|
GASTRO INTUB W/ ASP/LAVAGE
|
Facility
|
OP
|
$415.00
|
|
| Hospital Charge Code |
8150098
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$103.75 |
| Max. Negotiated Rate |
$394.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$249.00
|
| Rate for Payer: Cash Price |
$249.00
|
| Rate for Payer: Cigna Commercial |
$352.75
|
| Rate for Payer: First Health Commercial |
$373.50
|
| Rate for Payer: First Health Workers Compensation |
$160.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$373.50
|
| Rate for Payer: GEHA Commercial |
$332.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$373.50
|
| Rate for Payer: Humana ChoiceCare |
$107.90
|
| Rate for Payer: Multiplan All |
$377.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$249.00
|
| Rate for Payer: OMNI Networks Commercial |
$290.50
|
| Rate for Payer: One Health Plan PPO/POS |
$373.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$394.25
|
| Rate for Payer: Three Rivers Provider Network All |
$311.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$365.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$103.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$385.95
|
| Rate for Payer: Zelis Auto |
$166.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$207.50
|
| Rate for Payer: Zelis Worker's Compensation |
$113.30
|
|
|
GASTRO INTUB W/ ASP/LAVAGE
|
Facility
|
IP
|
$415.00
|
|
| Hospital Charge Code |
8150098
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$113.30 |
| Max. Negotiated Rate |
$394.25 |
| Rate for Payer: Cash Price |
$249.00
|
| Rate for Payer: Cigna Commercial |
$352.75
|
| Rate for Payer: First Health Commercial |
$373.50
|
| Rate for Payer: First Health Workers Compensation |
$160.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$373.50
|
| Rate for Payer: GEHA Commercial |
$290.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$373.50
|
| Rate for Payer: Multiplan All |
$377.65
|
| Rate for Payer: OMNI Networks Commercial |
$290.50
|
| Rate for Payer: One Health Plan PPO/POS |
$373.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$394.25
|
| Rate for Payer: Three Rivers Provider Network All |
$311.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$385.95
|
| Rate for Payer: Zelis Auto |
$166.00
|
| Rate for Payer: Zelis Worker's Compensation |
$113.30
|
|
|
GASTROPLASTY DUODENAL SWITCH
|
Facility
|
IP
|
$4,143.00
|
|
|
Service Code
|
CPT 43845
|
| Hospital Charge Code |
6143845
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,131.04 |
| Max. Negotiated Rate |
$3,935.85 |
| Rate for Payer: Cash Price |
$2,485.80
|
| Rate for Payer: Cigna Commercial |
$3,521.55
|
| Rate for Payer: First Health Commercial |
$3,728.70
|
| Rate for Payer: First Health Workers Compensation |
$1,599.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,728.70
|
| Rate for Payer: GEHA Commercial |
$2,900.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,728.70
|
| Rate for Payer: Multiplan All |
$3,770.13
|
| Rate for Payer: OMNI Networks Commercial |
$2,900.10
|
| Rate for Payer: One Health Plan PPO/POS |
$3,728.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,935.85
|
| Rate for Payer: Three Rivers Provider Network All |
$3,107.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,852.99
|
| Rate for Payer: Zelis Auto |
$1,657.20
|
| Rate for Payer: Zelis Worker's Compensation |
$1,131.04
|
|
|
GASTROPLASTY DUODENAL SWITCH
|
Facility
|
OP
|
$4,143.00
|
|
|
Service Code
|
CPT 43845
|
| Hospital Charge Code |
6143845
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,035.75 |
| Max. Negotiated Rate |
$3,935.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,485.80
|
| Rate for Payer: Cash Price |
$2,485.80
|
| Rate for Payer: Cigna Commercial |
$3,521.55
|
| Rate for Payer: First Health Commercial |
$3,728.70
|
| Rate for Payer: First Health Workers Compensation |
$1,599.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,728.70
|
| Rate for Payer: GEHA Commercial |
$3,314.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,728.70
|
| Rate for Payer: Humana ChoiceCare |
$1,077.18
|
| Rate for Payer: Multiplan All |
$3,770.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,485.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,900.10
|
| Rate for Payer: One Health Plan PPO/POS |
$3,728.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,935.85
|
| Rate for Payer: Three Rivers Provider Network All |
$3,107.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,645.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,035.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,852.99
