|
FL IVP
|
Facility
|
OP
|
$1,543.00
|
|
|
Service Code
|
CPT 74400
|
| Hospital Charge Code |
2400090
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$115.93 |
| Max. Negotiated Rate |
$1,465.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$257.43
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$925.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$257.43
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$203.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$169.04
|
| Rate for Payer: Cash Price |
$925.80
|
| Rate for Payer: Cash Price |
$925.80
|
| Rate for Payer: Cigna Commercial |
$1,311.55
|
| Rate for Payer: First Health Commercial |
$1,388.70
|
| Rate for Payer: First Health Workers Compensation |
$163.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,388.70
|
| Rate for Payer: GEHA Commercial |
$1,234.40
|
| Rate for Payer: GEHA Medicare |
$169.04
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,388.70
|
| Rate for Payer: Humana ChoiceCare |
$185.94
|
| Rate for Payer: Humana Medicare Advantage |
$169.04
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$283.99
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$208.09
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$169.04
|
| Rate for Payer: Multiplan All |
$1,404.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$287.37
|
| Rate for Payer: OMNI Networks Commercial |
$1,080.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,388.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$240.27
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$208.09
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$169.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,465.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$338.08
|
| Rate for Payer: Three Rivers Provider Network All |
$1,157.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$165.66
|
| Rate for Payer: United Healthcare Commercial |
$1,311.55
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$169.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,434.99
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$169.04
|
| Rate for Payer: Zelis Auto |
$617.20
|
| Rate for Payer: Zelis Medicare |
$143.68
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$202.85
|
| Rate for Payer: Zelis Worker's Compensation |
$115.93
|
|
|
FL IVP
|
Facility
|
IP
|
$1,543.00
|
|
|
Service Code
|
CPT 74400
|
| Hospital Charge Code |
2400090
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$115.93 |
| Max. Negotiated Rate |
$1,465.85 |
| Rate for Payer: Cash Price |
$925.80
|
| Rate for Payer: Cash Price |
$925.80
|
| Rate for Payer: Cigna Commercial |
$1,311.55
|
| Rate for Payer: First Health Commercial |
$1,388.70
|
| Rate for Payer: First Health Workers Compensation |
$163.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,388.70
|
| Rate for Payer: GEHA Commercial |
$1,080.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,388.70
|
| Rate for Payer: Multiplan All |
$1,404.13
|
| Rate for Payer: OMNI Networks Commercial |
$1,080.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,388.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,465.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,157.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,434.99
|
| Rate for Payer: Zelis Auto |
$617.20
|
| Rate for Payer: Zelis Worker's Compensation |
$115.93
|
|
|
FL MOD BARIUM SWALLOW
|
Facility
|
IP
|
$967.00
|
|
|
Service Code
|
CPT 74230
|
| Hospital Charge Code |
2406509
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$112.12 |
| Max. Negotiated Rate |
$918.65 |
| Rate for Payer: Cash Price |
$580.20
|
| Rate for Payer: Cash Price |
$580.20
|
| Rate for Payer: Cigna Commercial |
$821.95
|
| Rate for Payer: First Health Commercial |
$870.30
|
| Rate for Payer: First Health Workers Compensation |
$158.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$870.30
|
| Rate for Payer: GEHA Commercial |
$676.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$870.30
|
| Rate for Payer: Multiplan All |
$879.97
|
| Rate for Payer: OMNI Networks Commercial |
$676.90
|
| Rate for Payer: One Health Plan PPO/POS |
$870.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$918.65
|
| Rate for Payer: Three Rivers Provider Network All |
$725.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$899.31
|
| Rate for Payer: Zelis Auto |
$386.80
|
| Rate for Payer: Zelis Worker's Compensation |
$112.12
|
|
|
FL MOD BARIUM SWALLOW
|
Facility
|
OP
|
$967.00
|
|
|
Service Code
|
CPT 74230
|
| Hospital Charge Code |
2406509
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$104.01 |
| Max. Negotiated Rate |
$918.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$131.29
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$580.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$131.29
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$104.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$169.04
|
| Rate for Payer: Cash Price |
$580.20
|
| Rate for Payer: Cash Price |
$580.20
|
| Rate for Payer: Cigna Commercial |
$821.95
|
| Rate for Payer: First Health Commercial |
$870.30
|
| Rate for Payer: First Health Workers Compensation |
