|
AMPICILLIN 1GM VIAL
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
3300060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$24.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$22.10
|
| Rate for Payer: First Health Commercial |
$23.40
|
| Rate for Payer: First Health Workers Compensation |
$10.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$23.40
|
| Rate for Payer: GEHA Commercial |
$0.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$23.40
|
| Rate for Payer: Humana ChoiceCare |
$6.76
|
| Rate for Payer: Multiplan All |
$23.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$15.60
|
| Rate for Payer: OMNI Networks Commercial |
$18.20
|
| Rate for Payer: One Health Plan PPO/POS |
$23.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$24.70
|
| Rate for Payer: Three Rivers Provider Network All |
$19.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$22.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$24.18
|
| Rate for Payer: Zelis Auto |
$10.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$13.00
|
| Rate for Payer: Zelis Worker's Compensation |
$7.10
|
|
|
AMPICILLIN 1GM VIAL
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
3300060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.10 |
| Max. Negotiated Rate |
$24.70 |
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$22.10
|
| Rate for Payer: First Health Commercial |
$23.40
|
| Rate for Payer: First Health Workers Compensation |
$10.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$23.40
|
| Rate for Payer: GEHA Commercial |
$18.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$23.40
|
| Rate for Payer: Multiplan All |
$23.66
|
| Rate for Payer: OMNI Networks Commercial |
$18.20
|
| Rate for Payer: One Health Plan PPO/POS |
$23.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$24.70
|
| Rate for Payer: Three Rivers Provider Network All |
$19.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$24.18
|
| Rate for Payer: Zelis Auto |
$10.40
|
| Rate for Payer: Zelis Worker's Compensation |
$7.10
|
|
|
AMPICILLIN 250 MG VIAL
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
3302899
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| 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: 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 |
$0.61
|
| 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
|
|
|
AMPICILLIN 250 MG VIAL
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
3302899
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
AMPICILLIN CAP 250MG
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 67253018010
|
| Hospital Charge Code |
3300061
|
|
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
|
|
|
AMPICILLIN CAP 250MG
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 67253018010
|
| Hospital Charge Code |
3300061
|
|
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
|
|
|
AMPICILLIN & SULBACTAM 1.5GM VIAL
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT J0295
|
| Hospital Charge Code |
3300058
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
AMPICILLIN & SULBACTAM 1.5GM VIAL
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT J0295
|
| Hospital Charge Code |
3300058
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30.00
|
| 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 |
$1.53
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Humana ChoiceCare |
$13.00
|
| 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: 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 |
$12.50
|
| 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
|
|
|
AMPICILLIN & SULBACTAM 3GM VIAL
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
CPT J0295
|
| Hospital Charge Code |
3300059
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$45.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$40.80
|
| Rate for Payer: First Health Commercial |
$43.20
|
| Rate for Payer: First Health Workers Compensation |
$18.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$43.20
|
| Rate for Payer: GEHA Commercial |
$1.53
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$43.20
|
| Rate for Payer: Humana ChoiceCare |
$12.48
|
| Rate for Payer: Multiplan All |
$43.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$28.80
|
| Rate for Payer: OMNI Networks Commercial |
$33.60
|
| Rate for Payer: One Health Plan PPO/POS |
$43.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$45.60
|
| Rate for Payer: Three Rivers Provider Network All |
$36.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$42.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$44.64
|
| Rate for Payer: Zelis Auto |
$19.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$24.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.10
|
|
|
AMPICILLIN & SULBACTAM 3GM VIAL
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
CPT J0295
|
| Hospital Charge Code |
3300059
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.10 |
| Max. Negotiated Rate |
$45.60 |
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$40.80
|
| Rate for Payer: First Health Commercial |
$43.20
|
| Rate for Payer: First Health Workers Compensation |
