|
FORESKN MANJ W/LSS PREPUTIAL ADS&STRETCH
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
CPT 54450
|
| Hospital Charge Code |
6154450
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$49.14 |
| Max. Negotiated Rate |
$171.00 |
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$153.00
|
| Rate for Payer: First Health Commercial |
$162.00
|
| Rate for Payer: First Health Workers Compensation |
$69.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$162.00
|
| Rate for Payer: GEHA Commercial |
$126.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$162.00
|
| Rate for Payer: Multiplan All |
$163.80
|
| Rate for Payer: OMNI Networks Commercial |
$126.00
|
| Rate for Payer: One Health Plan PPO/POS |
$162.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$171.00
|
| Rate for Payer: Three Rivers Provider Network All |
$135.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$167.40
|
| Rate for Payer: Zelis Auto |
$72.00
|
| Rate for Payer: Zelis Worker's Compensation |
$49.14
|
|
|
FOSAPREPITANT 150 MG SDV
|
Facility
|
IP
|
$144.56
|
|
|
Service Code
|
CPT J1453
|
| Hospital Charge Code |
3303165
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.46 |
| Max. Negotiated Rate |
$137.33 |
| Rate for Payer: Cash Price |
$86.74
|
| Rate for Payer: Cigna Commercial |
$122.88
|
| Rate for Payer: First Health Commercial |
$130.10
|
| Rate for Payer: First Health Workers Compensation |
$55.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$130.10
|
| Rate for Payer: GEHA Commercial |
$101.19
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$130.10
|
| Rate for Payer: Multiplan All |
$131.55
|
| Rate for Payer: OMNI Networks Commercial |
$101.19
|
| Rate for Payer: One Health Plan PPO/POS |
$130.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$137.33
|
| Rate for Payer: Three Rivers Provider Network All |
$108.42
|
| Rate for Payer: United Payors & United Providers UP&UP |
$134.44
|
| Rate for Payer: Zelis Auto |
$57.82
|
| Rate for Payer: Zelis Worker's Compensation |
$39.46
|
|
|
FOSAPREPITANT 150 MG SDV
|
Facility
|
OP
|
$144.56
|
|
|
Service Code
|
CPT J1453
|
| Hospital Charge Code |
3303165
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$137.33 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$86.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2.06
|
| Rate for Payer: Cash Price |
$86.74
|
| Rate for Payer: Cash Price |
$86.74
|
| Rate for Payer: Cigna Commercial |
$122.88
|
| Rate for Payer: First Health Commercial |
$130.10
|
| Rate for Payer: First Health Workers Compensation |
$55.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$130.10
|
| Rate for Payer: GEHA Commercial |
$0.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$130.10
|
| Rate for Payer: Humana ChoiceCare |
$37.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2.10
|
| Rate for Payer: Multiplan All |
$131.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$86.74
|
| Rate for Payer: OMNI Networks Commercial |
$101.19
|
| Rate for Payer: One Health Plan PPO/POS |
$130.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2.42
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$137.33
|
| Rate for Payer: Three Rivers Provider Network All |
$108.42
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$127.21
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.10
|
| Rate for Payer: United Payors & United Providers UP&UP |
$134.44
|
| Rate for Payer: Zelis Auto |
$57.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$72.28
|
| Rate for Payer: Zelis Worker's Compensation |
$39.46
|
|
|
FOSFOMYCIN THROMETHAMINE 3 GM
|
Facility
|
IP
|
$597.00
|
|
|
Service Code
|
NDC 00456430001
|
| Hospital Charge Code |
3302928
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$162.98 |
| Max. Negotiated Rate |
$567.15 |
| Rate for Payer: Cash Price |
$358.20
|
| Rate for Payer: Cigna Commercial |
$507.45
|
| Rate for Payer: First Health Commercial |
$537.30
|
| Rate for Payer: First Health Workers Compensation |
$230.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$537.30
|
| Rate for Payer: GEHA Commercial |
$417.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$537.30
|
| Rate for Payer: Multiplan All |
$543.27
|
| Rate for Payer: OMNI Networks Commercial |
$417.90
|
| Rate for Payer: One Health Plan PPO/POS |
$537.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$567.15
|
| Rate for Payer: Three Rivers Provider Network All |
$447.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$555.21
|
| Rate for Payer: Zelis Auto |
$238.80
|
| Rate for Payer: Zelis Worker's Compensation |
$162.98
|
|
|
FOSFOMYCIN THROMETHAMINE 3 GM
|
Facility
|
OP
|
$597.00
|
|
|
Service Code
|
NDC 00456430001
|
| Hospital Charge Code |
3302928
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$149.25 |
| Max. Negotiated Rate |
$567.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$358.20
|
| Rate for Payer: Cash Price |
$358.20
|
| Rate for Payer: Cigna Commercial |
$507.45
|
| Rate for Payer: First Health Commercial |
