|
ALBUTEROL INHALER 90MCG - 18G
|
Facility
|
OP
|
$291.00
|
|
|
Service Code
|
NDC 00173068220
|
| Hospital Charge Code |
3301645
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$72.75 |
| Max. Negotiated Rate |
$276.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$174.60
|
| Rate for Payer: Cash Price |
$174.60
|
| Rate for Payer: Cigna Commercial |
$247.35
|
| Rate for Payer: First Health Commercial |
$261.90
|
| Rate for Payer: First Health Workers Compensation |
$112.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$261.90
|
| Rate for Payer: GEHA Commercial |
$232.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$261.90
|
| Rate for Payer: Humana ChoiceCare |
$75.66
|
| Rate for Payer: Multiplan All |
$264.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$174.60
|
| Rate for Payer: OMNI Networks Commercial |
$203.70
|
| Rate for Payer: One Health Plan PPO/POS |
$261.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$276.45
|
| Rate for Payer: Three Rivers Provider Network All |
$218.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$256.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$72.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$270.63
|
| Rate for Payer: Zelis Auto |
$116.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$145.50
|
| Rate for Payer: Zelis Worker's Compensation |
$79.44
|
|
|
ALBUTEROL INHALER 90MCG - 18G
|
Facility
|
IP
|
$291.00
|
|
|
Service Code
|
NDC 00173068220
|
| Hospital Charge Code |
3301645
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$79.44 |
| Max. Negotiated Rate |
$276.45 |
| Rate for Payer: Cash Price |
$174.60
|
| Rate for Payer: Cigna Commercial |
$247.35
|
| Rate for Payer: First Health Commercial |
$261.90
|
| Rate for Payer: First Health Workers Compensation |
$112.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$261.90
|
| Rate for Payer: GEHA Commercial |
$203.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$261.90
|
| Rate for Payer: Multiplan All |
$264.81
|
| Rate for Payer: OMNI Networks Commercial |
$203.70
|
| Rate for Payer: One Health Plan PPO/POS |
$261.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$276.45
|
| Rate for Payer: Three Rivers Provider Network All |
$218.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$270.63
|
| Rate for Payer: Zelis Auto |
$116.40
|
| Rate for Payer: Zelis Worker's Compensation |
$79.44
|
|
|
ALBUTEROL INH - MDI
|
Facility
|
IP
|
$183.00
|
|
|
Service Code
|
NDC 00173068224
|
| Hospital Charge Code |
3300026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.96 |
| Max. Negotiated Rate |
$173.85 |
| Rate for Payer: Cash Price |
$109.80
|
| Rate for Payer: Cigna Commercial |
$155.55
|
| Rate for Payer: First Health Commercial |
$164.70
|
| Rate for Payer: First Health Workers Compensation |
$70.66
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$164.70
|
| Rate for Payer: GEHA Commercial |
$128.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$164.70
|
| Rate for Payer: Multiplan All |
$166.53
|
| Rate for Payer: OMNI Networks Commercial |
$128.10
|
| Rate for Payer: One Health Plan PPO/POS |
$164.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$173.85
|
| Rate for Payer: Three Rivers Provider Network All |
$137.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$170.19
|
| Rate for Payer: Zelis Auto |
$73.20
|
| Rate for Payer: Zelis Worker's Compensation |
$49.96
|
|
|
ALBUTEROL INH - MDI
|
Facility
|
OP
|
$183.00
|
|
|
Service Code
|
NDC 00173068224
|
| Hospital Charge Code |
3300026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.75 |
| Max. Negotiated Rate |
$173.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$109.80
|
| Rate for Payer: Cash Price |
$109.80
|
| Rate for Payer: Cigna Commercial |
$155.55
|
| Rate for Payer: First Health Commercial |
$164.70
|
| Rate for Payer: First Health Workers Compensation |
$70.66
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$164.70
|
| Rate for Payer: GEHA Commercial |
$146.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$164.70
|
| Rate for Payer: Humana ChoiceCare |
$47.58
|
| Rate for Payer: Multiplan All |
$166.53
|
| Rate for Payer: New Mexico Health Connections Medicare |
$109.80
|
| Rate for Payer: OMNI Networks Commercial |
$128.10
|
| Rate for Payer: One Health Plan PPO/POS |
$164.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$173.85
|
| Rate for Payer: Three Rivers Provider Network All |
$137.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$161.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$45.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$170.19
|
| Rate for Payer: Zelis Auto |
$73.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$91.50
|
| Rate for Payer: Zelis Worker's Compensation |
$49.96
|
|
|
ALBUTEROL RESPICLICK
|
Facility
|
OP
|
$360.00
|
|
|
Service Code
|
NDC 59310058020
|
| Hospital Charge Code |
3301690
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.00 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$216.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$306.00
|
| Rate for Payer: First Health Commercial |
$324.00
|
| Rate for Payer: First Health Workers Compensation |
$139.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$324.00
|
| Rate for Payer: GEHA Commercial |
$288.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$324.00
|
| Rate for Payer: Humana ChoiceCare |
$93.60
|
| Rate for Payer: Multiplan All |
$327.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$216.00
