|
IM ADM THRU 18YR ANY RTE 1ST/ONLY COMPT
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
CPT 90460
|
| Hospital Charge Code |
21999424
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$38.51 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$30.50
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Humana ChoiceCare |
$5.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$31.12
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.60
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$35.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$31.12
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.12
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
IM ADM THRU 18YR ANY RTE 1ST/ONLY COMPT
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
CPT 90460
|
| Hospital Charge Code |
21999424
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
IM ADM THRU 18YR ANY RTE 1ST/ONLY COMPT
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
CPT 90460
|
| Hospital Charge Code |
21600114
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$38.51 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$30.50
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Humana ChoiceCare |
$5.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$31.12
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.60
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$35.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$31.12
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.12
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
IM ADM THRU 18YR ANY RTE 1ST/ONLY COMPT
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
CPT 90460
|
| Hospital Charge Code |
21600114
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
IM ADM THRU 18YR ANY RTE 1ST/ONLY COMPT
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
CPT 90460
|
| Hospital Charge Code |
9390460
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$38.51 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$30.50
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Humana ChoiceCare |
$5.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$31.12
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.60
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$35.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$31.12
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.12
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
IM ADM THRU 18YR ANY RTE 1ST/ONLY COMPT
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
CPT 90460
|
| Hospital Charge Code |
9390460
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
IM ADM THRU 18YR ANY RTE ADDL VAC/TOX CO
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
CPT 90461
|
| Hospital Charge Code |
21999427
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$38.51 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$30.50
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Humana ChoiceCare |
$5.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$31.12
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.60
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$35.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$31.12
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.12
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
IM ADM THRU 18YR ANY RTE ADDL VAC/TOX CO
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
CPT 90461
|
| Hospital Charge Code |
21999427
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
IM ADM THRU 18YR ANY RTE ADDL VAC/TOX CO
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
CPT 90461
|
| Hospital Charge Code |
21600115
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
IM ADM THRU 18YR ANY RTE ADDL VAC/TOX CO
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
CPT 90461
|
| Hospital Charge Code |
21600115
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$38.51 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$30.50
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Humana ChoiceCare |
$5.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$31.12
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.60
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$35.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$31.12
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.12
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
IMAGE-GUIDED CATHETER FLUID COLLECTION D
|
Facility
|
OP
|
$434.00
|
|
|
Service Code
|
CPT 10030
|
| Hospital Charge Code |
6162322
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$118.48 |
| Max. Negotiated Rate |
$1,336.18 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$222.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$260.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$222.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$175.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$668.09
|
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Cigna Commercial |
$368.90
|
| Rate for Payer: First Health Commercial |
$390.60
|
| Rate for Payer: First Health Workers Compensation |
$167.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$390.60
|
| Rate for Payer: GEHA Commercial |
$347.20
|
| Rate for Payer: GEHA Medicare |
$668.09
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$390.60
|
| Rate for Payer: Humana ChoiceCare |
$734.90
|
| Rate for Payer: Humana Medicare Advantage |
$668.09
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,122.39
