|
HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITHOUT IMPLANT
|
Facility
|
OP
|
$6,161.78
|
|
|
Service Code
|
CPT 28289
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,749.66 |
| Max. Negotiated Rate |
$6,161.78 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,208.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,208.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,749.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,080.89
|
| Rate for Payer: First Health Workers Compensation |
$3,965.11
|
| Rate for Payer: GEHA Medicare |
$3,080.89
|
| Rate for Payer: Humana ChoiceCare |
$3,388.98
|
| Rate for Payer: Humana Medicare Advantage |
$3,080.89
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,175.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,785.30
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,080.89
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,237.51
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,061.37
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,785.30
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,080.89
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,161.78
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,019.27
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,785.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,080.89
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,080.89
|
| Rate for Payer: Zelis Medicare |
$2,618.76
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,697.07
|
| Rate for Payer: Zelis Worker's Compensation |
$2,803.61
|
|
|
HALLUX VALGUS NIGHT SPLINT
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
CPT L3100
|
| Hospital Charge Code |
8233962
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$34.40 |
| Max. Negotiated Rate |
$81.70 |
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$73.10
|
| Rate for Payer: First Health Commercial |
$77.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$77.40
|
| Rate for Payer: GEHA Commercial |
$60.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$77.40
|
| Rate for Payer: Multiplan All |
$78.26
|
| Rate for Payer: OMNI Networks Commercial |
$60.20
|
| Rate for Payer: One Health Plan PPO/POS |
$77.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$81.70
|
| Rate for Payer: Three Rivers Provider Network All |
$64.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$79.98
|
| Rate for Payer: Zelis Auto |
$34.40
|
|
|
HALLUX VALGUS NIGHT SPLINT
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
CPT L3100
|
| Hospital Charge Code |
8800011
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$34.40 |
| Max. Negotiated Rate |
$81.70 |
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$73.10
|
| Rate for Payer: First Health Commercial |
$77.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$77.40
|
| Rate for Payer: GEHA Commercial |
$60.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$77.40
|
| Rate for Payer: Multiplan All |
$78.26
|
| Rate for Payer: OMNI Networks Commercial |
$60.20
|
| Rate for Payer: One Health Plan PPO/POS |
$77.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$81.70
|
| Rate for Payer: Three Rivers Provider Network All |
$64.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$79.98
|
| Rate for Payer: Zelis Auto |
$34.40
|
|
|
HALLUX VALGUS NIGHT SPLINT
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
CPT L3100
|
| Hospital Charge Code |
8800011
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$22.36 |
| Max. Negotiated Rate |
$81.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$78.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$51.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$78.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$62.22
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$73.10
|
| Rate for Payer: First Health Commercial |
$77.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$77.40
|
| Rate for Payer: GEHA Commercial |
$68.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$77.40
|
| Rate for Payer: Humana ChoiceCare |
$22.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$63.49
|
| Rate for Payer: Multiplan All |
$78.26
|
| Rate for Payer: New Mexico Health Connections Medicare |
$51.60
|
| Rate for Payer: OMNI Networks Commercial |
$60.20
|
| Rate for Payer: One Health Plan PPO/POS |
$77.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$73.30
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$63.49
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$81.70
|
| Rate for Payer: Three Rivers Provider Network All |
$64.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$75.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$63.49
|
| Rate for Payer: United Payors & United Providers UP&UP |
$79.98
|
| Rate for Payer: Zelis Auto |
$34.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$43.00
|
|
|
HALLUX VALGUS NIGHT SPLINT
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
CPT L3100
|
| Hospital Charge Code |
8233962
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$22.36 |
| Max. Negotiated Rate |
$81.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$78.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$51.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$78.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$62.22
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$73.10
|
| Rate for Payer: First Health Commercial |
$77.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$77.40
|
| Rate for Payer: GEHA Commercial |
$68.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$77.40
|
| Rate for Payer: Humana ChoiceCare |
$22.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$63.49
|
| Rate for Payer: Multiplan All |
$78.26
|