$18.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$43.20
|
| Rate for Payer: GEHA Commercial |
$33.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$43.20
|
| Rate for Payer: Multiplan All |
$43.68
|
| Rate for Payer: OMNI Networks Commercial |
$33.60
|
| Rate for Payer: One Health Plan PPO/POS |
$43.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$45.60
|
| Rate for Payer: Three Rivers Provider Network All |
$36.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$44.64
|
| Rate for Payer: Zelis Auto |
$19.20
|
| Rate for Payer: Zelis Worker's Compensation |
$13.10
|
|
|
AMPUTATE HAND AT WRIST
|
Facility
|
OP
|
$1,171.00
|
|
|
Service Code
|
CPT 25922
|
| Hospital Charge Code |
6125922
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$319.68 |
| Max. Negotiated Rate |
$3,101.54 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,225.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$702.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,225.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,763.37
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,550.77
|
| Rate for Payer: Cash Price |
$702.60
|
| Rate for Payer: Cash Price |
$702.60
|
| Rate for Payer: Cigna Commercial |
$995.35
|
| Rate for Payer: First Health Commercial |
$1,053.90
|
| Rate for Payer: First Health Workers Compensation |
$452.12
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,053.90
|
| Rate for Payer: GEHA Commercial |
$936.80
|
| Rate for Payer: GEHA Medicare |
$1,550.77
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,053.90
|
| Rate for Payer: Humana ChoiceCare |
$1,705.85
|
| Rate for Payer: Humana Medicare Advantage |
$1,550.77
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,605.29
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,799.28
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,550.77
|
| Rate for Payer: Multiplan All |
$1,065.61
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,636.31
|
| Rate for Payer: OMNI Networks Commercial |
$819.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,053.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,077.52
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,799.28
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,550.77
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,112.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,101.54
|
| Rate for Payer: Three Rivers Provider Network All |
$878.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,519.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,799.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,550.77
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,089.03
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,550.77
|
| Rate for Payer: Zelis Auto |
$468.40
|
| Rate for Payer: Zelis Medicare |
$1,318.15
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,860.92
|
| Rate for Payer: Zelis Worker's Compensation |
$319.68
|
|
|
AMPUTATE HAND AT WRIST
|
Facility
|
IP
|
$1,171.00
|
|
|
Service Code
|
CPT 25922
|
| Hospital Charge Code |
6125922
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$319.68 |
| Max. Negotiated Rate |
$1,112.45 |
| Rate for Payer: Cash Price |
$702.60
|
| Rate for Payer: Cigna Commercial |
$995.35
|
| Rate for Payer: First Health Commercial |
$1,053.90
|
| Rate for Payer: First Health Workers Compensation |
$452.12
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,053.90
|
| Rate for Payer: GEHA Commercial |
$819.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,053.90
|
| Rate for Payer: Multiplan All |
$1,065.61
|
| Rate for Payer: OMNI Networks Commercial |
$819.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,053.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,112.45
|
| Rate for Payer: Three Rivers Provider Network All |
$878.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,089.03
|
| Rate for Payer: Zelis Auto |
$468.40
|
| Rate for Payer: Zelis Worker's Compensation |
$319.68
|
|
|
AMPUTATE HAND AT WRIST
|
Facility
|
IP
|
$1,417.00
|
|
|
Service Code
|
CPT 25920
|
| Hospital Charge Code |
6125920
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$386.84 |
| Max. Negotiated Rate |
$1,346.15 |
| Rate for Payer: Cash Price |
$850.20
|
| Rate for Payer: Cigna Commercial |
$1,204.45
|
| Rate for Payer: First Health Commercial |
$1,275.30
|
| Rate for Payer: First Health Workers Compensation |
$547.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,275.30
|
| Rate for Payer: GEHA Commercial |
$991.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,275.30
|
| Rate for Payer: Multiplan All |
$1,289.47
|
| Rate for Payer: OMNI Networks Commercial |
$991.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,275.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,346.15
|
| Rate for Payer: Three Rivers Provider Network All |
$1,062.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,317.81
|
| Rate for Payer: Zelis Auto |
$566.80
|
| Rate for Payer: Zelis Worker's Compensation |
$386.84
|
|
|
AMPUTATE HAND AT WRIST
|
Facility
|
OP
|
$1,417.00
|
|
|
Service Code
|
CPT 25920
|
| Hospital Charge Code |