$158.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$870.30
|
| Rate for Payer: GEHA Commercial |
$773.60
|
| Rate for Payer: GEHA Medicare |
$169.04
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$870.30
|
| Rate for Payer: Humana ChoiceCare |
$185.94
|
| Rate for Payer: Humana Medicare Advantage |
$169.04
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$283.99
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$106.13
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$169.04
|
| Rate for Payer: Multiplan All |
$879.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$287.37
|
| Rate for Payer: OMNI Networks Commercial |
$676.90
|
| Rate for Payer: One Health Plan PPO/POS |
$870.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$122.54
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$106.13
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$169.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$918.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$338.08
|
| Rate for Payer: Three Rivers Provider Network All |
$725.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$165.66
|
| Rate for Payer: United Healthcare Commercial |
$821.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$106.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$169.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$899.31
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$169.04
|
| Rate for Payer: Zelis Auto |
$386.80
|
| Rate for Payer: Zelis Medicare |
$143.68
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$202.85
|
| Rate for Payer: Zelis Worker's Compensation |
$112.12
|
|
|
FLOVENT 220MCG INHALER
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
NDC 00173072020
|
| Hospital Charge Code |
3305014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$385.50 |
| Max. Negotiated Rate |
$1,464.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$925.20
|
| Rate for Payer: Cash Price |
$925.20
|
| Rate for Payer: Cigna Commercial |
$1,310.70
|
| Rate for Payer: First Health Commercial |
$1,387.80
|
| Rate for Payer: First Health Workers Compensation |
$595.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,387.80
|
| Rate for Payer: GEHA Commercial |
$1,233.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,387.80
|
| Rate for Payer: Humana ChoiceCare |
$400.92
|
| Rate for Payer: Multiplan All |
$1,403.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$925.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,079.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,387.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,464.90
|
| Rate for Payer: Three Rivers Provider Network All |
$1,156.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,356.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$385.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,434.06
|
| Rate for Payer: Zelis Auto |
$616.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$771.00
|
| Rate for Payer: Zelis Worker's Compensation |
$420.97
|
|
|
FLOVENT 220MCG INHALER
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
NDC 00173072020
|
| Hospital Charge Code |
3305014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$420.97 |
| Max. Negotiated Rate |
$1,464.90 |
| Rate for Payer: Cash Price |
$925.20
|
| Rate for Payer: Cigna Commercial |
$1,310.70
|
| Rate for Payer: First Health Commercial |
$1,387.80
|
| Rate for Payer: First Health Workers Compensation |
$595.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,387.80
|
| Rate for Payer: GEHA Commercial |
$1,079.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,387.80
|
| Rate for Payer: Multiplan All |
$1,403.22
|
| Rate for Payer: OMNI Networks Commercial |
$1,079.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,387.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,464.90
|
| Rate for Payer: Three Rivers Provider Network All |
$1,156.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,434.06
|
| Rate for Payer: Zelis Auto |
$616.80
|
| Rate for Payer: Zelis Worker's Compensation |
$420.97
|
|
|
FLOW CYTOMETRY CELL SURF MARKER TECHL ON
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
CPT 88185
|
| Hospital Charge Code |
22990950
|
|
Hospital Revenue Code
|
311
|
| Min. Negotiated Rate |
$30.94 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$39.06
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$84.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$39.06
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$30.94
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$119.00
|
| Rate for Payer: First Health Commercial |
$126.00
|
| Rate for Payer: First Health Workers Compensation |
$47.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$126.00
|
| Rate for Payer: GEHA Commercial |
$112.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$126.00
|
| Rate for Payer: Humana ChoiceCare |
$36.40
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$31.57
|
| Rate for Payer: Multiplan All |
$127.40
|
| Rate for Payer: New Mexico Health Connections Medicare |
$84.00
|
| Rate for Payer: OMNI Networks Commercial |
$98.00
|
| Rate for Payer: One Health Plan PPO/POS |