$537.30
|
| Rate for Payer: First Health Workers Compensation |
$230.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$537.30
|
| Rate for Payer: GEHA Commercial |
$477.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$537.30
|
| Rate for Payer: Humana ChoiceCare |
$155.22
|
| Rate for Payer: Multiplan All |
$543.27
|
| Rate for Payer: New Mexico Health Connections Medicare |
$358.20
|
| Rate for Payer: OMNI Networks Commercial |
$417.90
|
| Rate for Payer: One Health Plan PPO/POS |
$537.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$567.15
|
| Rate for Payer: Three Rivers Provider Network All |
$447.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$525.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$149.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$555.21
|
| Rate for Payer: Zelis Auto |
$238.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$298.50
|
| Rate for Payer: Zelis Worker's Compensation |
$162.98
|
|
|
FOSFREE TABS
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00178003160
|
| Hospital Charge Code |
3300625
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
FOSFREE TABS
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00178003160
|
| Hospital Charge Code |
3300625
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
FOSINOPRIL SODIUM TAB 20MG
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 00087060945
|
| Hospital Charge Code |
3300363
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.55 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$11.05
|
| Rate for Payer: First Health Commercial |
$11.70
|
| Rate for Payer: First Health Workers Compensation |
$5.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11.70
|
| Rate for Payer: GEHA Commercial |
$9.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11.70
|
| Rate for Payer: Multiplan All |
$11.83
|
| Rate for Payer: OMNI Networks Commercial |
$9.10
|
| Rate for Payer: One Health Plan PPO/POS |
$11.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12.35
|
| Rate for Payer: Three Rivers Provider Network All |
$9.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12.09
|
| Rate for Payer: Zelis Auto |
$5.20
|
| Rate for Payer: Zelis Worker's Compensation |
$3.55
|
|
|
FOSINOPRIL SODIUM TAB 20MG
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
NDC 00087060945
|
| Hospital Charge Code |
3300363
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$11.05
|
| Rate for Payer: First Health Commercial |
$11.70
|
| Rate for Payer: First Health Workers Compensation |
$5.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11.70
|
| Rate for Payer: GEHA Commercial |
$10.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11.70
|
| Rate for Payer: Humana ChoiceCare |
$3.38
|
| Rate for Payer: Multiplan All |
$11.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.80
|
| Rate for Payer: OMNI Networks Commercial |
$9.10
|
| Rate for Payer: One Health Plan PPO/POS |
$11.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12.35
|
| Rate for Payer: Three Rivers Provider Network All |
$9.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12.09
|
| Rate for Payer: Zelis Auto |
$5.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.55
|
|
|
FOSPHENYTOIN 500 MG/10 ML INJ
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
CPT Q2009
|
| Hospital Charge Code |
3300364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.00 |
| Max. Negotiated Rate |
$30.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$27.20
|
| Rate for Payer: First Health Commercial |
$28.80
|
| Rate for Payer: First Health Workers Compensation |
$12.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$28.80
|
| Rate for Payer: GEHA Commercial |
$25.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$28.80
|
| Rate for Payer: Humana ChoiceCare |
$8.32
|
| Rate for Payer: Multiplan All |
$29.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$19.20
|
| Rate for Payer: OMNI Networks Commercial |
$22.40
|
| Rate for Payer: One Health Plan PPO/POS |
$28.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$30.40
|
| Rate for Payer: Three Rivers Provider Network All |
$24.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$28.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$29.76
|
| Rate for Payer: Zelis Auto |
$12.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$16.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.74
|
|
|
FOSPHENYTOIN 500 MG/10 ML INJ
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
CPT Q2009
|
| Hospital Charge Code |
3300364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$30.40 |
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$27.20
|
| Rate for Payer: First Health Commercial |
$28.80
|
| Rate for Payer: First Health Workers Compensation |
$12.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$28.80
|
| Rate for Payer: GEHA Commercial |
$22.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$28.80
|
| Rate for Payer: Multiplan All |
$29.12