6125920
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$354.25 |
| Max. Negotiated Rate |
$1,346.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$850.20
|
| Rate for Payer: Cash Price |
$850.20
|
| Rate for Payer: Cigna Commercial |
$1,204.45
|
| Rate for Payer: First Health Commercial |
$1,275.30
|
| Rate for Payer: First Health Workers Compensation |
$547.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,275.30
|
| Rate for Payer: GEHA Commercial |
$1,133.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,275.30
|
| Rate for Payer: Humana ChoiceCare |
$368.42
|
| Rate for Payer: Multiplan All |
$1,289.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$850.20
|
| Rate for Payer: OMNI Networks Commercial |
$991.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,275.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,346.15
|
| Rate for Payer: Three Rivers Provider Network All |
$1,062.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,246.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$354.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,317.81
|
| Rate for Payer: Zelis Auto |
$566.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$708.50
|
| Rate for Payer: Zelis Worker's Compensation |
$386.84
|
|
|
AMPUTATE LEG AT THIGH
|
Facility
|
IP
|
$1,987.00
|
|
|
Service Code
|
CPT 27591
|
| Hospital Charge Code |
6127591
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$542.45 |
| Max. Negotiated Rate |
$1,887.65 |
| Rate for Payer: Cash Price |
$1,192.20
|
| Rate for Payer: Cigna Commercial |
$1,688.95
|
| Rate for Payer: First Health Commercial |
$1,788.30
|
| Rate for Payer: First Health Workers Compensation |
$767.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,788.30
|
| Rate for Payer: GEHA Commercial |
$1,390.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,788.30
|
| Rate for Payer: Multiplan All |
$1,808.17
|
| Rate for Payer: OMNI Networks Commercial |
$1,390.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,788.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,887.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,490.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,847.91
|
| Rate for Payer: Zelis Auto |
$794.80
|
| Rate for Payer: Zelis Worker's Compensation |
$542.45
|
|
|
AMPUTATE LEG AT THIGH
|
Facility
|
IP
|
$1,435.00
|
|
|
Service Code
|
CPT 27592
|
| Hospital Charge Code |
6127592
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$391.75 |
| Max. Negotiated Rate |
$1,363.25 |
| Rate for Payer: Cash Price |
$861.00
|
| Rate for Payer: Cigna Commercial |
$1,219.75
|
| Rate for Payer: First Health Commercial |
$1,291.50
|
| Rate for Payer: First Health Workers Compensation |
$554.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,291.50
|
| Rate for Payer: GEHA Commercial |
$1,004.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,291.50
|
| Rate for Payer: Multiplan All |
$1,305.85
|
| Rate for Payer: OMNI Networks Commercial |
$1,004.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,291.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,363.25
|
| Rate for Payer: Three Rivers Provider Network All |
$1,076.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,334.55
|
| Rate for Payer: Zelis Auto |
$574.00
|
| Rate for Payer: Zelis Worker's Compensation |
$391.75
|
|
|
AMPUTATE LEG AT THIGH
|
Facility
|
OP
|
$1,435.00
|
|
|
Service Code
|
CPT 27592
|
| Hospital Charge Code |
6127592
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$358.75 |
| Max. Negotiated Rate |
$1,363.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$861.00
|
| Rate for Payer: Cash Price |
$861.00
|
| Rate for Payer: Cigna Commercial |
$1,219.75
|
| Rate for Payer: First Health Commercial |
$1,291.50
|
| Rate for Payer: First Health Workers Compensation |
$554.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,291.50
|
| Rate for Payer: GEHA Commercial |
$1,148.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,291.50
|
| Rate for Payer: Humana ChoiceCare |
$373.10
|
| Rate for Payer: Multiplan All |
$1,305.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$861.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,004.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,291.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,363.25
|
| Rate for Payer: Three Rivers Provider Network All |
$1,076.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,262.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$358.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,334.55
|
| Rate for Payer: Zelis Auto |
$574.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$717.50
|
| Rate for Payer: Zelis Worker's Compensation |
$391.75
|
|
|
AMPUTATE LEG AT THIGH
|
Facility
|
OP
|
$1,987.00
|
|
|
Service Code
|
CPT 27591
|
| Hospital Charge Code |
6127591
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$496.75 |
| Max. Negotiated Rate |
$1,887.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,192.20
|
| Rate for Payer: Cash Price |
$1,192.20
|
| Rate for Payer: Cigna Commercial |
$1,688.95
|
| Rate for Payer: First Health Commercial |
$1,788.30
|