$126.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$36.46
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$31.57
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$133.00
|
| Rate for Payer: Three Rivers Provider Network All |
$105.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$123.20
|
| Rate for Payer: United Healthcare Commercial |
$119.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.57
|
| Rate for Payer: United Payors & United Providers UP&UP |
$130.20
|
| Rate for Payer: Zelis Auto |
$56.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$70.00
|
| Rate for Payer: Zelis Worker's Compensation |
$33.73
|
|
|
FLOW CYTOMETRY CELL SURF MARKER TECHL ON
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
CPT 88185
|
| Hospital Charge Code |
22990950
|
|
Hospital Revenue Code
|
311
|
| Min. Negotiated Rate |
$33.73 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$119.00
|
| Rate for Payer: First Health Commercial |
$126.00
|
| Rate for Payer: First Health Workers Compensation |
$47.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$126.00
|
| Rate for Payer: GEHA Commercial |
$98.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$126.00
|
| Rate for Payer: Multiplan All |
$127.40
|
| Rate for Payer: OMNI Networks Commercial |
$98.00
|
| Rate for Payer: One Health Plan PPO/POS |
$126.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$133.00
|
| Rate for Payer: Three Rivers Provider Network All |
$105.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$130.20
|
| Rate for Payer: Zelis Auto |
$56.00
|
| Rate for Payer: Zelis Worker's Compensation |
$33.73
|
|
|
FLOW CYTOMETRY /TC 1 MARKER
|
Facility
|
OP
|
$292.00
|
|
|
Service Code
|
CPT 88184
|
| Hospital Charge Code |
22990952
|
|
Hospital Revenue Code
|
311
|
| Min. Negotiated Rate |
$64.28 |
| Max. Negotiated Rate |
$683.14 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$122.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$175.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$122.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$97.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$341.57
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cigna Commercial |
$248.20
|
| Rate for Payer: First Health Commercial |
$262.80
|
| Rate for Payer: First Health Workers Compensation |
$90.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$262.80
|
| Rate for Payer: GEHA Commercial |
$233.60
|
| Rate for Payer: GEHA Medicare |
$341.57
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$262.80
|
| Rate for Payer: Humana ChoiceCare |
$375.73
|
| Rate for Payer: Humana Medicare Advantage |
$341.57
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$573.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$98.99
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$341.57
|
| Rate for Payer: Multiplan All |
$265.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$580.67
|
| Rate for Payer: OMNI Networks Commercial |
$204.40
|
| Rate for Payer: One Health Plan PPO/POS |
$262.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$114.30
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$98.99
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$341.57
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$277.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$683.14
|
| Rate for Payer: Three Rivers Provider Network All |
$219.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$334.74
|
| Rate for Payer: United Healthcare Commercial |
$248.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$98.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$341.57
|
| Rate for Payer: United Payors & United Providers UP&UP |
$271.56
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$341.57
|
| Rate for Payer: Zelis Auto |
$116.80
|
| Rate for Payer: Zelis Medicare |
$290.33
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$409.88
|
| Rate for Payer: Zelis Worker's Compensation |
$64.28
|
|
|
FLOW CYTOMETRY /TC 1 MARKER
|
Facility
|
IP
|
$292.00
|
|
|
Service Code
|
CPT 88184
|
| Hospital Charge Code |
22990952
|
|
Hospital Revenue Code
|
311
|
| Min. Negotiated Rate |
$64.28 |
| Max. Negotiated Rate |
$277.40 |
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cigna Commercial |
$248.20
|
| Rate for Payer: First Health Commercial |
$262.80
|
| Rate for Payer: First Health Workers Compensation |
$90.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$262.80
|
| Rate for Payer: GEHA Commercial |
$204.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$262.80
|
| Rate for Payer: Multiplan All |
$265.72
|
| Rate for Payer: OMNI Networks Commercial |
$204.40
|
| Rate for Payer: One Health Plan PPO/POS |
$262.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$277.40
|
| Rate for Payer: Three Rivers Provider Network All |
$219.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$271.56
|
| Rate for Payer: Zelis Auto |
$116.80
|
| Rate for Payer: Zelis Worker's Compensation |
$64.28
|
|
|
FL PICC LINE PLACEMENT
|
Facility
|
OP
|
$3,457.00
|
|
|
Service Code
|
CPT 36569
|
| Hospital Charge Code |
2401120
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$894.39 |
| Max. Negotiated Rate |
