|
EYE DROPS - LUBRICANT
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 15718091730
|
| Hospital Charge Code |
3301737
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$4.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
EYE DROPS - LUBRICANT
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 15718091730
|
| Hospital Charge Code |
3301737
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Humana ChoiceCare |
$1.82
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.20
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
EYE WASH SOLUTION 120 ML
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300676
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.75 |
| Max. Negotiated Rate |
$37.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$33.15
|
| Rate for Payer: First Health Commercial |
$35.10
|
| Rate for Payer: First Health Workers Compensation |
$15.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$35.10
|
| Rate for Payer: GEHA Commercial |
$31.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$35.10
|
| Rate for Payer: Humana ChoiceCare |
$10.14
|
| Rate for Payer: Multiplan All |
$35.49
|
| Rate for Payer: New Mexico Health Connections Medicare |
$23.40
|
| Rate for Payer: OMNI Networks Commercial |
$27.30
|
| Rate for Payer: One Health Plan PPO/POS |
$35.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$37.05
|
| Rate for Payer: Three Rivers Provider Network All |
$29.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$34.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$36.27
|
| Rate for Payer: Zelis Auto |
$15.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$19.50
|
| Rate for Payer: Zelis Worker's Compensation |
$10.65
|
|
|
EYE WASH SOLUTION 120 ML
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300676
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.65 |
| Max. Negotiated Rate |
$37.05 |
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$33.15
|
| Rate for Payer: First Health Commercial |
$35.10
|
| Rate for Payer: First Health Workers Compensation |
$15.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$35.10
|
| Rate for Payer: GEHA Commercial |
$27.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$35.10
|
| Rate for Payer: Multiplan All |
$35.49
|
| Rate for Payer: OMNI Networks Commercial |
$27.30
|
| Rate for Payer: One Health Plan PPO/POS |
$35.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$37.05
|
| Rate for Payer: Three Rivers Provider Network All |
$29.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$36.27
|
| Rate for Payer: Zelis Auto |
$15.60
|
| Rate for Payer: Zelis Worker's Compensation |
$10.65
|
|
|
EZETIMIBE 10MG TAB
|
Facility
|
IP
|
$44.00
|
|
|
Service Code
|
NDC 50268029812
|
| Hospital Charge Code |
3300317
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.01 |
| Max. Negotiated Rate |
$41.80 |
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$37.40
|
| Rate for Payer: First Health Commercial |
$39.60
|
| Rate for Payer: First Health Workers Compensation |
$16.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$39.60
|
| Rate for Payer: GEHA Commercial |
$30.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$39.60
|
| Rate for Payer: Multiplan All |
$40.04
|
| Rate for Payer: OMNI Networks Commercial |
$30.80
|
| Rate for Payer: One Health Plan PPO/POS |
$39.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$41.80
|
| Rate for Payer: Three Rivers Provider Network All |
$33.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$40.92
|
| Rate for Payer: Zelis Auto |
$17.60
|
| Rate for Payer: Zelis Worker's Compensation |
$12.01
|
|
|
EZETIMIBE 10MG TAB
|
Facility
|
OP
|
$44.00
|
|
|
Service Code
|
NDC 50268029812
|
| Hospital Charge Code |
3300317
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$41.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$37.40
|
| Rate for Payer: First Health Commercial |
$39.60
|
| Rate for Payer: First Health Workers Compensation |
$16.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$39.60
|
| Rate for Payer: GEHA Commercial |
$35.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$39.60
|
| Rate for Payer: Humana ChoiceCare |
$11.44
|
| Rate for Payer: Multiplan All |
$40.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$26.40
|
| Rate for Payer: OMNI Networks Commercial |
$30.80
|
| Rate for Payer: One Health Plan PPO/POS |
$39.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$41.80
|
| Rate for Payer: Three Rivers Provider Network All |
$33.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$38.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$40.92
|
| Rate for Payer: Zelis Auto |
$17.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.01
|
|
|
FACE BONE GRAFT
|
Facility
|
OP
|
$2,588.00
|
|
|
Service Code
|
CPT 21210
|
| Hospital Charge Code |
6121210
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$706.52 |
| Max. Negotiated Rate |
$11,234.32 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$4,345.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,552.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$4,345.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3,442.85
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5,617.16
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cigna Commercial |
$2,199.80
|
| Rate for Payer: First Health Commercial |
$2,329.20
|
| Rate for Payer: First Health Workers Compensation |
$999.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,329.20
|
| Rate for Payer: GEHA Commercial |
$2,070.40
|
| Rate for Payer: GEHA Medicare |
$5,617.16
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,329.20
|