|
| Rate for Payer: Zelis Auto |
$1,657.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,071.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1,131.04
|
|
|
GASTROPLASTY W/O V-BAND
|
Facility
|
IP
|
$2,691.00
|
|
|
Service Code
|
CPT 43843
|
| Hospital Charge Code |
6143843
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$734.64 |
| Max. Negotiated Rate |
$2,556.45 |
| Rate for Payer: Cash Price |
$1,614.60
|
| Rate for Payer: Cigna Commercial |
$2,287.35
|
| Rate for Payer: First Health Commercial |
$2,421.90
|
| Rate for Payer: First Health Workers Compensation |
$1,039.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,421.90
|
| Rate for Payer: GEHA Commercial |
$1,883.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,421.90
|
| Rate for Payer: Multiplan All |
$2,448.81
|
| Rate for Payer: OMNI Networks Commercial |
$1,883.70
|
| Rate for Payer: One Health Plan PPO/POS |
$2,421.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,556.45
|
| Rate for Payer: Three Rivers Provider Network All |
$2,018.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,502.63
|
| Rate for Payer: Zelis Auto |
$1,076.40
|
| Rate for Payer: Zelis Worker's Compensation |
$734.64
|
|
|
GASTROPLASTY W/O V-BAND
|
Facility
|
OP
|
$2,691.00
|
|
|
Service Code
|
CPT 43843
|
| Hospital Charge Code |
6143843
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$2,556.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,614.60
|
| Rate for Payer: Cash Price |
$1,614.60
|
| Rate for Payer: Cigna Commercial |
$2,287.35
|
| Rate for Payer: First Health Commercial |
$2,421.90
|
| Rate for Payer: First Health Workers Compensation |
$1,039.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,421.90
|
| Rate for Payer: GEHA Commercial |
$2,152.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,421.90
|
| Rate for Payer: Humana ChoiceCare |
$699.66
|
| Rate for Payer: Multiplan All |
$2,448.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,614.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,883.70
|
| Rate for Payer: One Health Plan PPO/POS |
$2,421.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,556.45
|
| Rate for Payer: Three Rivers Provider Network All |
$2,018.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,368.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$672.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,502.63
|
| Rate for Payer: Zelis Auto |
$1,076.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,345.50
|
| Rate for Payer: Zelis Worker's Compensation |
$734.64
|
|
|
GAVILAX 510 GM BOTTLE
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 43386031214
|
| Hospital Charge Code |
3300730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$7.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Humana ChoiceCare |
$2.34
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5.40
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.50
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
GAVILAX 510 GM BOTTLE
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 43386031214
|
| Hospital Charge Code |
3300730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$6.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
GE HEALTHCARE PAPER 15MM
|
Facility
|
OP
|
$393.00
|
|
| Hospital Charge Code |
90030870
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$98.25 |
| Max. Negotiated Rate |
$373.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$235.80
|
| Rate for Payer: Cash Price |
$235.80
|
| Rate for Payer: Cigna Commercial |
$334.05
|
| Rate for Payer: First Health Commercial |
$353.70
|
| Rate for Payer: First Health Workers Compensation |
$151.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$353.70
|
| Rate for Payer: GEHA Commercial |
$314.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$353.70
|
| Rate for Payer: Humana ChoiceCare |
$102.18
|
| Rate for Payer: Multiplan All |
$357.63
|
| Rate for Payer: New Mexico Health Connections Medicare |
$235.80
|
| Rate for Payer: OMNI Networks Commercial |
$275.10
|
| Rate for Payer: One Health Plan PPO/POS |
$353.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$373.35
|
| Rate for Payer: Three Rivers Provider Network All |
$294.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$345.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$98.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$365.49
|
| Rate for Payer: Zelis Auto |
$157.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$196.50