$3,284.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,128.99
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,074.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,128.99
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$894.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,475.05
|
| Rate for Payer: Cash Price |
$2,074.20
|
| Rate for Payer: Cash Price |
$2,074.20
|
| Rate for Payer: Cigna Commercial |
$2,938.45
|
| Rate for Payer: First Health Commercial |
$3,111.30
|
| Rate for Payer: First Health Workers Compensation |
$1,898.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,111.30
|
| Rate for Payer: GEHA Commercial |
$2,765.60
|
| Rate for Payer: GEHA Medicare |
$1,475.05
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,111.30
|
| Rate for Payer: Humana ChoiceCare |
$1,622.56
|
| Rate for Payer: Humana Medicare Advantage |
$1,475.05
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,478.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$912.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,475.05
|
| Rate for Payer: Multiplan All |
$3,145.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,507.59
|
| Rate for Payer: OMNI Networks Commercial |
$2,419.90
|
| Rate for Payer: One Health Plan PPO/POS |
$3,111.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,053.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$912.60
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,475.05
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,284.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$2,950.10
|
| Rate for Payer: Three Rivers Provider Network All |
$2,592.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,445.55
|
| Rate for Payer: United Healthcare Managed Medicaid |
$912.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,475.05
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,215.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,475.05
|
| Rate for Payer: Zelis Auto |
$1,382.80
|
| Rate for Payer: Zelis Medicare |
$1,253.79
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,770.06
|
| Rate for Payer: Zelis Worker's Compensation |
$1,342.30
|
|
|
FL PICC LINE PLACEMENT
|
Facility
|
IP
|
$3,457.00
|
|
|
Service Code
|
CPT 36569
|
| Hospital Charge Code |
2401120
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$943.76 |
| Max. Negotiated Rate |
$3,284.15 |
| Rate for Payer: Cash Price |
$2,074.20
|
| Rate for Payer: Cigna Commercial |
$2,938.45
|
| Rate for Payer: First Health Commercial |
$3,111.30
|
| Rate for Payer: First Health Workers Compensation |
$1,334.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,111.30
|
| Rate for Payer: GEHA Commercial |
$2,419.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,111.30
|
| Rate for Payer: Multiplan All |
$3,145.87
|
| Rate for Payer: OMNI Networks Commercial |
$2,419.90
|
| Rate for Payer: One Health Plan PPO/POS |
$3,111.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,284.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,592.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,215.01
|
| Rate for Payer: Zelis Auto |
$1,382.80
|
| Rate for Payer: Zelis Worker's Compensation |
$943.76
|
|
|
FL RETROGRADE UROGRAM
|
Facility
|
OP
|
$1,460.00
|
|
|
Service Code
|
CPT 74420
|
| Hospital Charge Code |
2404420
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$96.78 |
| Max. Negotiated Rate |
$1,387.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$257.43
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$876.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$257.43
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$203.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$339.11
|
| Rate for Payer: Cash Price |
$876.00
|
| Rate for Payer: Cash Price |
$876.00
|
| Rate for Payer: Cigna Commercial |
$1,241.00
|
| Rate for Payer: First Health Commercial |
$1,314.00
|
| Rate for Payer: First Health Workers Compensation |
$136.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,314.00
|
| Rate for Payer: GEHA Commercial |
$1,168.00
|
| Rate for Payer: GEHA Medicare |
$339.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,314.00
|
| Rate for Payer: Humana ChoiceCare |
$373.02
|
| Rate for Payer: Humana Medicare Advantage |
$339.11
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$569.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$208.09
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$339.11
|
| Rate for Payer: Multiplan All |
$1,328.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$576.49
|
| Rate for Payer: OMNI Networks Commercial |
$1,022.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,314.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$240.27
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$208.09
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$339.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,387.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$678.22
|
| Rate for Payer: Three Rivers Provider Network All |
$1,095.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$332.33
|
| Rate for Payer: United Healthcare Commercial |
$1,241.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$339.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,357.80