| Rate for Payer: Humana ChoiceCare |
$6,178.88
|
| Rate for Payer: Humana Medicare Advantage |
$5,617.16
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$9,436.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,512.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5,617.16
|
| Rate for Payer: Multiplan All |
$2,355.08
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9,549.17
|
| Rate for Payer: OMNI Networks Commercial |
$1,811.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,329.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$4,056.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3,512.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5,617.16
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,458.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11,234.32
|
| Rate for Payer: Three Rivers Provider Network All |
$1,941.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,504.82
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,512.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,617.16
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,406.84
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5,617.16
|
| Rate for Payer: Zelis Auto |
$1,035.20
|
| Rate for Payer: Zelis Medicare |
$4,774.59
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,740.59
|
| Rate for Payer: Zelis Worker's Compensation |
$706.52
|
|
|
FACE BONE GRAFT
|
Facility
|
IP
|
$2,588.00
|
|
|
Service Code
|
CPT 21210
|
| Hospital Charge Code |
6121210
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$706.52 |
| Max. Negotiated Rate |
$2,458.60 |
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cigna Commercial |
$2,199.80
|
| Rate for Payer: First Health Commercial |
$2,329.20
|
| Rate for Payer: First Health Workers Compensation |
$999.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,329.20
|
| Rate for Payer: GEHA Commercial |
$1,811.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,329.20
|
| Rate for Payer: Multiplan All |
$2,355.08
|
| Rate for Payer: OMNI Networks Commercial |
$1,811.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,329.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,458.60
|
| Rate for Payer: Three Rivers Provider Network All |
$1,941.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,406.84
|
| Rate for Payer: Zelis Auto |
$1,035.20
|
| Rate for Payer: Zelis Worker's Compensation |
$706.52
|
|
|
factor ii (prothrombin) dna REF511162
|
Facility
|
IP
|
$396.00
|
|
|
Service Code
|
CPT 81240
|
| Hospital Charge Code |
2299302
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$52.53 |
| Max. Negotiated Rate |
$376.20 |
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$336.60
|
| Rate for Payer: First Health Commercial |
$356.40
|
| Rate for Payer: First Health Workers Compensation |
$74.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$356.40
|
| Rate for Payer: GEHA Commercial |
$277.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$356.40
|
| Rate for Payer: Multiplan All |
$360.36
|
| Rate for Payer: OMNI Networks Commercial |
$277.20
|
| Rate for Payer: One Health Plan PPO/POS |
$356.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$376.20
|
| Rate for Payer: Three Rivers Provider Network All |
$297.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$368.28
|
| Rate for Payer: Zelis Auto |
$158.40
|
| Rate for Payer: Zelis Worker's Compensation |
$52.53
|
|
|
factor ii (prothrombin) dna REF511162
|
Facility
|
OP
|
$396.00
|
|
|
Service Code
|
CPT 81240
|
| Hospital Charge Code |
2299302
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$52.53 |
| Max. Negotiated Rate |
$376.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$118.25
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$237.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$118.25
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$93.67
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$65.69
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$336.60
|
| Rate for Payer: First Health Commercial |
$356.40
|
| Rate for Payer: First Health Workers Compensation |
$74.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$356.40
|
| Rate for Payer: GEHA Commercial |
$316.80
|
| Rate for Payer: GEHA Medicare |
$65.69
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$356.40
|
| Rate for Payer: Humana ChoiceCare |
$72.26
|
| Rate for Payer: Humana Medicare Advantage |
$65.69
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$110.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$95.58
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$65.69
|
| Rate for Payer: Multiplan All |
$360.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$111.67
|
| Rate for Payer: OMNI Networks Commercial |
$277.20
|
| Rate for Payer: One Health Plan PPO/POS |
$356.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$110.36
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$95.58
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$65.69
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$376.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$131.38
|
| Rate for Payer: Three Rivers Provider Network All |
$297.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$64.38
|
| Rate for Payer: United Healthcare Commercial |
$336.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$95.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$65.69
|
| Rate for Payer: United Payors & United Providers UP&UP |
$368.28
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$65.69
|
| Rate for Payer: Zelis Auto |
$158.40
|
| Rate for Payer: Zelis Medicare |
$55.84
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$78.83