|
| Rate for Payer: Zelis Worker's Compensation |
$107.29
|
|
|
GE HEALTHCARE PAPER 15MM
|
Facility
|
IP
|
$393.00
|
|
| Hospital Charge Code |
90030870
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$107.29 |
| Max. Negotiated Rate |
$373.35 |
| Rate for Payer: Cash Price |
$235.80
|
| Rate for Payer: Cigna Commercial |
$334.05
|
| Rate for Payer: First Health Commercial |
$353.70
|
| Rate for Payer: First Health Workers Compensation |
$151.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$353.70
|
| Rate for Payer: GEHA Commercial |
$275.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$353.70
|
| Rate for Payer: Multiplan All |
$357.63
|
| Rate for Payer: OMNI Networks Commercial |
$275.10
|
| Rate for Payer: One Health Plan PPO/POS |
$353.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$373.35
|
| Rate for Payer: Three Rivers Provider Network All |
$294.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$365.49
|
| Rate for Payer: Zelis Auto |
$157.20
|
| Rate for Payer: Zelis Worker's Compensation |
$107.29
|
|
|
GELATIN ADSORBABLE SPONGE SIZE 100
|
Facility
|
IP
|
$228.00
|
|
|
Service Code
|
NDC 00009034201
|
| Hospital Charge Code |
3300374
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$62.24 |
| Max. Negotiated Rate |
$216.60 |
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$193.80
|
| Rate for Payer: First Health Commercial |
$205.20
|
| Rate for Payer: First Health Workers Compensation |
$88.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$205.20
|
| Rate for Payer: GEHA Commercial |
$159.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$205.20
|
| Rate for Payer: Multiplan All |
$207.48
|
| Rate for Payer: OMNI Networks Commercial |
$159.60
|
| Rate for Payer: One Health Plan PPO/POS |
$205.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$216.60
|
| Rate for Payer: Three Rivers Provider Network All |
$171.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$212.04
|
| Rate for Payer: Zelis Auto |
$91.20
|
| Rate for Payer: Zelis Worker's Compensation |
$62.24
|
|
|
GELATIN ADSORBABLE SPONGE SIZE 100
|
Facility
|
OP
|
$228.00
|
|
|
Service Code
|
NDC 00009034201
|
| Hospital Charge Code |
3300374
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$57.00 |
| Max. Negotiated Rate |
$216.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$193.80
|
| Rate for Payer: First Health Commercial |
$205.20
|
| Rate for Payer: First Health Workers Compensation |
$88.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$205.20
|
| Rate for Payer: GEHA Commercial |
$182.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$205.20
|
| Rate for Payer: Humana ChoiceCare |
$59.28
|
| Rate for Payer: Multiplan All |
$207.48
|
| Rate for Payer: New Mexico Health Connections Medicare |
$136.80
|
| Rate for Payer: OMNI Networks Commercial |
$159.60
|
| Rate for Payer: One Health Plan PPO/POS |
$205.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$216.60
|
| Rate for Payer: Three Rivers Provider Network All |
$171.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$200.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$57.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$212.04
|
| Rate for Payer: Zelis Auto |
$91.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$114.00
|
| Rate for Payer: Zelis Worker's Compensation |
$62.24
|
|
|
GELATIN ADSORBABLE SPONGE SIZE 200
|
Facility
|
OP
|
$359.00
|
|
|
Service Code
|
NDC 00009034903
|
| Hospital Charge Code |
3300375
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$89.75 |
| Max. Negotiated Rate |
$341.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$215.40
|
| Rate for Payer: Cash Price |
$215.40
|
| Rate for Payer: Cigna Commercial |
$305.15
|
| Rate for Payer: First Health Commercial |
$323.10
|
| Rate for Payer: First Health Workers Compensation |
$138.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$323.10
|
| Rate for Payer: GEHA Commercial |
$287.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$323.10
|
| Rate for Payer: Humana ChoiceCare |
$93.34
|
| Rate for Payer: Multiplan All |
$326.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$215.40
|
| Rate for Payer: OMNI Networks Commercial |
$251.30
|
| Rate for Payer: One Health Plan PPO/POS |
$323.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$341.05
|
| Rate for Payer: Three Rivers Provider Network All |
$269.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$315.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$89.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$333.87