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$339.11
|
| Rate for Payer: Zelis Auto |
$584.00
|
| Rate for Payer: Zelis Medicare |
$288.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$406.93
|
| Rate for Payer: Zelis Worker's Compensation |
$96.78
|
|
|
FL RETROGRADE UROGRAM
|
Facility
|
IP
|
$1,460.00
|
|
|
Service Code
|
CPT 74420
|
| Hospital Charge Code |
2404420
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$96.78 |
| Max. Negotiated Rate |
$1,387.00 |
| Rate for Payer: Cash Price |
$876.00
|
| Rate for Payer: Cash Price |
$876.00
|
| Rate for Payer: Cigna Commercial |
$1,241.00
|
| Rate for Payer: First Health Commercial |
$1,314.00
|
| Rate for Payer: First Health Workers Compensation |
$136.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,314.00
|
| Rate for Payer: GEHA Commercial |
$1,022.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,314.00
|
| Rate for Payer: Multiplan All |
$1,328.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,022.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,314.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,387.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,095.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,357.80
|
| Rate for Payer: Zelis Auto |
$584.00
|
| Rate for Payer: Zelis Worker's Compensation |
$96.78
|
|
|
FL SMALL BOWEL FOLLOW THROUGH
|
Facility
|
OP
|
$1,166.00
|
|
|
Service Code
|
CPT 74250
|
| Hospital Charge Code |
2400057
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$104.01 |
| Max. Negotiated Rate |
$1,107.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$131.29
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$699.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$131.29
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$104.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$169.04
|
| Rate for Payer: Cash Price |
$699.60
|
| Rate for Payer: Cash Price |
$699.60
|
| Rate for Payer: Cigna Commercial |
$991.10
|
| Rate for Payer: First Health Commercial |
$1,049.40
|
| Rate for Payer: First Health Workers Compensation |
$149.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,049.40
|
| Rate for Payer: GEHA Commercial |
$932.80
|
| Rate for Payer: GEHA Medicare |
$169.04
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,049.40
|
| Rate for Payer: Humana ChoiceCare |
$185.94
|
| Rate for Payer: Humana Medicare Advantage |
$169.04
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$283.99
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$106.13
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$169.04
|
| Rate for Payer: Multiplan All |
$1,061.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$287.37
|
| Rate for Payer: OMNI Networks Commercial |
$816.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,049.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$122.54
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$106.13
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$169.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,107.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$338.08
|
| Rate for Payer: Three Rivers Provider Network All |
$874.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$165.66
|
| Rate for Payer: United Healthcare Commercial |
$991.10
|
| Rate for Payer: United Healthcare Managed Medicaid |
$106.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$169.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,084.38
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$169.04
|
| Rate for Payer: Zelis Auto |
$466.40
|
| Rate for Payer: Zelis Medicare |
$143.68
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$202.85
|
| Rate for Payer: Zelis Worker's Compensation |
$105.71
|
|
|
FL SMALL BOWEL FOLLOW THROUGH
|
Facility
|
IP
|
$1,166.00
|
|
|
Service Code
|
CPT 74250
|
| Hospital Charge Code |
2400057
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$105.71 |
| Max. Negotiated Rate |
$1,107.70 |
| Rate for Payer: Cash Price |
$699.60
|
| Rate for Payer: Cash Price |
$699.60
|
| Rate for Payer: Cigna Commercial |
$991.10
|
| Rate for Payer: First Health Commercial |
$1,049.40
|
| Rate for Payer: First Health Workers Compensation |
$149.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,049.40
|
| Rate for Payer: GEHA Commercial |
$816.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,049.40
|
| Rate for Payer: Multiplan All |
$1,061.06
|
| Rate for Payer: OMNI Networks Commercial |
$816.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,049.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,107.70
|
| Rate for Payer: Three Rivers Provider Network All |
$874.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,084.38
|
| Rate for Payer: Zelis Auto |
$466.40
|
| Rate for Payer: Zelis Worker's Compensation |
$105.71
|
|
|
FLUCONAZOLE 200MG/100ML PREMIX
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT J1450
|
| Hospital Charge Code |
3300343
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.49 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$42.50
|
| Rate for Payer: First Health Commercial |
$45.00
|