|
| Rate for Payer: OMNI Networks Commercial |
$252.00
|
| Rate for Payer: One Health Plan PPO/POS |
$324.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$342.00
|
| Rate for Payer: Three Rivers Provider Network All |
$270.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$316.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$90.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$334.80
|
| Rate for Payer: Zelis Auto |
$144.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$180.00
|
| Rate for Payer: Zelis Worker's Compensation |
$98.28
|
|
|
ALBUTEROL RESPICLICK
|
Facility
|
IP
|
$360.00
|
|
|
Service Code
|
NDC 59310058020
|
| Hospital Charge Code |
3301690
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.28 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$306.00
|
| Rate for Payer: First Health Commercial |
$324.00
|
| Rate for Payer: First Health Workers Compensation |
$139.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$324.00
|
| Rate for Payer: GEHA Commercial |
$252.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$324.00
|
| Rate for Payer: Multiplan All |
$327.60
|
| Rate for Payer: OMNI Networks Commercial |
$252.00
|
| Rate for Payer: One Health Plan PPO/POS |
$324.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$342.00
|
| Rate for Payer: Three Rivers Provider Network All |
$270.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$334.80
|
| Rate for Payer: Zelis Auto |
$144.00
|
| Rate for Payer: Zelis Worker's Compensation |
$98.28
|
|
|
ALBUTEROL SULFATE 2MG TAB
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 53489017601
|
| Hospital Charge Code |
3300027
|
|
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
|
|
|
ALBUTEROL SULFATE 2MG TAB
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 53489017601
|
| Hospital Charge Code |
3300027
|
|
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
|
|
|
ALBUTEROL SYRUP 2MG/5ML
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00603100858
|
| Hospital Charge Code |
3300028
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| 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: 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 |
$4.80
|
| 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
|
|
|
ALBUTEROL SYRUP 2MG/5ML
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00603100858
|
| Hospital Charge Code |
3300028
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
ALCOHOL AND/OR DRUG SCREENING
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT H0049
|
| Hospital Charge Code |
810049
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$13.65 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$42.50
|
| Rate for Payer: First Health Commercial |
$45.00
|
| Rate for Payer: First Health Workers Compensation |
$19.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.00
|
| Rate for Payer: GEHA Commercial |
$35.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Multiplan All |
$45.50
|
| Rate for Payer: OMNI Networks Commercial |
$35.00
|
| Rate for Payer: One Health Plan PPO/POS |
$45.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47.50
|
| Rate for Payer: Three Rivers Provider Network All |
$37.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46.50
|
| Rate for Payer: Zelis Auto |
$20.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.65
|
|
|
ALCOHOL AND/OR DRUG SCREENING
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT H0049
|
| Hospital Charge Code |
810049
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$40.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$40.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$32.08
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$42.50
|
| Rate for Payer: First Health Commercial |
$45.00
|
| Rate for Payer: First Health Workers Compensation |
$19.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.00
|
| Rate for Payer: GEHA Commercial |
$40.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Humana ChoiceCare |
$13.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$32.74
|
| Rate for Payer: Multiplan All |
$45.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.00
|
| Rate for Payer: OMNI Networks Commercial |
$35.00
|
| Rate for Payer: One Health Plan PPO/POS |
$45.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$37.80
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$32.74
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47.50
|
| Rate for Payer: Three Rivers Provider Network All |
$37.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$44.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$32.74
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46.50
|
| Rate for Payer: Zelis Auto |
$20.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$25.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.65
|
|
|
ALCOHOL AND/OR DRUG SCREENING
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT H0049
|
| Hospital Charge Code |
850049
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$40.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$40.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$32.08
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$42.50
|
| Rate for Payer: First Health Commercial |
$45.00
|
| Rate for Payer: First Health Workers Compensation |
$19.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.00
|
| Rate for Payer: GEHA Commercial |
$40.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Humana ChoiceCare |
