129.20
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: First Health Workers Compensation |
$58.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$136.80
|
| Rate for Payer: GEHA Commercial |
$106.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$136.80
|
| Rate for Payer: Multiplan All |
$138.32
|
| Rate for Payer: OMNI Networks Commercial |
$106.40
|
| Rate for Payer: One Health Plan PPO/POS |
$136.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$144.40
|
| Rate for Payer: Three Rivers Provider Network All |
$114.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$141.36
|
| Rate for Payer: Zelis Auto |
$60.80
|
| Rate for Payer: Zelis Worker's Compensation |
$41.50
|
|
|
EVACUATION SUBUNGUAL HEMATOMA
|
Facility
|
OP
|
$551.00
|
|
|
Service Code
|
CPT 11740
|
| Hospital Charge Code |
1900022
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$62.21 |
| Max. Negotiated Rate |
$523.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$78.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$330.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$78.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$62.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$122.40
|
| Rate for Payer: Cash Price |
$330.60
|
| Rate for Payer: Cash Price |
$330.60
|
| Rate for Payer: Cigna Commercial |
$468.35
|
| Rate for Payer: First Health Commercial |
$495.90
|
| Rate for Payer: First Health Workers Compensation |
$212.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$495.90
|
| Rate for Payer: GEHA Commercial |
$440.80
|
| Rate for Payer: GEHA Medicare |
$122.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$495.90
|
| Rate for Payer: Humana ChoiceCare |
$134.64
|
| Rate for Payer: Humana Medicare Advantage |
$122.40
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$205.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$63.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$122.40
|
| Rate for Payer: Multiplan All |
$501.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$208.08
|
| Rate for Payer: OMNI Networks Commercial |
$385.70
|
| Rate for Payer: One Health Plan PPO/POS |
$495.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$73.29
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$63.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$122.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$523.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$244.80
|
| Rate for Payer: Three Rivers Provider Network All |
$413.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$119.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$63.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.40
|
| Rate for Payer: United Payors & United Providers UP&UP |
$512.43
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$122.40
|
| Rate for Payer: Zelis Auto |
$220.40
|
| Rate for Payer: Zelis Medicare |
$104.04
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$146.88
|
| Rate for Payer: Zelis Worker's Compensation |
$150.42
|
|
|
EVACUATION SUBUNGUAL HEMATOMA
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
CPT 11740
|
| Hospital Charge Code |
20300022
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$41.50 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$129.20
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: First Health Workers Compensation |
$58.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$136.80
|
| Rate for Payer: GEHA Commercial |
$106.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$136.80
|
| Rate for Payer: Multiplan All |
$138.32
|
| Rate for Payer: OMNI Networks Commercial |
$106.40
|
| Rate for Payer: One Health Plan PPO/POS |
$136.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$144.40
|
| Rate for Payer: Three Rivers Provider Network All |
$114.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$141.36
|
| Rate for Payer: Zelis Auto |
$60.80
|
| Rate for Payer: Zelis Worker's Compensation |
$41.50
|
|
|
EVACUATION SUBUNGUAL HEMATOMA
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
CPT 11740
|
| Hospital Charge Code |
8711740
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$41.50 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$129.20
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: First Health Workers Compensation |
$58.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$136.80
|
| Rate for Payer: GEHA Commercial |
$106.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$136.80
|
| Rate for Payer: Multiplan All |
$138.32
|
| Rate for Payer: OMNI Networks Commercial |
$106.40
|
| Rate for Payer: One Health Plan PPO/POS |
$136.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$144.40
|
| Rate for Payer: Three Rivers Provider Network All |
$114.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$141.36
|
| Rate for Payer: Zelis Auto |
$60.80
|
| Rate for Payer: Zelis Worker's Compensation |
$41.50
|
|
|
EVACUATION SUBUNGUAL HEMATOMA
|
Facility
|
IP
|
$97.00
|
|
|
Service Code
|
CPT 11740
|
| Hospital Charge Code |
21600084
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$26.48 |
| Max. Negotiated Rate |
$92.15 |
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$82.45
|
| Rate for Payer: First Health Commercial |
$87.30
|
| Rate for Payer: First Health Workers Compensation |
$37.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$87.30
|
| Rate for Payer: GEHA Commercial |
$67.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$87.30
|
| Rate for Payer: Multiplan All |
$88.27
|
| Rate for Payer: OMNI Networks Commercial |
$67.90
|
| Rate for Payer: One Health Plan PPO/POS |
$87.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$92.15
|
| Rate for Payer: Three Rivers Provider Network All |
$72.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$90.21
|
| Rate for Payer: Zelis Auto |
$38.80
|
| Rate for Payer: Zelis Worker's Compensation |
$26.48
|
|
|
EVACUATION SUBUNGUAL HEMATOMA
|
Facility
|
OP
|
$156.21
|
|
|
Service Code
|
CPT 11740
|
| Hospital Charge Code |
7211740
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$42.65 |
| Max. Negotiated Rate |
$244.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$78.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$93.73
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$78.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$62.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$122.40
|
| Rate for Payer: Cash Price |
$93.73
|
| Rate for Payer: Cash Price |
$93.73
|
| Rate for Payer: Cigna Commercial |
$132.78
|
| Rate for Payer: First Health Commercial |
$140.59
|
| Rate for Payer: First Health Workers Compensation |
$60.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$140.59
|
| Rate for Payer: GEHA Commercial |
$124.97
|
| Rate for Payer: GEHA Medicare |
$122.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$140.59
|
| Rate for Payer: Humana ChoiceCare |