| Rate for Payer: First Health Workers Compensation |
$19.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.00
|
| Rate for Payer: GEHA Commercial |
$2.49
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Humana ChoiceCare |
$13.00
|
| Rate for Payer: Multiplan All |
$45.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.00
|
| Rate for Payer: OMNI Networks Commercial |
$35.00
|
| Rate for Payer: One Health Plan PPO/POS |
$45.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47.50
|
| Rate for Payer: Three Rivers Provider Network All |
$37.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$44.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46.50
|
| Rate for Payer: Zelis Auto |
$20.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$25.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.65
|
|
|
FLUCONAZOLE 200MG/100ML PREMIX
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT J1450
|
| Hospital Charge Code |
3300343
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.65 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$42.50
|
| Rate for Payer: First Health Commercial |
$45.00
|
| Rate for Payer: First Health Workers Compensation |
$19.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.00
|
| Rate for Payer: GEHA Commercial |
$35.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Multiplan All |
$45.50
|
| Rate for Payer: OMNI Networks Commercial |
$35.00
|
| Rate for Payer: One Health Plan PPO/POS |
$45.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47.50
|
| Rate for Payer: Three Rivers Provider Network All |
$37.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46.50
|
| Rate for Payer: Zelis Auto |
$20.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.65
|
|
|
FLUCONAZOLE 400 MG/200 ML IVPB
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3303119
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$13.65 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$42.50
|
| Rate for Payer: First Health Commercial |
$45.00
|
| Rate for Payer: First Health Workers Compensation |
$19.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.00
|
| Rate for Payer: GEHA Commercial |
$35.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Multiplan All |
$45.50
|
| Rate for Payer: OMNI Networks Commercial |
$35.00
|
| Rate for Payer: One Health Plan PPO/POS |
$45.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47.50
|
| Rate for Payer: Three Rivers Provider Network All |
$37.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46.50
|
| Rate for Payer: Zelis Auto |
$20.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.65
|
|
|
FLUCONAZOLE 400 MG/200 ML IVPB
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3303119
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$12.50 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$42.50
|
| Rate for Payer: First Health Commercial |
$45.00
|
| Rate for Payer: First Health Workers Compensation |
$19.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.00
|
| Rate for Payer: GEHA Commercial |
$40.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Humana ChoiceCare |
$13.00
|
| Rate for Payer: Multiplan All |
$45.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.00
|
| Rate for Payer: OMNI Networks Commercial |
$35.00
|
| Rate for Payer: One Health Plan PPO/POS |
$45.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47.50
|
| Rate for Payer: Three Rivers Provider Network All |
$37.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$44.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46.50
|
| Rate for Payer: Zelis Auto |
$20.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$25.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.65
|
|
|
FLUCONAZOLE ORAL SUSP 40 MG/ML
|
Facility
|
OP
|
$178.00
|
|
|
Service Code
|
NDC 57237015035
|
| Hospital Charge Code |
3302841
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$169.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$151.30
|
| Rate for Payer: First Health Commercial |
$160.20
|
| Rate for Payer: First Health Workers Compensation |
$68.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$160.20
|
| Rate for Payer: GEHA Commercial |
$142.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$160.20
|
| Rate for Payer: Humana ChoiceCare |
$46.28
|
| Rate for Payer: Multiplan All |
$161.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$106.80
|
| Rate for Payer: OMNI Networks Commercial |
$124.60
|
| Rate for Payer: One Health Plan PPO/POS |
$160.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$169.10
|
| Rate for Payer: Three Rivers Provider Network All |
$133.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$156.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$44.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$165.54
|
| Rate for Payer: Zelis Auto |
$71.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$89.00
|
| Rate for Payer: Zelis Worker's Compensation |
$48.59
|
|
|
FLUCONAZOLE ORAL SUSP 40 MG/ML
|
Facility
|
IP
|
$178.00
|
|
|
Service Code
|
NDC 57237015035
|
| Hospital Charge Code |
3302841
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.59 |
| Max. Negotiated Rate |
$169.10 |