|
| Rate for Payer: OMNI Networks Commercial |
$22.40
|
| Rate for Payer: One Health Plan PPO/POS |
$28.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$30.40
|
| Rate for Payer: Three Rivers Provider Network All |
$24.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$29.76
|
| Rate for Payer: Zelis Auto |
$12.80
|
| Rate for Payer: Zelis Worker's Compensation |
$8.74
|
|
|
fragile x w/rflx southern blot REF511919
|
Facility
|
IP
|
$456.00
|
|
|
Service Code
|
CPT 81243
|
| Hospital Charge Code |
2200786
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$45.51 |
| Max. Negotiated Rate |
$433.20 |
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cigna Commercial |
$387.60
|
| Rate for Payer: First Health Commercial |
$410.40
|
| Rate for Payer: First Health Workers Compensation |
$64.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$410.40
|
| Rate for Payer: GEHA Commercial |
$319.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$410.40
|
| Rate for Payer: Multiplan All |
$414.96
|
| Rate for Payer: OMNI Networks Commercial |
$319.20
|
| Rate for Payer: One Health Plan PPO/POS |
$410.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$433.20
|
| Rate for Payer: Three Rivers Provider Network All |
$342.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$424.08
|
| Rate for Payer: Zelis Auto |
$182.40
|
| Rate for Payer: Zelis Worker's Compensation |
$45.51
|
|
|
fragile x w/rflx southern blot REF511919
|
Facility
|
OP
|
$456.00
|
|
|
Service Code
|
CPT 81243
|
| Hospital Charge Code |
2200786
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$45.51 |
| Max. Negotiated Rate |
$433.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$85.56
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$273.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$85.56
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$67.78
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$57.04
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cigna Commercial |
$387.60
|
| Rate for Payer: First Health Commercial |
$410.40
|
| Rate for Payer: First Health Workers Compensation |
$64.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$410.40
|
| Rate for Payer: GEHA Commercial |
$364.80
|
| Rate for Payer: GEHA Medicare |
$57.04
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$410.40
|
| Rate for Payer: Humana ChoiceCare |
$62.74
|
| Rate for Payer: Humana Medicare Advantage |
$57.04
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$95.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$69.16
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$57.04
|
| Rate for Payer: Multiplan All |
$414.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$96.97
|
| Rate for Payer: OMNI Networks Commercial |
$319.20
|
| Rate for Payer: One Health Plan PPO/POS |
$410.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$79.86
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$69.16
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$57.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$433.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$114.08
|
| Rate for Payer: Three Rivers Provider Network All |
$342.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$55.90
|
| Rate for Payer: United Healthcare Commercial |
$387.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$69.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$57.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$424.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$57.04
|
| Rate for Payer: Zelis Auto |
$182.40
|
| Rate for Payer: Zelis Medicare |
$48.48
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$68.45
|
| Rate for Payer: Zelis Worker's Compensation |
$45.51
|
|
|
FRAGMENTING OF KIDNEY STONE
|
Facility
|
IP
|
$1,167.00
|
|
|
Service Code
|
CPT 50590
|
| Hospital Charge Code |
6150590
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$318.59 |
| Max. Negotiated Rate |
$1,108.65 |
| Rate for Payer: Cash Price |
$700.20
|
| Rate for Payer: Cigna Commercial |
$991.95
|
| Rate for Payer: First Health Commercial |
$1,050.30
|
| Rate for Payer: First Health Workers Compensation |
$450.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,050.30
|
| Rate for Payer: GEHA Commercial |
$816.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,050.30
|
| Rate for Payer: Multiplan All |
$1,061.97
|
| Rate for Payer: OMNI Networks Commercial |
$816.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,050.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,108.65
|
| Rate for Payer: Three Rivers Provider Network All |
$875.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,085.31
|
| Rate for Payer: Zelis Auto |
$466.80
|
| Rate for Payer: Zelis Worker's Compensation |
$318.59
|
|
|
FRAGMENTING OF KIDNEY STONE
|
Facility
|
OP
|
$1,167.00
|
|
|
Service Code
|
CPT 50590
|
| Hospital Charge Code |
6150590
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$318.59 |
| Max. Negotiated Rate |