| Rate for Payer: First Health Workers Compensation |
$767.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,788.30
|
| Rate for Payer: GEHA Commercial |
$1,589.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,788.30
|
| Rate for Payer: Humana ChoiceCare |
$516.62
|
| Rate for Payer: Multiplan All |
$1,808.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,192.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,390.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,788.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,887.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,490.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,748.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$496.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,847.91
|
| Rate for Payer: Zelis Auto |
$794.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$993.50
|
| Rate for Payer: Zelis Worker's Compensation |
$542.45
|
|
|
AMPUTATE LEG AT THIGH
|
Facility
|
OP
|
$1,697.00
|
|
|
Service Code
|
CPT 27590
|
| Hospital Charge Code |
6127590
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$424.25 |
| Max. Negotiated Rate |
$1,612.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,018.20
|
| Rate for Payer: Cash Price |
$1,018.20
|
| Rate for Payer: Cigna Commercial |
$1,442.45
|
| Rate for Payer: First Health Commercial |
$1,527.30
|
| Rate for Payer: First Health Workers Compensation |
$655.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,527.30
|
| Rate for Payer: GEHA Commercial |
$1,357.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,527.30
|
| Rate for Payer: Humana ChoiceCare |
$441.22
|
| Rate for Payer: Multiplan All |
$1,544.27
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,018.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,187.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,527.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,612.15
|
| Rate for Payer: Three Rivers Provider Network All |
$1,272.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,493.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$424.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,578.21
|
| Rate for Payer: Zelis Auto |
$678.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$848.50
|
| Rate for Payer: Zelis Worker's Compensation |
$463.28
|
|
|
AMPUTATE LEG AT THIGH
|
Facility
|
IP
|
$1,697.00
|
|
|
Service Code
|
CPT 27590
|
| Hospital Charge Code |
6127590
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$463.28 |
| Max. Negotiated Rate |
$1,612.15 |
| Rate for Payer: Cash Price |
$1,018.20
|
| Rate for Payer: Cigna Commercial |
$1,442.45
|
| Rate for Payer: First Health Commercial |
$1,527.30
|
| Rate for Payer: First Health Workers Compensation |
$655.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,527.30
|
| Rate for Payer: GEHA Commercial |
$1,187.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,527.30
|
| Rate for Payer: Multiplan All |
$1,544.27
|
| Rate for Payer: OMNI Networks Commercial |
$1,187.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,527.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,612.15
|
| Rate for Payer: Three Rivers Provider Network All |
$1,272.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,578.21
|
| Rate for Payer: Zelis Auto |
$678.80
|
| Rate for Payer: Zelis Worker's Compensation |
$463.28
|
|
|
AMPUTATE LOWER LEG AT KNEE
|
Facility
|
IP
|
$1,513.00
|
|
|
Service Code
|
CPT 27598
|
| Hospital Charge Code |
6127598
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$413.05 |
| Max. Negotiated Rate |
$1,437.35 |
| Rate for Payer: Cash Price |
$907.80
|
| Rate for Payer: Cigna Commercial |
$1,286.05
|
| Rate for Payer: First Health Commercial |
$1,361.70
|
| Rate for Payer: First Health Workers Compensation |
$584.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,361.70
|
| Rate for Payer: GEHA Commercial |
$1,059.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,361.70
|
| Rate for Payer: Multiplan All |
$1,376.83
|
| Rate for Payer: OMNI Networks Commercial |
$1,059.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,361.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,437.35
|
| Rate for Payer: Three Rivers Provider Network All |
$1,134.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,407.09
|
| Rate for Payer: Zelis Auto |
$605.20
|
| Rate for Payer: Zelis Worker's Compensation |
$413.05
|
|
|
AMPUTATE LOWER LEG AT KNEE
|
Facility
|
OP
|
$1,513.00
|
|
|
Service Code
|
CPT 27598
|
| Hospital Charge Code |
6127598
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$378.25 |
| Max. Negotiated Rate |
$1,437.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$907.80
|
| Rate for Payer: Cash Price |
$907.80
|
| Rate for Payer: Cigna Commercial |
$1,286.05
|
| Rate for Payer: First Health Commercial |
$1,361.70
|
| Rate for Payer: First Health Workers Compensation |
$584.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,361.70
|
| Rate for Payer: GEHA Commercial |
$1,210.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,361.70
|
| Rate for Payer: Humana ChoiceCare |
$393.38
|
| Rate for Payer: Multiplan All |