|
| Rate for Payer: Zelis Auto |
$143.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$179.50
|
| Rate for Payer: Zelis Worker's Compensation |
$98.01
|
|
|
GELATIN ADSORBABLE SPONGE SIZE 200
|
Facility
|
IP
|
$359.00
|
|
|
Service Code
|
NDC 00009034903
|
| Hospital Charge Code |
3300375
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$98.01 |
| Max. Negotiated Rate |
$341.05 |
| Rate for Payer: Cash Price |
$215.40
|
| Rate for Payer: Cigna Commercial |
$305.15
|
| Rate for Payer: First Health Commercial |
$323.10
|
| Rate for Payer: First Health Workers Compensation |
$138.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$323.10
|
| Rate for Payer: GEHA Commercial |
$251.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$323.10
|
| Rate for Payer: Multiplan All |
$326.69
|
| Rate for Payer: OMNI Networks Commercial |
$251.30
|
| Rate for Payer: One Health Plan PPO/POS |
$323.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$341.05
|
| Rate for Payer: Three Rivers Provider Network All |
$269.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$333.87
|
| Rate for Payer: Zelis Auto |
$143.60
|
| Rate for Payer: Zelis Worker's Compensation |
$98.01
|
|
|
GELLHORN LONGSTEM SIZE 1.5
|
Facility
|
IP
|
$357.00
|
|
|
Service Code
|
CPT A4561
|
| Hospital Charge Code |
7007003
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$97.46 |
| Max. Negotiated Rate |
$339.15 |
| Rate for Payer: Cash Price |
$214.20
|
| Rate for Payer: Cigna Commercial |
$303.45
|
| Rate for Payer: First Health Commercial |
$321.30
|
| Rate for Payer: First Health Workers Compensation |
$137.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$321.30
|
| Rate for Payer: GEHA Commercial |
$249.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$321.30
|
| Rate for Payer: Multiplan All |
$324.87
|
| Rate for Payer: OMNI Networks Commercial |
$249.90
|
| Rate for Payer: One Health Plan PPO/POS |
$321.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$339.15
|
| Rate for Payer: Three Rivers Provider Network All |
$267.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$332.01
|
| Rate for Payer: Zelis Auto |
$142.80
|
| Rate for Payer: Zelis Worker's Compensation |
$97.46
|
|
|
GELLHORN LONGSTEM SIZE 1.5
|
Facility
|
OP
|
$357.00
|
|
|
Service Code
|
CPT A4561
|
| Hospital Charge Code |
7007003
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$89.25 |
| Max. Negotiated Rate |
$339.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$214.20
|
| Rate for Payer: Cash Price |
$214.20
|
| Rate for Payer: Cigna Commercial |
$303.45
|
| Rate for Payer: First Health Commercial |
$321.30
|
| Rate for Payer: First Health Workers Compensation |
$137.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$321.30
|
| Rate for Payer: GEHA Commercial |
$285.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$321.30
|
| Rate for Payer: Humana ChoiceCare |
$92.82
|
| Rate for Payer: Multiplan All |
$324.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$214.20
|
| Rate for Payer: OMNI Networks Commercial |
$249.90
|
| Rate for Payer: One Health Plan PPO/POS |
$321.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$339.15
|
| Rate for Payer: Three Rivers Provider Network All |
$267.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$314.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$89.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$332.01
|
| Rate for Payer: Zelis Auto |
$142.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$178.50
|
| Rate for Payer: Zelis Worker's Compensation |
$97.46
|
|
|
GELLHORN LONGSTEM SIZE 2.25
|
Facility
|
IP
|
$357.00
|
|
|
Service Code
|
CPT A4561
|
| Hospital Charge Code |
7007005
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$97.46 |
| Max. Negotiated Rate |
$339.15 |
| Rate for Payer: Cash Price |
$214.20
|
| Rate for Payer: Cigna Commercial |
$303.45
|
| Rate for Payer: First Health Commercial |
$321.30
|
| Rate for Payer: First Health Workers Compensation |
$137.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$321.30
|
| Rate for Payer: GEHA Commercial |
$249.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$321.30
|
| Rate for Payer: Multiplan All |
$324.87
|
| Rate for Payer: OMNI Networks Commercial |
$249.90
|
| Rate for Payer: One Health Plan PPO/POS |
$321.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$339.15
|
| Rate for Payer: Three Rivers Provider Network All |
$267.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$332.01
|