$13.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$32.74
|
| Rate for Payer: Multiplan All |
$45.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.00
|
| Rate for Payer: OMNI Networks Commercial |
$35.00
|
| Rate for Payer: One Health Plan PPO/POS |
$45.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$37.80
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$32.74
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47.50
|
| Rate for Payer: Three Rivers Provider Network All |
$37.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$44.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$32.74
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46.50
|
| Rate for Payer: Zelis Auto |
$20.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$25.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.65
|
|
|
ALCOHOL AND/OR DRUG SCREENING
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT H0049
|
| Hospital Charge Code |
850049
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$13.65 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$42.50
|
| Rate for Payer: First Health Commercial |
$45.00
|
| Rate for Payer: First Health Workers Compensation |
$19.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.00
|
| Rate for Payer: GEHA Commercial |
$35.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Multiplan All |
$45.50
|
| Rate for Payer: OMNI Networks Commercial |
$35.00
|
| Rate for Payer: One Health Plan PPO/POS |
$45.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47.50
|
| Rate for Payer: Three Rivers Provider Network All |
$37.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46.50
|
| Rate for Payer: Zelis Auto |
$20.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.65
|
|
|
ALCOHOL AND/OR DRUG SERVICES, BRIEF INTE
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT H0050
|
| Hospital Charge Code |
850050
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$27.30 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$85.00
|
| Rate for Payer: First Health Commercial |
$90.00
|
| Rate for Payer: First Health Workers Compensation |
$38.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$90.00
|
| Rate for Payer: GEHA Commercial |
$70.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$90.00
|
| Rate for Payer: Multiplan All |
$91.00
|
| Rate for Payer: OMNI Networks Commercial |
$70.00
|
| Rate for Payer: One Health Plan PPO/POS |
$90.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$95.00
|
| Rate for Payer: Three Rivers Provider Network All |
$75.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$93.00
|
| Rate for Payer: Zelis Auto |
$40.00
|
| Rate for Payer: Zelis Worker's Compensation |
$27.30
|
|
|
ALCOHOL AND/OR DRUG SERVICES, BRIEF INTE
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT H0050
|
| Hospital Charge Code |
850050
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$81.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$60.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$81.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$64.17
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$85.00
|
| Rate for Payer: First Health Commercial |
$90.00
|
| Rate for Payer: First Health Workers Compensation |
$38.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$90.00
|
| Rate for Payer: GEHA Commercial |
$80.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$90.00
|
| Rate for Payer: Humana ChoiceCare |
$26.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$65.47
|
| Rate for Payer: Multiplan All |
$91.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$60.00
|
| Rate for Payer: OMNI Networks Commercial |
$70.00
|
| Rate for Payer: One Health Plan PPO/POS |
$90.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$75.60
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$65.47
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$95.00
|
| Rate for Payer: Three Rivers Provider Network All |
$75.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$88.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$65.47
|
| Rate for Payer: United Payors & United Providers UP&UP |
$93.00
|
| Rate for Payer: Zelis Auto |
$40.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$50.00
|
| Rate for Payer: Zelis Worker's Compensation |
$27.30
|
|
|
ALCOHOL/DRUG BRIEF INTRVNTN SRVCE 15 MIN
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT H0050
|
| Hospital Charge Code |
810050
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$27.30 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$85.00
|
| Rate for Payer: First Health Commercial |
$90.00
|
| Rate for Payer: First Health Workers Compensation |
$38.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$90.00
|
| Rate for Payer: GEHA Commercial |
$70.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$90.00
|
| Rate for Payer: Multiplan All |
$91.00
|
| Rate for Payer: OMNI Networks Commercial |
$70.00
|
| Rate for Payer: One Health Plan PPO/POS |
$90.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$95.00
|
| Rate for Payer: Three Rivers Provider Network All |
$75.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$93.00
|
| Rate for Payer: Zelis Auto |
$40.00
|
| Rate for Payer: Zelis Worker's Compensation |
$27.30
|
|
|
ALCOHOL/DRUG BRIEF INTRVNTN SRVCE 15 MIN
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT H0050
|
| Hospital Charge Code |
810050