|
| Rate for Payer: Zelis Worker's Compensation |
$52.53
|
|
|
factor ix activity REF086298
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT 85250
|
| Hospital Charge Code |
2200215
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.18 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$34.27
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$34.27
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$27.15
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$19.04
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$34.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$174.40
|
| Rate for Payer: GEHA Medicare |
$19.04
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Humana ChoiceCare |
$20.94
|
| Rate for Payer: Humana Medicare Advantage |
$19.04
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$31.99
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$27.71
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$19.04
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$32.37
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$31.99
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$27.71
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$19.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$38.08
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.66
|
| Rate for Payer: United Healthcare Commercial |
$185.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$27.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$19.04
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Medicare |
$16.18
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.85
|
| Rate for Payer: Zelis Worker's Compensation |
$24.38
|
|
|
factor ix activity REF086298
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT 85250
|
| Hospital Charge Code |
2200215
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.38 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$34.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$152.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Worker's Compensation |
$24.38
|
|
|
factor vii activity REF800599
|
Facility
|
OP
|
$371.00
|
|
|
Service Code
|
CPT 85230
|
| Hospital Charge Code |
2200728
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.21 |
| Max. Negotiated Rate |
$352.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$32.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$222.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$32.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$25.52
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$17.90
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cigna Commercial |
$315.35
|
| Rate for Payer: First Health Commercial |
$333.90
|
| Rate for Payer: First Health Workers Compensation |
$33.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$333.90
|
| Rate for Payer: GEHA Commercial |
$296.80
|
| Rate for Payer: GEHA Medicare |
$17.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$333.90
|
| Rate for Payer: Humana ChoiceCare |
$19.69
|
| Rate for Payer: Humana Medicare Advantage |
$17.90
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$30.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$26.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$17.90
|
| Rate for Payer: Multiplan All |
$337.61
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.43
|
| Rate for Payer: OMNI Networks Commercial |
$259.70
|
| Rate for Payer: One Health Plan PPO/POS |
$333.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$30.07
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$26.04
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$17.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$352.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$35.80
|
| Rate for Payer: Three Rivers Provider Network All |
$278.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17.54
|
| Rate for Payer: United Healthcare Commercial |
$315.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.90
|
| Rate for Payer: United Payors & United Providers UP&UP |
$345.03
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$17.90
|
| Rate for Payer: Zelis Auto |
$148.40
|
| Rate for Payer: Zelis Medicare |
$15.21
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.48
|
| Rate for Payer: Zelis Worker's Compensation |
$23.39
|
|
|
factor vii activity REF800599
|
Facility
|
IP
|
$371.00
|
|
|
Service Code
|
CPT 85230
|
| Hospital Charge Code |
2200728
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.39 |
| Max. Negotiated Rate |
$352.45 |
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cigna Commercial |
$315.35
|
| Rate for Payer: First Health Commercial |
$333.90
|
| Rate for Payer: First Health Workers Compensation |
$33.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$333.90
|
| Rate for Payer: GEHA Commercial |
$259.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$333.90
|
| Rate for Payer: Multiplan All |
$337.61
|
| Rate for Payer: OMNI Networks Commercial |
$259.70
|
| Rate for Payer: One Health Plan PPO/POS |
$333.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$352.45
|
| Rate for Payer: Three Rivers Provider Network All |
$278.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$345.03
|
| Rate for Payer: Zelis Auto |
$148.40
|
| Rate for Payer: Zelis Worker's Compensation |
$23.39
|
|
|
factor viii activity REF086264
|
Facility
|
IP
|
$295.00
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
2299406
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$23.64 |
| Max. Negotiated Rate |
$280.25 |
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$250.75
|
| Rate for Payer: First Health Commercial |