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$179.56
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$668.09
|
| Rate for Payer: Multiplan All |
$394.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,135.75
|
| Rate for Payer: OMNI Networks Commercial |
$303.80
|
| Rate for Payer: One Health Plan PPO/POS |
$390.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$207.33
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$179.56
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$668.09
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$412.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,336.18
|
| Rate for Payer: Three Rivers Provider Network All |
$325.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$654.73
|
| Rate for Payer: United Healthcare Managed Medicaid |
$179.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$668.09
|
| Rate for Payer: United Payors & United Providers UP&UP |
$403.62
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$668.09
|
| Rate for Payer: Zelis Auto |
$173.60
|
| Rate for Payer: Zelis Medicare |
$567.88
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$801.71
|
| Rate for Payer: Zelis Worker's Compensation |
$118.48
|
|
|
IMAGE-GUIDED CATHETER FLUID COLLECTION D
|
Facility
|
IP
|
$434.00
|
|
|
Service Code
|
CPT 10030
|
| Hospital Charge Code |
6162322
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$118.48 |
| Max. Negotiated Rate |
$412.30 |
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Cigna Commercial |
$368.90
|
| Rate for Payer: First Health Commercial |
$390.60
|
| Rate for Payer: First Health Workers Compensation |
$167.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$390.60
|
| Rate for Payer: GEHA Commercial |
$303.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$390.60
|
| Rate for Payer: Multiplan All |
$394.94
|
| Rate for Payer: OMNI Networks Commercial |
$303.80
|
| Rate for Payer: One Health Plan PPO/POS |
$390.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$412.30
|
| Rate for Payer: Three Rivers Provider Network All |
$325.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$403.62
|
| Rate for Payer: Zelis Auto |
$173.60
|
| Rate for Payer: Zelis Worker's Compensation |
$118.48
|
|
|
IMAGE GUIDED PLCMNT
|
Facility
|
OP
|
$3,025.00
|
|
| Hospital Charge Code |
2766908
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$756.25 |
| Max. Negotiated Rate |
$2,873.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,815.00
|
| Rate for Payer: Cash Price |
$1,815.00
|
| Rate for Payer: Cigna Commercial |
$2,571.25
|
| Rate for Payer: First Health Commercial |
$2,722.50
|
| Rate for Payer: First Health Workers Compensation |
$1,167.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,722.50
|
| Rate for Payer: GEHA Commercial |
$2,420.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,722.50
|
| Rate for Payer: Humana ChoiceCare |
$786.50
|
| Rate for Payer: Multiplan All |
$2,752.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,815.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,117.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,722.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,873.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,268.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,662.00
|
| Rate for Payer: United Healthcare Commercial |
$2,571.25
|
| Rate for Payer: United Healthcare Managed Medicaid |
$756.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,813.25
|
| Rate for Payer: Zelis Auto |
$1,210.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,512.50
|
| Rate for Payer: Zelis Worker's Compensation |
$825.83
|
|
|
IMAGE GUIDED PLCMNT
|
Facility
|
IP
|
$3,025.00
|
|
| Hospital Charge Code |
2766908
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$825.83 |
| Max. Negotiated Rate |
$2,873.75 |
| Rate for Payer: Cash Price |
$1,815.00
|
| Rate for Payer: Cigna Commercial |
$2,571.25
|
| Rate for Payer: First Health Commercial |
$2,722.50
|
| Rate for Payer: First Health Workers Compensation |
$1,167.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,722.50
|
| Rate for Payer: GEHA Commercial |
$2,117.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,722.50
|
| Rate for Payer: Multiplan All |
$2,752.75
|
| Rate for Payer: OMNI Networks Commercial |
$2,117.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,722.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,873.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,268.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,813.25
|
| Rate for Payer: Zelis Auto |
$1,210.00
|
| Rate for Payer: Zelis Worker's Compensation |
$825.83
|
|
|
IMDEVIMAB 300 MG/2.5 ML SUBQ INJ
|
Facility
|
IP
|
$1,370.00
|
|
|
Service Code
|
NDC 61755002601
|
| Hospital Charge Code |
3303075
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$374.01 |
| Max. Negotiated Rate |
$1,301.50 |
| Rate for Payer: Cash Price |
$822.00
|
| Rate for Payer: Cigna Commercial |
$1,164.50
|
| Rate for Payer: First Health Commercial |
$1,233.00
|
| Rate for Payer: First Health Workers Compensation |
$528.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,233.00
|
| Rate for Payer: GEHA Commercial |
$959.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,233.00
|
| Rate for Payer: Multiplan All |
$1,246.70
|
| Rate for Payer: OMNI Networks Commercial |
$959.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,233.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,301.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,027.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,274.10