| Rate for Payer: New Mexico Health Connections Medicare |
$51.60
|
| Rate for Payer: OMNI Networks Commercial |
$60.20
|
| Rate for Payer: One Health Plan PPO/POS |
$77.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$73.30
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$63.49
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$81.70
|
| Rate for Payer: Three Rivers Provider Network All |
$64.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$75.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$63.49
|
| Rate for Payer: United Payors & United Providers UP&UP |
$79.98
|
| Rate for Payer: Zelis Auto |
$34.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$43.00
|
|
|
HALOPERIDOL DEC 100 MG/1 ML INJ, IM
|
Facility
|
OP
|
$157.00
|
|
|
Service Code
|
CPT J1631
|
| Hospital Charge Code |
3303020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.84 |
| Max. Negotiated Rate |
$149.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$94.20
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cigna Commercial |
$133.45
|
| Rate for Payer: First Health Commercial |
$141.30
|
| Rate for Payer: First Health Workers Compensation |
$60.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$141.30
|
| Rate for Payer: GEHA Commercial |
$4.84
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$141.30
|
| Rate for Payer: Humana ChoiceCare |
$40.82
|
| Rate for Payer: Multiplan All |
$142.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$94.20
|
| Rate for Payer: OMNI Networks Commercial |
$109.90
|
| Rate for Payer: One Health Plan PPO/POS |
$141.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$149.15
|
| Rate for Payer: Three Rivers Provider Network All |
$117.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$138.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$39.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$146.01
|
| Rate for Payer: Zelis Auto |
$62.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$78.50
|
| Rate for Payer: Zelis Worker's Compensation |
$42.86
|
|
|
HALOPERIDOL DEC 100 MG/1 ML INJ, IM
|
Facility
|
IP
|
$157.00
|
|
|
Service Code
|
CPT J1631
|
| Hospital Charge Code |
3303020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.86 |
| Max. Negotiated Rate |
$149.15 |
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cigna Commercial |
$133.45
|
| Rate for Payer: First Health Commercial |
$141.30
|
| Rate for Payer: First Health Workers Compensation |
$60.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$141.30
|
| Rate for Payer: GEHA Commercial |
$109.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$141.30
|
| Rate for Payer: Multiplan All |
$142.87
|
| Rate for Payer: OMNI Networks Commercial |
$109.90
|
| Rate for Payer: One Health Plan PPO/POS |
$141.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$149.15
|
| Rate for Payer: Three Rivers Provider Network All |
$117.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$146.01
|
| Rate for Payer: Zelis Auto |
$62.80
|
| Rate for Payer: Zelis Worker's Compensation |
$42.86
|
|
|
HALOPERIDOL DECANOATE 50 MG/ML INJ - IM
|
Facility
|
IP
|
$161.00
|
|
|
Service Code
|
CPT J1631
|
| Hospital Charge Code |
3300394
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.95 |
| Max. Negotiated Rate |
$152.95 |
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cigna Commercial |
$136.85
|
| Rate for Payer: First Health Commercial |
$144.90
|
| Rate for Payer: First Health Workers Compensation |
$62.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$144.90
|
| Rate for Payer: GEHA Commercial |
$112.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$144.90
|
| Rate for Payer: Multiplan All |
$146.51
|
| Rate for Payer: OMNI Networks Commercial |
$112.70
|
| Rate for Payer: One Health Plan PPO/POS |
$144.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$152.95
|
| Rate for Payer: Three Rivers Provider Network All |
$120.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$149.73
|
| Rate for Payer: Zelis Auto |
$64.40
|
| Rate for Payer: Zelis Worker's Compensation |
$43.95
|
|
|
HALOPERIDOL DECANOATE 50 MG/ML INJ - IM
|
Facility
|
OP
|
$161.00
|
|
|
Service Code
|
CPT J1631
|
| Hospital Charge Code |
3300394
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.84 |
| Max. Negotiated Rate |
$152.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$96.60
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cigna Commercial |
$136.85
|
| Rate for Payer: First Health Commercial |
$144.90
|
| Rate for Payer: First Health Workers Compensation |
$62.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$144.90
|
| Rate for Payer: GEHA Commercial |
$4.84
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$144.90
|
| Rate for Payer: Humana ChoiceCare |
$41.86
|
| Rate for Payer: Multiplan All |
$146.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$96.60
|
| Rate for Payer: OMNI Networks Commercial |
$112.70
|
| Rate for Payer: One Health Plan PPO/POS |
$144.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$152.95
|
| Rate for Payer: Three Rivers Provider Network All |
$120.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$141.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$40.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$149.73
|
| Rate for Payer: Zelis Auto |
$64.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$80.50
|
| Rate for Payer: Zelis Worker's Compensation |
$43.95
|
|
|
HALOPERIDOL LACTATE 5 MG/1 ML INJ, IM
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
CPT J1630
|
| Hospital Charge Code |
3300395
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
HALOPERIDOL LACTATE 5 MG/1 ML INJ, IM
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
CPT J1630
|
| Hospital Charge Code |
3300395