$265.50
|
| Rate for Payer: First Health Workers Compensation |
$33.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$265.50
|
| Rate for Payer: GEHA Commercial |
$206.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$265.50
|
| Rate for Payer: Multiplan All |
$268.45
|
| Rate for Payer: OMNI Networks Commercial |
$206.50
|
| Rate for Payer: One Health Plan PPO/POS |
$265.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$280.25
|
| Rate for Payer: Three Rivers Provider Network All |
$221.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$274.35
|
| Rate for Payer: Zelis Auto |
$118.00
|
| Rate for Payer: Zelis Worker's Compensation |
$23.64
|
|
|
factor viii activity REF086264
|
Facility
|
OP
|
$295.00
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
2299406
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$15.21 |
| Max. Negotiated Rate |
$280.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$32.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$177.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$32.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$25.52
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$17.90
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$250.75
|
| Rate for Payer: First Health Commercial |
$265.50
|
| Rate for Payer: First Health Workers Compensation |
$33.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$265.50
|
| Rate for Payer: GEHA Commercial |
$236.00
|
| Rate for Payer: GEHA Medicare |
$17.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$265.50
|
| Rate for Payer: Humana ChoiceCare |
$19.69
|
| Rate for Payer: Humana Medicare Advantage |
$17.90
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$30.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$26.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$17.90
|
| Rate for Payer: Multiplan All |
$268.45
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.43
|
| Rate for Payer: OMNI Networks Commercial |
$206.50
|
| Rate for Payer: One Health Plan PPO/POS |
$265.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$30.07
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$26.04
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$17.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$280.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$35.80
|
| Rate for Payer: Three Rivers Provider Network All |
$221.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17.54
|
| Rate for Payer: United Healthcare Commercial |
$250.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.90
|
| Rate for Payer: United Payors & United Providers UP&UP |
$274.35
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$17.90
|
| Rate for Payer: Zelis Auto |
$118.00
|
| Rate for Payer: Zelis Medicare |
$15.21
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.48
|
| Rate for Payer: Zelis Worker's Compensation |
$23.64
|
|
|
factor v leiden REF 500586
|
Facility
|
OP
|
$396.00
|
|
|
Service Code
|
CPT 81241
|
| Hospital Charge Code |
2299189
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$62.36 |
| Max. Negotiated Rate |
$376.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$132.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$237.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$132.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$104.63
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$73.37
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$336.60
|
| Rate for Payer: First Health Commercial |
$356.40
|
| Rate for Payer: First Health Workers Compensation |
$91.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$356.40
|
| Rate for Payer: GEHA Commercial |
$316.80
|
| Rate for Payer: GEHA Medicare |
$73.37
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$356.40
|
| Rate for Payer: Humana ChoiceCare |
$80.71
|
| Rate for Payer: Humana Medicare Advantage |
$73.37
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$123.26
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$106.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$73.37
|
| Rate for Payer: Multiplan All |
$360.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$124.73
|
| Rate for Payer: OMNI Networks Commercial |
$277.20
|
| Rate for Payer: One Health Plan PPO/POS |
$356.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$123.27
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$106.76
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$73.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$376.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$146.74
|
| Rate for Payer: Three Rivers Provider Network All |
$297.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$71.90
|
| Rate for Payer: United Healthcare Commercial |
$336.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$106.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$73.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$368.28
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$73.37
|
| Rate for Payer: Zelis Auto |
$158.40
|
| Rate for Payer: Zelis Medicare |
$62.36
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$88.04
|
| Rate for Payer: Zelis Worker's Compensation |
$64.83
|
|
|
factor v leiden REF 500586
|
Facility
|
IP
|
$396.00
|
|
|
Service Code
|
CPT 81241
|
| Hospital Charge Code |
2299189
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$64.83 |
| Max. Negotiated Rate |
$376.20 |
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$336.60
|
| Rate for Payer: First Health Commercial |
$356.40
|
| Rate for Payer: First Health Workers Compensation |
$91.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$356.40