$1,376.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$907.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,059.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,361.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,437.35
|
| Rate for Payer: Three Rivers Provider Network All |
$1,134.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,331.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$378.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,407.09
|
| Rate for Payer: Zelis Auto |
$605.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$756.50
|
| Rate for Payer: Zelis Worker's Compensation |
$413.05
|
|
|
AMPUTATE METACARPAL BONE
|
Facility
|
IP
|
$1,429.00
|
|
|
Service Code
|
CPT 26910
|
| Hospital Charge Code |
6126910
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$390.12 |
| Max. Negotiated Rate |
$1,357.55 |
| Rate for Payer: Cash Price |
$857.40
|
| Rate for Payer: Cigna Commercial |
$1,214.65
|
| Rate for Payer: First Health Commercial |
$1,286.10
|
| Rate for Payer: First Health Workers Compensation |
$551.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,286.10
|
| Rate for Payer: GEHA Commercial |
$1,000.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,286.10
|
| Rate for Payer: Multiplan All |
$1,300.39
|
| Rate for Payer: OMNI Networks Commercial |
$1,000.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,286.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,357.55
|
| Rate for Payer: Three Rivers Provider Network All |
$1,071.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,328.97
|
| Rate for Payer: Zelis Auto |
$571.60
|
| Rate for Payer: Zelis Worker's Compensation |
$390.12
|
|
|
AMPUTATE METACARPAL BONE
|
Facility
|
OP
|
$1,429.00
|
|
|
Service Code
|
CPT 26910
|
| Hospital Charge Code |
6126910
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$390.12 |
| Max. Negotiated Rate |
$6,287.92 |
| 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 |
$857.40
|
| 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 |
$3,143.96
|
| Rate for Payer: Cash Price |
$857.40
|
| Rate for Payer: Cash Price |
$857.40
|
| Rate for Payer: Cigna Commercial |
$1,214.65
|
| Rate for Payer: First Health Commercial |
$1,286.10
|
| Rate for Payer: First Health Workers Compensation |
$551.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,286.10
|
| Rate for Payer: GEHA Commercial |
$1,143.20
|
| Rate for Payer: GEHA Medicare |
$3,143.96
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,286.10
|
| Rate for Payer: Humana ChoiceCare |
$3,458.36
|
| Rate for Payer: Humana Medicare Advantage |
$3,143.96
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,281.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,307.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,143.96
|
| Rate for Payer: Multiplan All |
$1,300.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,344.73
|
| Rate for Payer: OMNI Networks Commercial |
$1,000.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,286.10
|
| 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 |
$3,143.96
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,357.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,287.92
|
| Rate for Payer: Three Rivers Provider Network All |
$1,071.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,081.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,307.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,143.96
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,328.97
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,143.96
|
| Rate for Payer: Zelis Auto |
$571.60
|
| Rate for Payer: Zelis Medicare |
$2,672.37
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,772.75
|
| Rate for Payer: Zelis Worker's Compensation |
$390.12
|
|
|
AMPUTATE UPPER ARM & IMPLANT
|
Facility
|
OP
|
$1,651.00
|
|
|
Service Code
|
CPT 24931
|
| Hospital Charge Code |
6124931
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$412.75 |
| Max. Negotiated Rate |
$1,568.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$990.60
|
| Rate for Payer: Cash Price |
$990.60
|
| Rate for Payer: Cigna Commercial |
$1,403.35
|
| Rate for Payer: First Health Commercial |
$1,485.90
|
| Rate for Payer: First Health Workers Compensation |
$637.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,485.90
|
| Rate for Payer: GEHA Commercial |
$1,320.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,485.90
|
| Rate for Payer: Humana ChoiceCare |
$429.26
|
| Rate for Payer: Multiplan All |
$1,502.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$990.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,155.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,485.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,568.45
|
| Rate for Payer: Three Rivers Provider Network All |
$1,238.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,452.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$412.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,535.43
|
| Rate for Payer: Zelis Auto |
$660.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$825.50
|
| Rate for Payer: Zelis Worker's Compensation |
$450.72
|
|