| Rate for Payer: Zelis Auto |
$142.80
|
| Rate for Payer: Zelis Worker's Compensation |
$97.46
|
|
|
GELLHORN LONGSTEM SIZE 2.25
|
Facility
|
OP
|
$357.00
|
|
|
Service Code
|
CPT A4561
|
| Hospital Charge Code |
7007005
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$89.25 |
| Max. Negotiated Rate |
$339.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$214.20
|
| Rate for Payer: Cash Price |
$214.20
|
| Rate for Payer: Cigna Commercial |
$303.45
|
| Rate for Payer: First Health Commercial |
$321.30
|
| Rate for Payer: First Health Workers Compensation |
$137.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$321.30
|
| Rate for Payer: GEHA Commercial |
$285.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$321.30
|
| Rate for Payer: Humana ChoiceCare |
$92.82
|
| Rate for Payer: Multiplan All |
$324.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$214.20
|
| Rate for Payer: OMNI Networks Commercial |
$249.90
|
| Rate for Payer: One Health Plan PPO/POS |
$321.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$339.15
|
| Rate for Payer: Three Rivers Provider Network All |
$267.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$314.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$89.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$332.01
|
| Rate for Payer: Zelis Auto |
$142.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$178.50
|
| Rate for Payer: Zelis Worker's Compensation |
$97.46
|
|
|
GELLHORN SHORTSTEM SIZE 1.5
|
Facility
|
OP
|
$357.00
|
|
|
Service Code
|
CPT A4561
|
| Hospital Charge Code |
7007002
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$89.25 |
| Max. Negotiated Rate |
$339.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$214.20
|
| Rate for Payer: Cash Price |
$214.20
|
| Rate for Payer: Cigna Commercial |
$303.45
|
| Rate for Payer: First Health Commercial |
$321.30
|
| Rate for Payer: First Health Workers Compensation |
$137.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$321.30
|
| Rate for Payer: GEHA Commercial |
$285.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$321.30
|
| Rate for Payer: Humana ChoiceCare |
$92.82
|
| Rate for Payer: Multiplan All |
$324.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$214.20
|
| Rate for Payer: OMNI Networks Commercial |
$249.90
|
| Rate for Payer: One Health Plan PPO/POS |
$321.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$339.15
|
| Rate for Payer: Three Rivers Provider Network All |
$267.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$314.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$89.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$332.01
|
| Rate for Payer: Zelis Auto |
$142.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$178.50
|
| Rate for Payer: Zelis Worker's Compensation |
$97.46
|
|
|
GELLHORN SHORTSTEM SIZE 1.5
|
Facility
|
IP
|
$357.00
|
|
|
Service Code
|
CPT A4561
|
| Hospital Charge Code |
7007002
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$97.46 |
| Max. Negotiated Rate |
$339.15 |
| Rate for Payer: Cash Price |
$214.20
|
| Rate for Payer: Cigna Commercial |
$303.45
|
| Rate for Payer: First Health Commercial |
$321.30
|
| Rate for Payer: First Health Workers Compensation |
$137.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$321.30
|
| Rate for Payer: GEHA Commercial |
$249.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$321.30
|
| Rate for Payer: Multiplan All |
$324.87
|
| Rate for Payer: OMNI Networks Commercial |
$249.90
|
| Rate for Payer: One Health Plan PPO/POS |
$321.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$339.15
|
| Rate for Payer: Three Rivers Provider Network All |
$267.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$332.01
|
| Rate for Payer: Zelis Auto |
$142.80
|
| Rate for Payer: Zelis Worker's Compensation |
$97.46
|
|
|
GELLHORN SHORTSTEM SIZE 2.25
|
Facility
|
IP
|
$357.00
|
|
|
Service Code
|
CPT A4561
|
| Hospital Charge Code |
7007004
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$97.46 |
| Max. Negotiated Rate |
$339.15 |
| Rate for Payer: Cash Price |
$214.20
|
| Rate for Payer: Cigna Commercial |
$303.45
|
| Rate for Payer: First Health Commercial |
$321.30
|
| Rate for Payer: First Health Workers Compensation |
$137.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$321.30
|
| Rate for Payer: GEHA Commercial |
$249.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$321.30
|
| Rate for Payer: Multiplan All |
$324.87
|
| Rate for Payer: OMNI Networks Commercial |
$249.90
|
| Rate for Payer: One Health Plan PPO/POS |