|
| Rate for Payer: GEHA Commercial |
$277.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$356.40
|
| Rate for Payer: Multiplan All |
$360.36
|
| Rate for Payer: OMNI Networks Commercial |
$277.20
|
| Rate for Payer: One Health Plan PPO/POS |
$356.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$376.20
|
| Rate for Payer: Three Rivers Provider Network All |
$297.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$368.28
|
| Rate for Payer: Zelis Auto |
$158.40
|
| Rate for Payer: Zelis Worker's Compensation |
$64.83
|
|
|
factor xi activity REF086314
|
Facility
|
IP
|
$371.00
|
|
|
Service Code
|
CPT 85230
|
| Hospital Charge Code |
2299306
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.39 |
| Max. Negotiated Rate |
$352.45 |
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cigna Commercial |
$315.35
|
| Rate for Payer: First Health Commercial |
$333.90
|
| Rate for Payer: First Health Workers Compensation |
$33.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$333.90
|
| Rate for Payer: GEHA Commercial |
$259.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$333.90
|
| Rate for Payer: Multiplan All |
$337.61
|
| Rate for Payer: OMNI Networks Commercial |
$259.70
|
| Rate for Payer: One Health Plan PPO/POS |
$333.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$352.45
|
| Rate for Payer: Three Rivers Provider Network All |
$278.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$345.03
|
| Rate for Payer: Zelis Auto |
$148.40
|
| Rate for Payer: Zelis Worker's Compensation |
$23.39
|
|
|
factor xi activity REF086314
|
Facility
|
OP
|
$371.00
|
|
|
Service Code
|
CPT 85230
|
| Hospital Charge Code |
2299306
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.21 |
| Max. Negotiated Rate |
$352.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$32.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$222.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$32.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$25.52
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$17.90
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cigna Commercial |
$315.35
|
| Rate for Payer: First Health Commercial |
$333.90
|
| Rate for Payer: First Health Workers Compensation |
$33.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$333.90
|
| Rate for Payer: GEHA Commercial |
$296.80
|
| Rate for Payer: GEHA Medicare |
$17.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$333.90
|
| Rate for Payer: Humana ChoiceCare |
$19.69
|
| Rate for Payer: Humana Medicare Advantage |
$17.90
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$30.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$26.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$17.90
|
| Rate for Payer: Multiplan All |
$337.61
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.43
|
| Rate for Payer: OMNI Networks Commercial |
$259.70
|
| Rate for Payer: One Health Plan PPO/POS |
$333.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$30.07
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$26.04
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$17.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$352.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$35.80
|
| Rate for Payer: Three Rivers Provider Network All |
$278.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17.54
|
| Rate for Payer: United Healthcare Commercial |
$315.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.90
|
| Rate for Payer: United Payors & United Providers UP&UP |
$345.03
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$17.90
|
| Rate for Payer: Zelis Auto |
$148.40
|
| Rate for Payer: Zelis Medicare |
$15.21
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.48
|
| Rate for Payer: Zelis Worker's Compensation |
$23.39
|
|
|
FALOPE RING TUBAL KIT
|
Facility
|
OP
|
$900.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006714
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$855.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$540.00
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cigna Commercial |
$765.00
|
| Rate for Payer: First Health Commercial |
$810.00
|
| Rate for Payer: First Health Workers Compensation |
$347.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$810.00
|
| Rate for Payer: GEHA Commercial |
$720.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$810.00
|
| Rate for Payer: Humana ChoiceCare |
$234.00
|
| Rate for Payer: Multiplan All |
$819.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$540.00
|
| Rate for Payer: OMNI Networks Commercial |
$630.00
|
| Rate for Payer: One Health Plan PPO/POS |
$810.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$855.00
|
| Rate for Payer: Three Rivers Provider Network All |
$675.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$792.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$225.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$837.00
|
| Rate for Payer: Zelis Auto |
$360.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$450.00
|
| Rate for Payer: Zelis Worker's Compensation |
$245.70
|
|
|
FALOPE RING TUBAL KIT
|
Facility
|
IP
|
$900.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006714
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$245.70 |
| Max. Negotiated Rate |
$855.00 |
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cigna Commercial |
$765.00
|
| Rate for Payer: First Health Commercial |
$810.00
|
| Rate for Payer: First Health Workers Compensation |
$347.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$810.00
|
| Rate for Payer: GEHA Commercial |
$630.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$810.00