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$81.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$60.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$81.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$64.17
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$85.00
|
| Rate for Payer: First Health Commercial |
$90.00
|
| Rate for Payer: First Health Workers Compensation |
$38.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$90.00
|
| Rate for Payer: GEHA Commercial |
$80.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$90.00
|
| Rate for Payer: Humana ChoiceCare |
$26.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$65.47
|
| Rate for Payer: Multiplan All |
$91.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$60.00
|
| Rate for Payer: OMNI Networks Commercial |
$70.00
|
| Rate for Payer: One Health Plan PPO/POS |
$90.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$75.60
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$65.47
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$95.00
|
| Rate for Payer: Three Rivers Provider Network All |
$75.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$88.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$65.47
|
| Rate for Payer: United Payors & United Providers UP&UP |
$93.00
|
| Rate for Payer: Zelis Auto |
$40.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$50.00
|
| Rate for Payer: Zelis Worker's Compensation |
$27.30
|
|
|
ALCOHOL/SBSTNCE SCRN & INTRVNTN > 30 MIN
|
Facility
|
IP
|
$65.51
|
|
|
Service Code
|
CPT 99409
|
| Hospital Charge Code |
8599409
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$17.88 |
| Max. Negotiated Rate |
$62.23 |
| Rate for Payer: Cash Price |
$39.31
|
| Rate for Payer: Cigna Commercial |
$55.68
|
| Rate for Payer: First Health Commercial |
$58.96
|
| Rate for Payer: First Health Workers Compensation |
$25.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$58.96
|
| Rate for Payer: GEHA Commercial |
$45.86
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$58.96
|
| Rate for Payer: Multiplan All |
$59.61
|
| Rate for Payer: OMNI Networks Commercial |
$45.86
|
| Rate for Payer: One Health Plan PPO/POS |
$58.96
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$62.23
|
| Rate for Payer: Three Rivers Provider Network All |
$49.13
|
| Rate for Payer: United Payors & United Providers UP&UP |
$60.92
|
| Rate for Payer: Zelis Auto |
$26.20
|
| Rate for Payer: Zelis Worker's Compensation |
$17.88
|
|
|
ALCOHOL/SBSTNCE SCRN & INTRVNTN > 30 MIN
|
Facility
|
OP
|
$65.51
|
|
|
Service Code
|
CPT 99409
|
| Hospital Charge Code |
8599409
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$16.38 |
| Max. Negotiated Rate |
$62.23 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$39.31
|
| Rate for Payer: Cash Price |
$39.31
|
| Rate for Payer: Cigna Commercial |
$55.68
|
| Rate for Payer: First Health Commercial |
$58.96
|
| Rate for Payer: First Health Workers Compensation |
$25.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$58.96
|
| Rate for Payer: GEHA Commercial |
$52.41
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$58.96
|
| Rate for Payer: Humana ChoiceCare |
$17.03
|
| Rate for Payer: Multiplan All |
$59.61
|
| Rate for Payer: New Mexico Health Connections Medicare |
$39.31
|
| Rate for Payer: OMNI Networks Commercial |
$45.86
|
| Rate for Payer: One Health Plan PPO/POS |
$58.96
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$62.23
|
| Rate for Payer: Three Rivers Provider Network All |
$49.13
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$57.65
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.38
|
| Rate for Payer: United Payors & United Providers UP&UP |
$60.92
|
| Rate for Payer: Zelis Auto |
$26.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$32.76
|
| Rate for Payer: Zelis Worker's Compensation |
$17.88
|
|
|
ALCOHOL/SUB ABUSE ASSESS
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT G2011
|
| Hospital Charge Code |
9599225
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$13.92 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$43.35
|
| Rate for Payer: First Health Commercial |
$45.90
|
| Rate for Payer: First Health Workers Compensation |
$19.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.90
|
| Rate for Payer: GEHA Commercial |
$35.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.90
|
| Rate for Payer: Multiplan All |
$46.41
|
| Rate for Payer: OMNI Networks Commercial |
$35.70
|
| Rate for Payer: One Health Plan PPO/POS |
$45.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$48.45
|
| Rate for Payer: Three Rivers Provider Network All |
$38.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$47.43
|
| Rate for Payer: Zelis Auto |
$20.40
|
| Rate for Payer: Zelis Worker's Compensation |
$13.92
|
|
|
ALCOHOL/SUB ABUSE ASSESS
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
CPT G2011
|
| Hospital Charge Code |
9599225
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$13.92 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$25.75
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$25.75
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$20.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$23.25
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$43.35
|
| Rate for Payer: First Health Commercial |
$45.90
|
| Rate for Payer: First Health Workers Compensation |
$19.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.90
|
| Rate for Payer: GEHA Commercial |
$40.80