$6,549.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$4,182.14
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$700.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$4,182.14
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3,313.09
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,274.93
|
| Rate for Payer: Cash Price |
$700.20
|
| Rate for Payer: Cash Price |
$700.20
|
| Rate for Payer: Cigna Commercial |
$991.95
|
| Rate for Payer: First Health Commercial |
$1,050.30
|
| Rate for Payer: First Health Workers Compensation |
$450.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,050.30
|
| Rate for Payer: GEHA Commercial |
$933.60
|
| Rate for Payer: GEHA Medicare |
$3,274.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,050.30
|
| Rate for Payer: Humana ChoiceCare |
$3,602.42
|
| Rate for Payer: Humana Medicare Advantage |
$3,274.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,501.88
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,380.56
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,274.93
|
| Rate for Payer: Multiplan All |
$1,061.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,567.38
|
| Rate for Payer: OMNI Networks Commercial |
$816.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,050.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$3,903.33
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3,380.56
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,274.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,108.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,549.86
|
| Rate for Payer: Three Rivers Provider Network All |
$875.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,209.43
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,380.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,274.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,085.31
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,274.93
|
| Rate for Payer: Zelis Auto |
$466.80
|
| Rate for Payer: Zelis Medicare |
$2,783.69
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,929.92
|
| Rate for Payer: Zelis Worker's Compensation |
$318.59
|
|
|
FREE FASCIAL FLAP MICROVASC
|
Facility
|
OP
|
$4,752.00
|
|
|
Service Code
|
CPT 15758
|
| Hospital Charge Code |
6115758
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,188.00 |
| Max. Negotiated Rate |
$4,514.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,851.20
|
| Rate for Payer: Cash Price |
$2,851.20
|
| Rate for Payer: Cigna Commercial |
$4,039.20
|
| Rate for Payer: First Health Commercial |
$4,276.80
|
| Rate for Payer: First Health Workers Compensation |
$1,834.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,276.80
|
| Rate for Payer: GEHA Commercial |
$3,801.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,276.80
|
| Rate for Payer: Humana ChoiceCare |
$1,235.52
|
| Rate for Payer: Multiplan All |
$4,324.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,851.20
|
| Rate for Payer: OMNI Networks Commercial |
$3,326.40
|
| Rate for Payer: One Health Plan PPO/POS |
$4,276.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,514.40
|
| Rate for Payer: Three Rivers Provider Network All |
$3,564.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,181.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,188.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,419.36
|
| Rate for Payer: Zelis Auto |
$1,900.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,376.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,297.30
|
|
|
FREE FASCIAL FLAP MICROVASC
|
Facility
|
IP
|
$4,752.00
|
|
|
Service Code
|
CPT 15758
|
| Hospital Charge Code |
6115758
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,297.30 |
| Max. Negotiated Rate |
$4,514.40 |
| Rate for Payer: Cash Price |
$2,851.20
|
| Rate for Payer: Cigna Commercial |
$4,039.20
|
| Rate for Payer: First Health Commercial |
$4,276.80
|
| Rate for Payer: First Health Workers Compensation |
$1,834.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,276.80
|
| Rate for Payer: GEHA Commercial |
$3,326.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,276.80
|
| Rate for Payer: Multiplan All |
$4,324.32
|
| Rate for Payer: OMNI Networks Commercial |
$3,326.40
|
| Rate for Payer: One Health Plan PPO/POS |
$4,276.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,514.40
|
| Rate for Payer: Three Rivers Provider Network All |
$3,564.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,419.36
|
| Rate for Payer: Zelis Auto |
$1,900.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1,297.30
|
|
|
FREEING OF BOWEL ADHESION
|
Facility
|
OP
|
$2,304.00
|
|
|
Service Code
|
CPT 44005
|
| Hospital Charge Code |
6144005
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$576.00 |
| Max. Negotiated Rate |
$2,188.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,382.40
|
| Rate for Payer: Cash Price |
$1,382.40
|
| Rate for Payer: Cigna Commercial |
$1,958.40
|
| Rate for Payer: First Health Commercial |
$2,073.60
|