$134.64
|
| Rate for Payer: Humana Medicare Advantage |
$122.40
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$205.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$63.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$122.40
|
| Rate for Payer: Multiplan All |
$142.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$208.08
|
| Rate for Payer: OMNI Networks Commercial |
$109.35
|
| Rate for Payer: One Health Plan PPO/POS |
$140.59
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$73.29
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$63.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$122.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$148.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$244.80
|
| Rate for Payer: Three Rivers Provider Network All |
$117.16
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$119.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$63.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.40
|
| Rate for Payer: United Payors & United Providers UP&UP |
$145.28
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$122.40
|
| Rate for Payer: Zelis Auto |
$62.48
|
| Rate for Payer: Zelis Medicare |
$104.04
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$146.88
|
| Rate for Payer: Zelis Worker's Compensation |
$42.65
|
|
|
EVACUATION SUBUNGUAL HEMATOMA
|
Facility
|
OP
|
$543.00
|
|
|
Service Code
|
CPT 11740
|
| Hospital Charge Code |
9611740
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$62.21 |
| Max. Negotiated Rate |
$515.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$78.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$325.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$78.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$62.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$122.40
|
| Rate for Payer: Cash Price |
$325.80
|
| Rate for Payer: Cash Price |
$325.80
|
| Rate for Payer: Cigna Commercial |
$461.55
|
| Rate for Payer: First Health Commercial |
$488.70
|
| Rate for Payer: First Health Workers Compensation |
$209.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$488.70
|
| Rate for Payer: GEHA Commercial |
$434.40
|
| Rate for Payer: GEHA Medicare |
$122.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$488.70
|
| Rate for Payer: Humana ChoiceCare |
$134.64
|
| Rate for Payer: Humana Medicare Advantage |
$122.40
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$205.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$63.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$122.40
|
| Rate for Payer: Multiplan All |
$494.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$208.08
|
| Rate for Payer: OMNI Networks Commercial |
$380.10
|
| Rate for Payer: One Health Plan PPO/POS |
$488.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$73.29
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$63.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$122.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$515.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$244.80
|
| Rate for Payer: Three Rivers Provider Network All |
$407.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$119.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$63.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.40
|
| Rate for Payer: United Payors & United Providers UP&UP |
$504.99
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$122.40
|
| Rate for Payer: Zelis Auto |
$217.20
|
| Rate for Payer: Zelis Medicare |
$104.04
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$146.88
|
| Rate for Payer: Zelis Worker's Compensation |
$148.24
|
|
|
EVACUATION SUBUNGUAL HEMATOMA
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
CPT 11740
|
| Hospital Charge Code |
8711740
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$41.50 |
| Max. Negotiated Rate |
$244.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$78.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$91.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$78.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$62.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$122.40
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$129.20
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: First Health Workers Compensation |
$58.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$136.80
|
| Rate for Payer: GEHA Commercial |
$121.60
|
| Rate for Payer: GEHA Medicare |
$122.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$136.80
|
| Rate for Payer: Humana ChoiceCare |
$134.64
|
| Rate for Payer: Humana Medicare Advantage |
$122.40
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$205.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$63.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$122.40
|
| Rate for Payer: Multiplan All |
$138.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$208.08
|
| Rate for Payer: OMNI Networks Commercial |
$106.40
|
| Rate for Payer: One Health Plan PPO/POS |
$136.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$73.29
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$63.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$122.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$144.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$244.80
|
| Rate for Payer: Three Rivers Provider Network All |
$114.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$119.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$63.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.40
|
| Rate for Payer: United Payors & United Providers UP&UP |
$141.36
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$122.40
|
| Rate for Payer: Zelis Auto |
$60.80
|
| Rate for Payer: Zelis Medicare |
$104.04
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$146.88
|
| Rate for Payer: Zelis Worker's Compensation |
$41.50
|
|
|
EVACUATION SUBUNGUAL HEMATOMA
|
Facility
|
IP
|
$156.21
|
|
|
Service Code
|
CPT 11740
|
| Hospital Charge Code |
8511740
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$42.65 |
| Max. Negotiated Rate |
$148.40 |
| Rate for Payer: Cash Price |
$93.73
|
| Rate for Payer: Cigna Commercial |
$132.78
|
| Rate for Payer: First Health Commercial |
$140.59
|
| Rate for Payer: First Health Workers Compensation |
$60.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$140.59
|
| Rate for Payer: GEHA Commercial |
$109.35
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$140.59
|
| Rate for Payer: Multiplan All |
$142.15
|
| Rate for Payer: OMNI Networks Commercial |
$109.35
|
| Rate for Payer: One Health Plan PPO/POS |
$140.59
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$148.40
|
| Rate for Payer: Three Rivers Provider Network All |
$117.16
|
| Rate for Payer: United Payors & United Providers UP&UP |
$145.28
|
| Rate for Payer: Zelis Auto |
$62.48
|
| Rate for Payer: Zelis Worker's Compensation |
$42.65
|
|