|
| Rate for Payer: Multiplan All |
$819.00
|
| Rate for Payer: OMNI Networks Commercial |
$630.00
|
| Rate for Payer: One Health Plan PPO/POS |
$810.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$855.00
|
| Rate for Payer: Three Rivers Provider Network All |
$675.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$837.00
|
| Rate for Payer: Zelis Auto |
$360.00
|
| Rate for Payer: Zelis Worker's Compensation |
$245.70
|
|
|
FAMILY ADAPT BHV TX GDN PHYS/QHP EA 15 M
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 97156
|
| Hospital Charge Code |
4397925
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$27.30 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$85.00
|
| Rate for Payer: First Health Commercial |
$90.00
|
| Rate for Payer: First Health Workers Compensation |
$38.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$90.00
|
| Rate for Payer: GEHA Commercial |
$70.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$90.00
|
| Rate for Payer: Multiplan All |
$91.00
|
| Rate for Payer: OMNI Networks Commercial |
$70.00
|
| Rate for Payer: One Health Plan PPO/POS |
$90.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$95.00
|
| Rate for Payer: Three Rivers Provider Network All |
$75.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$93.00
|
| Rate for Payer: Zelis Auto |
$40.00
|
| Rate for Payer: Zelis Worker's Compensation |
$27.30
|
|
|
FAMILY ADAPT BHV TX GDN PHYS/QHP EA 15 M
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 97156
|
| Hospital Charge Code |
4397925
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$15.88 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$60.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$28.29
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$85.00
|
| Rate for Payer: First Health Commercial |
$90.00
|
| Rate for Payer: First Health Workers Compensation |
$22.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$90.00
|
| Rate for Payer: GEHA Commercial |
$80.00
|
| Rate for Payer: GEHA Medicare |
$28.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$90.00
|
| Rate for Payer: Humana ChoiceCare |
$31.12
|
| Rate for Payer: Humana Medicare Advantage |
$28.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$47.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$28.29
|
| Rate for Payer: Multiplan All |
$91.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$48.09
|
| Rate for Payer: OMNI Networks Commercial |
$70.00
|
| Rate for Payer: One Health Plan PPO/POS |
$90.00
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$28.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$95.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$56.58
|
| Rate for Payer: Three Rivers Provider Network All |
$75.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$27.72
|
| Rate for Payer: United Healthcare Commercial |
$85.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$25.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$93.00
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$28.29
|
| Rate for Payer: Zelis Auto |
$40.00
|
| Rate for Payer: Zelis Medicare |
$24.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.95
|
| Rate for Payer: Zelis Worker's Compensation |
$15.88
|
|
|
FAMILY PSYCHOTHERAPY W/O PATIENT PRESENT
|
Facility
|
OP
|
$333.00
|
|
|
Service Code
|
CPT 90846
|
| Hospital Charge Code |
8499235
|
|
Hospital Revenue Code
|
513
|
| Min. Negotiated Rate |
$80.00 |
| Max. Negotiated Rate |
$316.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$223.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$199.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$223.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$177.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$152.56
|
| Rate for Payer: Cash Price |
$199.80
|
| Rate for Payer: Cash Price |
$199.80
|
| Rate for Payer: Cash Price |
$199.80
|
| Rate for Payer: Cigna Commercial |
$283.05
|
| Rate for Payer: First Health Commercial |
$299.70
|
| Rate for Payer: First Health Workers Compensation |
$128.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$299.70
|
| Rate for Payer: GEHA Commercial |
$266.40
|
| Rate for Payer: GEHA Medicare |
$152.56
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$299.70
|
| Rate for Payer: Humana ChoiceCare |
$167.82
|
| Rate for Payer: Humana Medicare Advantage |
$152.56
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$256.30
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$180.65
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$152.56
|
| Rate for Payer: Multiplan All |
$303.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$259.35
|
| Rate for Payer: OMNI Networks Commercial |
$233.10
|
| Rate for Payer: One Health Plan PPO/POS |
$299.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$208.59
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$80.00
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$152.56
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$316.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$305.12
|
| Rate for Payer: Three Rivers Provider Network All |
$249.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$149.51
|
| Rate for Payer: United Healthcare Managed Medicaid |
$180.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$152.56
|
| Rate for Payer: United Payors & United Providers UP&UP |
$309.69
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$152.56
|
| Rate for Payer: Zelis Auto |
$133.20
|
| Rate for Payer: Zelis Medicare |
$129.68
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$183.07
|
| Rate for Payer: Zelis Worker's Compensation |
$90.91
|
|