|
| Rate for Payer: GEHA Medicare |
$23.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.90
|
| Rate for Payer: Humana ChoiceCare |
$25.57
|
| Rate for Payer: Humana Medicare Advantage |
$23.25
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$39.06
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$20.82
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$23.25
|
| Rate for Payer: Multiplan All |
$46.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$39.52
|
| Rate for Payer: OMNI Networks Commercial |
$35.70
|
| Rate for Payer: One Health Plan PPO/POS |
$45.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$24.04
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$20.82
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$23.25
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$48.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$46.50
|
| Rate for Payer: Three Rivers Provider Network All |
$38.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$22.79
|
| Rate for Payer: United Healthcare Managed Medicaid |
$20.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$47.43
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$23.25
|
| Rate for Payer: Zelis Auto |
$20.40
|
| Rate for Payer: Zelis Medicare |
$19.76
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$27.90
|
| Rate for Payer: Zelis Worker's Compensation |
$13.92
|
|
|
ALCOHOL/SUB ABUSE ASSESS
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT G2011
|
| Hospital Charge Code |
8499225
|
|
Hospital Revenue Code
|
513
|
| Min. Negotiated Rate |
$13.92 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$43.35
|
| Rate for Payer: First Health Commercial |
$45.90
|
| Rate for Payer: First Health Workers Compensation |
$19.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.90
|
| Rate for Payer: GEHA Commercial |
$35.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.90
|
| Rate for Payer: Multiplan All |
$46.41
|
| Rate for Payer: OMNI Networks Commercial |
$35.70
|
| Rate for Payer: One Health Plan PPO/POS |
$45.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$48.45
|
| Rate for Payer: Three Rivers Provider Network All |
$38.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$47.43
|
| Rate for Payer: Zelis Auto |
$20.40
|
| Rate for Payer: Zelis Worker's Compensation |
$13.92
|
|
|
ALCOHOL/SUB ABUSE ASSESS
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
CPT G2011
|
| Hospital Charge Code |
8499225
|
|
Hospital Revenue Code
|
513
|
| Min. Negotiated Rate |
$13.92 |
| Max. Negotiated Rate |
$80.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$25.75
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$25.75
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$20.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$23.25
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$43.35
|
| Rate for Payer: First Health Commercial |
$45.90
|
| Rate for Payer: First Health Workers Compensation |
$19.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.90
|
| Rate for Payer: GEHA Commercial |
$40.80
|
| Rate for Payer: GEHA Medicare |
$23.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.90
|
| Rate for Payer: Humana ChoiceCare |
$25.57
|
| Rate for Payer: Humana Medicare Advantage |
$23.25
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$39.06
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$20.82
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$23.25
|
| Rate for Payer: Multiplan All |
$46.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$39.52
|
| Rate for Payer: OMNI Networks Commercial |
$35.70
|
| Rate for Payer: One Health Plan PPO/POS |
$45.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$24.04
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$80.00
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$23.25
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$48.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$46.50
|
| Rate for Payer: Three Rivers Provider Network All |
$38.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$22.79
|
| Rate for Payer: United Healthcare Managed Medicaid |
$20.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$47.43
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$23.25
|
| Rate for Payer: Zelis Auto |
$20.40
|
| Rate for Payer: Zelis Medicare |
$19.76
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$27.90
|
| Rate for Payer: Zelis Worker's Compensation |
$13.92
|
|
|
ALCOHOL/SUBS INTERV 15-30MN
|
Facility
|
IP
|
$29.42
|
|
|
Service Code
|
CPT G0396
|
| Hospital Charge Code |
810396
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$8.03 |
| Max. Negotiated Rate |
$27.95 |
| Rate for Payer: Cash Price |
$17.65
|
| Rate for Payer: Cigna Commercial |
$25.01
|
| Rate for Payer: First Health Commercial |
$26.48
|
| Rate for Payer: First Health Workers Compensation |
$11.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$26.48
|
| Rate for Payer: GEHA Commercial |
$20.59
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$26.48
|
| Rate for Payer: Multiplan All |
$26.77
|
| Rate for Payer: OMNI Networks Commercial |
$20.59
|
| Rate for Payer: One Health Plan PPO/POS |
$26.48
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$27.95
|
| Rate for Payer: Three Rivers Provider Network All |
$22.07
|
| Rate for Payer: United Payors & United Providers UP&UP |
$27.36
|
| Rate for Payer: Zelis Auto |
$11.77
|
| Rate for Payer: Zelis Worker's Compensation |
$8.03
|
|