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$151.30
|
| Rate for Payer: First Health Commercial |
$160.20
|
| Rate for Payer: First Health Workers Compensation |
$68.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$160.20
|
| Rate for Payer: GEHA Commercial |
$124.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$160.20
|
| Rate for Payer: Multiplan All |
$161.98
|
| Rate for Payer: OMNI Networks Commercial |
$124.60
|
| Rate for Payer: One Health Plan PPO/POS |
$160.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$169.10
|
| Rate for Payer: Three Rivers Provider Network All |
$133.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$165.54
|
| Rate for Payer: Zelis Auto |
$71.20
|
| Rate for Payer: Zelis Worker's Compensation |
$48.59
|
|
|
fluconazole REF700485
|
Facility
|
OP
|
$251.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
2200819
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.84 |
| Max. Negotiated Rate |
$238.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$33.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$150.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$33.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$26.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$18.64
|
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cigna Commercial |
$213.35
|
| Rate for Payer: First Health Commercial |
$225.90
|
| Rate for Payer: First Health Workers Compensation |
$31.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$225.90
|
| Rate for Payer: GEHA Commercial |
$200.80
|
| Rate for Payer: GEHA Medicare |
$18.64
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$225.90
|
| Rate for Payer: Humana ChoiceCare |
$20.50
|
| Rate for Payer: Humana Medicare Advantage |
$18.64
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$31.32
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$27.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$18.64
|
| Rate for Payer: Multiplan All |
$228.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.69
|
| Rate for Payer: OMNI Networks Commercial |
$175.70
|
| Rate for Payer: One Health Plan PPO/POS |
$225.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$31.32
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$27.12
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$18.64
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$238.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$37.28
|
| Rate for Payer: Three Rivers Provider Network All |
$188.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.27
|
| Rate for Payer: United Healthcare Commercial |
$213.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$27.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: United Payors & United Providers UP&UP |
$233.43
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$18.64
|
| Rate for Payer: Zelis Auto |
$100.40
|
| Rate for Payer: Zelis Medicare |
$15.84
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.37
|
| Rate for Payer: Zelis Worker's Compensation |
$22.12
|
|
|
fluconazole REF700485
|
Facility
|
IP
|
$251.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
2200819
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$22.12 |
| Max. Negotiated Rate |
$238.45 |
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cigna Commercial |
$213.35
|
| Rate for Payer: First Health Commercial |
$225.90
|
| Rate for Payer: First Health Workers Compensation |
$31.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$225.90
|
| Rate for Payer: GEHA Commercial |
$175.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$225.90
|
| Rate for Payer: Multiplan All |
$228.41
|
| Rate for Payer: OMNI Networks Commercial |
$175.70
|
| Rate for Payer: One Health Plan PPO/POS |
$225.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$238.45
|
| Rate for Payer: Three Rivers Provider Network All |
$188.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$233.43
|
| Rate for Payer: Zelis Auto |
$100.40
|
| Rate for Payer: Zelis Worker's Compensation |
$22.12
|
|
|
FLUCONAZOLE TAB 100MG
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
NDC 68084072801
|
| Hospital Charge Code |
3300344
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$50.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$45.05
|
| Rate for Payer: First Health Commercial |
$47.70
|
| Rate for Payer: First Health Workers Compensation |
$20.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$47.70
|
| Rate for Payer: GEHA Commercial |
$42.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$47.70
|
| Rate for Payer: Humana ChoiceCare |
$13.78
|
| Rate for Payer: Multiplan All |
$48.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.80
|
| Rate for Payer: OMNI Networks Commercial |
$37.10
|
| Rate for Payer: One Health Plan PPO/POS |
$47.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$50.35
|
| Rate for Payer: Three Rivers Provider Network All |
$39.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$46.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$49.29
|
| Rate for Payer: Zelis Auto |
$21.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$26.50
|
| Rate for Payer: Zelis Worker's Compensation |
$14.47
|
|