$321.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$339.15
|
| Rate for Payer: Three Rivers Provider Network All |
$267.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$332.01
|
| Rate for Payer: Zelis Auto |
$142.80
|
| Rate for Payer: Zelis Worker's Compensation |
$97.46
|
|
|
GELLHORN SHORTSTEM SIZE 2.25
|
Facility
|
OP
|
$357.00
|
|
|
Service Code
|
CPT A4561
|
| Hospital Charge Code |
7007004
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$89.25 |
| Max. Negotiated Rate |
$339.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$214.20
|
| Rate for Payer: Cash Price |
$214.20
|
| Rate for Payer: Cigna Commercial |
$303.45
|
| Rate for Payer: First Health Commercial |
$321.30
|
| Rate for Payer: First Health Workers Compensation |
$137.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$321.30
|
| Rate for Payer: GEHA Commercial |
$285.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$321.30
|
| Rate for Payer: Humana ChoiceCare |
$92.82
|
| Rate for Payer: Multiplan All |
$324.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$214.20
|
| Rate for Payer: OMNI Networks Commercial |
$249.90
|
| Rate for Payer: One Health Plan PPO/POS |
$321.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$339.15
|
| Rate for Payer: Three Rivers Provider Network All |
$267.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$314.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$89.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$332.01
|
| Rate for Payer: Zelis Auto |
$142.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$178.50
|
| Rate for Payer: Zelis Worker's Compensation |
$97.46
|
|
|
GELLHORN SHORTSTEM SIZE 3.25
|
Facility
|
IP
|
$357.00
|
|
|
Service Code
|
CPT A4561
|
| Hospital Charge Code |
7007006
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$97.46 |
| Max. Negotiated Rate |
$339.15 |
| Rate for Payer: Cash Price |
$214.20
|
| Rate for Payer: Cigna Commercial |
$303.45
|
| Rate for Payer: First Health Commercial |
$321.30
|
| Rate for Payer: First Health Workers Compensation |
$137.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$321.30
|
| Rate for Payer: GEHA Commercial |
$249.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$321.30
|
| Rate for Payer: Multiplan All |
$324.87
|
| Rate for Payer: OMNI Networks Commercial |
$249.90
|
| Rate for Payer: One Health Plan PPO/POS |
$321.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$339.15
|
| Rate for Payer: Three Rivers Provider Network All |
$267.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$332.01
|
| Rate for Payer: Zelis Auto |
$142.80
|
| Rate for Payer: Zelis Worker's Compensation |
$97.46
|
|
|
GELLHORN SHORTSTEM SIZE 3.25
|
Facility
|
OP
|
$357.00
|
|
|
Service Code
|
CPT A4561
|
| Hospital Charge Code |
7007006
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$89.25 |
| Max. Negotiated Rate |
$339.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$214.20
|
| Rate for Payer: Cash Price |
$214.20
|
| Rate for Payer: Cigna Commercial |
$303.45
|
| Rate for Payer: First Health Commercial |
$321.30
|
| Rate for Payer: First Health Workers Compensation |
$137.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$321.30
|
| Rate for Payer: GEHA Commercial |
$285.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$321.30
|
| Rate for Payer: Humana ChoiceCare |
$92.82
|
| Rate for Payer: Multiplan All |
$324.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$214.20
|
| Rate for Payer: OMNI Networks Commercial |
$249.90
|
| Rate for Payer: One Health Plan PPO/POS |
$321.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$339.15
|
| Rate for Payer: Three Rivers Provider Network All |
$267.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$314.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$89.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$332.01
|
| Rate for Payer: Zelis Auto |
$142.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$178.50
|
| Rate for Payer: Zelis Worker's Compensation |
$97.46
|
|
|
GEMCITABINE 1 GM/26.3 ML INJ
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
3303029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.86 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$64.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$117.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: OMNI Networks Commercial |
$117.60
|
| Rate for Payer: One Health Plan PPO/POS |
$151.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Worker's Compensation |
$45.86
|
|