| Rate for Payer: First Health Workers Compensation |
$889.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,073.60
|
| Rate for Payer: GEHA Commercial |
$1,843.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,073.60
|
| Rate for Payer: Humana ChoiceCare |
$599.04
|
| Rate for Payer: Multiplan All |
$2,096.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,382.40
|
| Rate for Payer: OMNI Networks Commercial |
$1,612.80
|
| Rate for Payer: One Health Plan PPO/POS |
$2,073.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,188.80
|
| Rate for Payer: Three Rivers Provider Network All |
$1,728.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,027.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$576.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,142.72
|
| Rate for Payer: Zelis Auto |
$921.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,152.00
|
| Rate for Payer: Zelis Worker's Compensation |
$628.99
|
|
|
FREEING OF BOWEL ADHESION
|
Facility
|
IP
|
$2,304.00
|
|
|
Service Code
|
CPT 44005
|
| Hospital Charge Code |
6144005
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$628.99 |
| Max. Negotiated Rate |
$2,188.80 |
| Rate for Payer: Cash Price |
$1,382.40
|
| Rate for Payer: Cigna Commercial |
$1,958.40
|
| Rate for Payer: First Health Commercial |
$2,073.60
|
| Rate for Payer: First Health Workers Compensation |
$889.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,073.60
|
| Rate for Payer: GEHA Commercial |
$1,612.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,073.60
|
| Rate for Payer: Multiplan All |
$2,096.64
|
| Rate for Payer: OMNI Networks Commercial |
$1,612.80
|
| Rate for Payer: One Health Plan PPO/POS |
$2,073.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,188.80
|
| Rate for Payer: Three Rivers Provider Network All |
$1,728.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,142.72
|
| Rate for Payer: Zelis Auto |
$921.60
|
| Rate for Payer: Zelis Worker's Compensation |
$628.99
|
|
|
FREE MYO/SKIN FLAP MICROVASC
|
Facility
|
OP
|
$4,802.00
|
|
|
Service Code
|
CPT 15756
|
| Hospital Charge Code |
6115756
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,200.50 |
| Max. Negotiated Rate |
$4,561.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,881.20
|
| Rate for Payer: Cash Price |
$2,881.20
|
| Rate for Payer: Cigna Commercial |
$4,081.70
|
| Rate for Payer: First Health Commercial |
$4,321.80
|
| Rate for Payer: First Health Workers Compensation |
$1,854.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,321.80
|
| Rate for Payer: GEHA Commercial |
$3,841.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,321.80
|
| Rate for Payer: Humana ChoiceCare |
$1,248.52
|
| Rate for Payer: Multiplan All |
$4,369.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,881.20
|
| Rate for Payer: OMNI Networks Commercial |
$3,361.40
|
| Rate for Payer: One Health Plan PPO/POS |
$4,321.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,561.90
|
| Rate for Payer: Three Rivers Provider Network All |
$3,601.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,225.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,200.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,465.86
|
| Rate for Payer: Zelis Auto |
$1,920.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,401.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,310.95
|
|
|
FREE MYO/SKIN FLAP MICROVASC
|
Facility
|
IP
|
$4,802.00
|
|
|
Service Code
|
CPT 15756
|
| Hospital Charge Code |
6115756
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,310.95 |
| Max. Negotiated Rate |
$4,561.90 |
| Rate for Payer: Cash Price |
$2,881.20
|
| Rate for Payer: Cigna Commercial |
$4,081.70
|
| Rate for Payer: First Health Commercial |
$4,321.80
|
| Rate for Payer: First Health Workers Compensation |
$1,854.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,321.80
|
| Rate for Payer: GEHA Commercial |
$3,361.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,321.80
|
| Rate for Payer: Multiplan All |
$4,369.82
|
| Rate for Payer: OMNI Networks Commercial |
$3,361.40
|
| Rate for Payer: One Health Plan PPO/POS |
$4,321.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,561.90
|
| Rate for Payer: Three Rivers Provider Network All |
$3,601.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,465.86
|
| Rate for Payer: Zelis Auto |
$1,920.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1,310.95
|
|
|
FREE SKIN FLAP MICROVASC
|
Facility
|
OP
|
$4,745.00
|
|
|
Service Code
|
CPT 15757
|
| Hospital Charge Code |
6115757
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,186.25 |
| Max. Negotiated Rate |
$4,507.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,847.00
|
| Rate for Payer: Cash Price |
$2,847.00
|
| Rate for Payer: Cigna Commercial |
$4,033.25
|
| Rate for Payer: First Health Commercial |
$4,270.50
|
| Rate for Payer: First Health Workers Compensation |
$1,832.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,270.50
|
| Rate for Payer: GEHA Commercial |