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$0.88
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Humana ChoiceCare |
$1.56
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.60
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
HALOPERIDOL ORAL CONC 2MG/ML
|
Facility
|
OP
|
$41.00
|
|
|
Service Code
|
NDC 00121058104
|
| Hospital Charge Code |
3300396
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$32.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Humana ChoiceCare |
$10.66
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.60
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$36.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.50
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
HALOPERIDOL ORAL CONC 2MG/ML
|
Facility
|
IP
|
$41.00
|
|
|
Service Code
|
NDC 00121058104
|
| Hospital Charge Code |
3300396
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$28.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
HALOPERIDOL TAB 0.5MG
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 00781139113
|
| Hospital Charge Code |
3300397
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
HALOPERIDOL TAB 0.5MG
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 00781139113
|
| Hospital Charge Code |
3300397
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$4.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Humana ChoiceCare |
$1.30
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.00
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
HALOPERIDOL TAB 1MG
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 51079073420
|
| Hospital Charge Code |
3300398
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Humana ChoiceCare |
$1.82
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.20
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
HALOPERIDOL TAB 1MG
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 51079073420
|
| Hospital Charge Code |
3300398
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$4.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
HALOPERIDOL TAB 2MG
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 51079073520
|
| Hospital Charge Code |
3300399
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$6.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Humana ChoiceCare |
$2.08
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.80
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
HALOPERIDOL TAB 2MG
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 51079073520
|
| Hospital Charge Code |
3300399
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
HAND-HELD PEFR METER
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
CPT A4614
|
| Hospital Charge Code |
21600119
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$7.37 |
| Max. Negotiated Rate |
$25.65 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$22.95
|
| Rate for Payer: First Health Commercial |
$24.30
|
| Rate for Payer: First Health Workers Compensation |
$10.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$24.30
|
| Rate for Payer: GEHA Commercial |
$18.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$24.30
|
| Rate for Payer: Multiplan All |
$24.57
|
| Rate for Payer: OMNI Networks Commercial |
$18.90
|
| Rate for Payer: One Health Plan PPO/POS |
$24.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$25.65
|
| Rate for Payer: Three Rivers Provider Network All |
$20.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$25.11
|
| Rate for Payer: Zelis Auto |
$10.80
|
| Rate for Payer: Zelis Worker's Compensation |
$7.37
|
|
|
HAND-HELD PEFR METER
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
CPT A4614
|
| Hospital Charge Code |
21600119
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$25.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$22.95
|
| Rate for Payer: First Health Commercial |
$24.30
|
| Rate for Payer: First Health Workers Compensation |
$10.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$24.30
|
| Rate for Payer: GEHA Commercial |
$21.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$24.30
|
| Rate for Payer: Humana ChoiceCare |
$7.02
|
| Rate for Payer: Multiplan All |
$24.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$16.20
|
| Rate for Payer: OMNI Networks Commercial |
$18.90
|
| Rate for Payer: One Health Plan PPO/POS |
$24.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$25.65
|
| Rate for Payer: Three Rivers Provider Network All |
$20.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$23.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$25.11
|
| Rate for Payer: Zelis Auto |
$10.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$13.50
|
| Rate for Payer: Zelis Worker's Compensation |
$7.37
|
|
|
HAND TENDON/MUSCLE TRANSFER
|
Facility
|
OP
|
$1,566.00
|
|
|
Service Code
|
CPT 26494
|
| Hospital Charge Code |
6126494
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$427.52 |
| Max. Negotiated Rate |
$6,161.78 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,855.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$939.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,855.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2,261.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,080.89
|
| Rate for Payer: Cash Price |
$939.60
|
| Rate for Payer: Cash Price |
$939.60
|
| Rate for Payer: Cigna Commercial |
$1,331.10
|
| Rate for Payer: First Health Commercial |
$1,409.40
|
| Rate for Payer: First Health Workers Compensation |
$604.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,409.40
|
| Rate for Payer: GEHA Commercial |
$1,252.80
|
| Rate for Payer: GEHA Medicare |
$3,080.89
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,409.40
|
| Rate for Payer: Humana ChoiceCare |