|
| Rate for Payer: Zelis Auto |
$548.00
|
| Rate for Payer: Zelis Worker's Compensation |
$374.01
|
|
|
IMDEVIMAB 300 MG/2.5 ML SUBQ INJ
|
Facility
|
OP
|
$1,370.00
|
|
|
Service Code
|
NDC 61755002601
|
| Hospital Charge Code |
3303075
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$342.50 |
| Max. Negotiated Rate |
$1,301.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$822.00
|
| Rate for Payer: Cash Price |
$822.00
|
| Rate for Payer: Cigna Commercial |
$1,164.50
|
| Rate for Payer: First Health Commercial |
$1,233.00
|
| Rate for Payer: First Health Workers Compensation |
$528.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,233.00
|
| Rate for Payer: GEHA Commercial |
$1,096.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,233.00
|
| Rate for Payer: Humana ChoiceCare |
$356.20
|
| Rate for Payer: Multiplan All |
$1,246.70
|
| Rate for Payer: New Mexico Health Connections Medicare |
$822.00
|
| Rate for Payer: OMNI Networks Commercial |
$959.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,233.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,301.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,027.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,205.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$342.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,274.10
|
| Rate for Payer: Zelis Auto |
$548.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$685.00
|
| Rate for Payer: Zelis Worker's Compensation |
$374.01
|
|
|
IM INJECTION
|
Facility
|
OP
|
$231.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
6180015
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.50 |
| Max. Negotiated Rate |
$219.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$138.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$30.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$67.58
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$196.35
|
| Rate for Payer: First Health Commercial |
$207.90
|
| Rate for Payer: First Health Workers Compensation |
$89.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$207.90
|
| Rate for Payer: GEHA Commercial |
$184.80
|
| Rate for Payer: GEHA Medicare |
$67.58
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$207.90
|
| Rate for Payer: Humana ChoiceCare |
$74.34
|
| Rate for Payer: Humana Medicare Advantage |
$67.58
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$113.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$31.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$67.58
|
| Rate for Payer: Multiplan All |
$210.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$114.89
|
| Rate for Payer: OMNI Networks Commercial |
$161.70
|
| Rate for Payer: One Health Plan PPO/POS |
$207.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$35.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$31.12
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$67.58
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$219.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$135.16
|
| Rate for Payer: Three Rivers Provider Network All |
$173.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$66.23
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$67.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$214.83
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$67.58
|
| Rate for Payer: Zelis Auto |
$92.40
|
| Rate for Payer: Zelis Medicare |
$57.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.10
|
| Rate for Payer: Zelis Worker's Compensation |
$63.06
|
|
|
IM INJECTION
|
Facility
|
IP
|
$231.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
6180015
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$63.06 |
| Max. Negotiated Rate |
$219.45 |
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$196.35
|
| Rate for Payer: First Health Commercial |
$207.90
|
| Rate for Payer: First Health Workers Compensation |
$89.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$207.90
|
| Rate for Payer: GEHA Commercial |
$161.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$207.90
|
| Rate for Payer: Multiplan All |
$210.21
|
| Rate for Payer: OMNI Networks Commercial |
$161.70
|
| Rate for Payer: One Health Plan PPO/POS |
$207.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$219.45
|
| Rate for Payer: Three Rivers Provider Network All |
$173.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$214.83
|
| Rate for Payer: Zelis Auto |
$92.40
|
| Rate for Payer: Zelis Worker's Compensation |
$63.06
|
|
|
IMIPENEM/CILASTATIN 500 MG/500 MG PWVL
|
Facility
|
OP
|
$122.00
|
|
|
Service Code
|
CPT J0743
|
| Hospital Charge Code |
3302628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.28 |
| Max. Negotiated Rate |
$115.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$103.70
|
| Rate for Payer: First Health Commercial |
$109.80
|
| Rate for Payer: First Health Workers Compensation |
$47.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$109.80
|
| Rate for Payer: GEHA Commercial |
$11.28
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$109.80
|
| Rate for Payer: Humana ChoiceCare |
$31.72
|
| Rate for Payer: Multiplan All |
$111.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$73.20
|
| Rate for Payer: OMNI Networks Commercial |
$85.40
|
| Rate for Payer: One Health Plan PPO/POS |
$109.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$115.90
|
| Rate for Payer: Three Rivers Provider Network All |