$3,796.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,270.50
|
| Rate for Payer: Humana ChoiceCare |
$1,233.70
|
| Rate for Payer: Multiplan All |
$4,317.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,847.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,321.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4,270.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,507.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3,558.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,175.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,186.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,412.85
|
| Rate for Payer: Zelis Auto |
$1,898.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,372.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1,295.38
|
|
|
FREE SKIN FLAP MICROVASC
|
Facility
|
IP
|
$4,745.00
|
|
|
Service Code
|
CPT 15757
|
| Hospital Charge Code |
6115757
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,295.38 |
| Max. Negotiated Rate |
$4,507.75 |
| Rate for Payer: Cash Price |
$2,847.00
|
| Rate for Payer: Cigna Commercial |
$4,033.25
|
| Rate for Payer: First Health Commercial |
$4,270.50
|
| Rate for Payer: First Health Workers Compensation |
$1,832.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,270.50
|
| Rate for Payer: GEHA Commercial |
$3,321.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,270.50
|
| Rate for Payer: Multiplan All |
$4,317.95
|
| Rate for Payer: OMNI Networks Commercial |
$3,321.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4,270.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,507.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3,558.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,412.85
|
| Rate for Payer: Zelis Auto |
$1,898.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,295.38
|
|
|
FREE T3 (Vitros)
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
CPT 84481
|
| Hospital Charge Code |
2232248
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$22.03 |
| Max. Negotiated Rate |
$237.50 |
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$212.50
|
| Rate for Payer: First Health Commercial |
$225.00
|
| Rate for Payer: First Health Workers Compensation |
$31.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$225.00
|
| Rate for Payer: GEHA Commercial |
$175.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$225.00
|
| Rate for Payer: Multiplan All |
$227.50
|
| Rate for Payer: OMNI Networks Commercial |
$175.00
|
| Rate for Payer: One Health Plan PPO/POS |
$225.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$237.50
|
| Rate for Payer: Three Rivers Provider Network All |
$187.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$232.50
|
| Rate for Payer: Zelis Auto |
$100.00
|
| Rate for Payer: Zelis Worker's Compensation |
$22.03
|
|
|
FREE T3 (Vitros)
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
CPT 84481
|
| Hospital Charge Code |
2232248
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$237.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$30.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$150.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$30.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$24.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$16.94
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$212.50
|
| Rate for Payer: First Health Commercial |
$225.00
|
| Rate for Payer: First Health Workers Compensation |
$31.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$225.00
|
| Rate for Payer: GEHA Commercial |
$200.00
|
| Rate for Payer: GEHA Medicare |
$16.94
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$225.00
|
| Rate for Payer: Humana ChoiceCare |
$18.63
|
| Rate for Payer: Humana Medicare Advantage |
$16.94
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$28.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$24.65
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$16.94
|
| Rate for Payer: Multiplan All |
$227.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$28.80
|
| Rate for Payer: OMNI Networks Commercial |
$175.00
|
| Rate for Payer: One Health Plan PPO/POS |
$225.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$28.46
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$24.65
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$16.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$237.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$33.88
|
| Rate for Payer: Three Rivers Provider Network All |
$187.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16.60
|
| Rate for Payer: United Healthcare Commercial |
$212.50
|
| Rate for Payer: United Healthcare Managed Medicaid |
$24.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$232.50
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$16.94
|
| Rate for Payer: Zelis Auto |
$100.00
|
| Rate for Payer: Zelis Medicare |
$14.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.33
|
| Rate for Payer: Zelis Worker's Compensation |
$22.03
|
|