$3,388.98
|
| Rate for Payer: Humana Medicare Advantage |
$3,080.89
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,175.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,307.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,080.89
|
| Rate for Payer: Multiplan All |
$1,425.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,237.51
|
| Rate for Payer: OMNI Networks Commercial |
$1,096.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,409.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,664.73
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,307.85
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,080.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,487.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,161.78
|
| Rate for Payer: Three Rivers Provider Network All |
$1,174.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,019.27
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,307.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,080.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,456.38
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,080.89
|
| Rate for Payer: Zelis Auto |
$626.40
|
| Rate for Payer: Zelis Medicare |
$2,618.76
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,697.07
|
| Rate for Payer: Zelis Worker's Compensation |
$427.52
|
|
|
HAND TENDON/MUSCLE TRANSFER
|
Facility
|
IP
|
$1,566.00
|
|
|
Service Code
|
CPT 26494
|
| Hospital Charge Code |
6126494
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$427.52 |
| Max. Negotiated Rate |
$1,487.70 |
| Rate for Payer: Cash Price |
$939.60
|
| Rate for Payer: Cigna Commercial |
$1,331.10
|
| Rate for Payer: First Health Commercial |
$1,409.40
|
| Rate for Payer: First Health Workers Compensation |
$604.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,409.40
|
| Rate for Payer: GEHA Commercial |
$1,096.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,409.40
|
| Rate for Payer: Multiplan All |
$1,425.06
|
| Rate for Payer: OMNI Networks Commercial |
$1,096.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,409.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,487.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,174.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,456.38
|
| Rate for Payer: Zelis Auto |
$626.40
|
| Rate for Payer: Zelis Worker's Compensation |
$427.52
|
|
|
HAND TENDON RECONSTRUCTION
|
Facility
|
IP
|
$1,373.00
|
|
|
Service Code
|
CPT 26502
|
| Hospital Charge Code |
6126502
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$374.83 |
| Max. Negotiated Rate |
$1,304.35 |
| Rate for Payer: Cash Price |
$823.80
|
| Rate for Payer: Cigna Commercial |
$1,167.05
|
| Rate for Payer: First Health Commercial |
$1,235.70
|
| Rate for Payer: First Health Workers Compensation |
$530.12
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,235.70
|
| Rate for Payer: GEHA Commercial |
$961.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,235.70
|
| Rate for Payer: Multiplan All |
$1,249.43
|
| Rate for Payer: OMNI Networks Commercial |
$961.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,235.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,304.35
|
| Rate for Payer: Three Rivers Provider Network All |
$1,029.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,276.89
|
| Rate for Payer: Zelis Auto |
$549.20
|
| Rate for Payer: Zelis Worker's Compensation |
$374.83
|
|
|
HAND TENDON RECONSTRUCTION
|
Facility
|
OP
|
$1,373.00
|
|
|
Service Code
|
CPT 26502
|
| Hospital Charge Code |
6126502
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$374.83 |
| Max. Negotiated Rate |
$6,161.78 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,855.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$823.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,855.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2,261.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,080.89
|
| Rate for Payer: Cash Price |
$823.80
|
| Rate for Payer: Cash Price |
$823.80
|
| Rate for Payer: Cigna Commercial |
$1,167.05
|
| Rate for Payer: First Health Commercial |
$1,235.70
|
| Rate for Payer: First Health Workers Compensation |
$530.12
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,235.70
|
| Rate for Payer: GEHA Commercial |
$1,098.40
|
| Rate for Payer: GEHA Medicare |
$3,080.89
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,235.70
|
| Rate for Payer: Humana ChoiceCare |
$3,388.98
|
| Rate for Payer: Humana Medicare Advantage |
$3,080.89
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,175.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,307.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,080.89
|
| Rate for Payer: Multiplan All |
$1,249.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,237.51
|
| Rate for Payer: OMNI Networks Commercial |
$961.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,235.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,664.73
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,307.85
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,080.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,304.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,161.78
|
| Rate for Payer: Three Rivers Provider Network All |
$1,029.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,019.27
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,307.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,080.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,276.89
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,080.89
|
| Rate for Payer: Zelis Auto |
$549.20
|
| Rate for Payer: Zelis Medicare |
$2,618.76
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,697.07
|
| Rate for Payer: Zelis Worker's Compensation |
$374.83
|
|