$91.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$107.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$30.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$113.46
|
| Rate for Payer: Zelis Auto |
$48.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$61.00
|
| Rate for Payer: Zelis Worker's Compensation |
$33.31
|
|
|
IMIPENEM/CILASTATIN 500 MG/500 MG PWVL
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
CPT J0743
|
| Hospital Charge Code |
3302628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.31 |
| Max. Negotiated Rate |
$115.90 |
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$103.70
|
| Rate for Payer: First Health Commercial |
$109.80
|
| Rate for Payer: First Health Workers Compensation |
$47.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$109.80
|
| Rate for Payer: GEHA Commercial |
$85.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$109.80
|
| Rate for Payer: Multiplan All |
$111.02
|
| Rate for Payer: OMNI Networks Commercial |
$85.40
|
| Rate for Payer: One Health Plan PPO/POS |
$109.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$115.90
|
| Rate for Payer: Three Rivers Provider Network All |
$91.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$113.46
|
| Rate for Payer: Zelis Auto |
$48.80
|
| Rate for Payer: Zelis Worker's Compensation |
$33.31
|
|
|
IMIPRAMINE HCL TAB 25MG
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
NDC 53489033101
|
| Hospital Charge Code |
3300446
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.25 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22.20
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$29.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Humana ChoiceCare |
$9.62
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.20
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$32.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$18.50
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
IMIPRAMINE HCL TAB 25MG
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
NDC 53489033101
|
| Hospital Charge Code |
3300446
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$25.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
IMIPRAMINE HCL TAB 50MG
|
Facility
|
OP
|
$44.00
|
|
|
Service Code
|
NDC 00781176613
|
| Hospital Charge Code |
3300447
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$41.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$37.40
|
| Rate for Payer: First Health Commercial |
$39.60
|
| Rate for Payer: First Health Workers Compensation |
$16.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$39.60
|
| Rate for Payer: GEHA Commercial |
$35.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$39.60
|
| Rate for Payer: Humana ChoiceCare |
$11.44
|
| Rate for Payer: Multiplan All |
$40.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$26.40
|
| Rate for Payer: OMNI Networks Commercial |
$30.80
|
| Rate for Payer: One Health Plan PPO/POS |
$39.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$41.80
|
| Rate for Payer: Three Rivers Provider Network All |
$33.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$38.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$40.92
|
| Rate for Payer: Zelis Auto |
$17.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.01
|
|
|
IMIPRAMINE HCL TAB 50MG
|
Facility
|
IP
|
$44.00
|
|
|
Service Code
|
NDC 00781176613
|
| Hospital Charge Code |
3300447
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.01 |
| Max. Negotiated Rate |
$41.80 |
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$37.40
|
| Rate for Payer: First Health Commercial |
$39.60
|
| Rate for Payer: First Health Workers Compensation |
$16.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$39.60
|
| Rate for Payer: GEHA Commercial |
$30.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$39.60
|
| Rate for Payer: Multiplan All |
$40.04
|
| Rate for Payer: OMNI Networks Commercial |
$30.80
|
| Rate for Payer: One Health Plan PPO/POS |
$39.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$41.80
|
| Rate for Payer: Three Rivers Provider Network All |
$33.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$40.92
|
| Rate for Payer: Zelis Auto |
$17.60
|
| Rate for Payer: Zelis Worker's Compensation |
$12.01
|
|
|
imipramine REF007468
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
2200106
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$120.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$76.20
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$107.95
|
| Rate for Payer: First Health Commercial |
$114.30
|
| Rate for Payer: First Health Workers Compensation |
$27.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$114.30
|
| Rate for Payer: GEHA Commercial |
$101.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$114.30
|
| Rate for Payer: Humana ChoiceCare |
$33.02
|
| Rate for Payer: Multiplan All |
$115.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$76.20
|
| Rate for Payer: OMNI Networks Commercial |
$88.90
|
| Rate for Payer: One Health Plan PPO/POS |
$114.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$120.65
|
| Rate for Payer: Three Rivers Provider Network All |
$95.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$111.76
|
| Rate for Payer: United Healthcare Commercial |
$107.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$118.11
|
| Rate for Payer: Zelis Auto |
$50.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$63.50
|
| Rate for Payer: Zelis Worker's Compensation |
$19.29
|
|
