|
anti ss-b REF 012690
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2232307
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$15.24 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$32.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$115.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$32.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$25.57
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$17.93
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$163.20
|
| Rate for Payer: First Health Commercial |
$172.80
|
| Rate for Payer: First Health Workers Compensation |
$29.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$172.80
|
| Rate for Payer: GEHA Commercial |
$153.60
|
| Rate for Payer: GEHA Medicare |
$17.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$172.80
|
| Rate for Payer: Humana ChoiceCare |
$19.72
|
| Rate for Payer: Humana Medicare Advantage |
$17.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$30.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$26.09
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$17.93
|
| Rate for Payer: Multiplan All |
$174.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.48
|
| Rate for Payer: OMNI Networks Commercial |
$134.40
|
| Rate for Payer: One Health Plan PPO/POS |
$172.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$30.13
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$26.09
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$17.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$182.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$35.86
|
| Rate for Payer: Three Rivers Provider Network All |
$144.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17.57
|
| Rate for Payer: United Healthcare Commercial |
$163.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$178.56
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$17.93
|
| Rate for Payer: Zelis Auto |
$76.80
|
| Rate for Payer: Zelis Medicare |
$15.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.52
|
| Rate for Payer: Zelis Worker's Compensation |
$20.72
|
|
|
antistreptolysin O (ASO) ab REF006031
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
CPT 86060
|
| Hospital Charge Code |
22990343
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.21 |
| Max. Negotiated Rate |
$136.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$13.14
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$86.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$13.14
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$10.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$7.30
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$122.40
|
| Rate for Payer: First Health Commercial |
$129.60
|
| Rate for Payer: First Health Workers Compensation |
$11.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$129.60
|
| Rate for Payer: GEHA Commercial |
$115.20
|
| Rate for Payer: GEHA Medicare |
$7.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$129.60
|
| Rate for Payer: Humana ChoiceCare |
$8.03
|
| Rate for Payer: Humana Medicare Advantage |
$7.30
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$12.26
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$10.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$7.30
|
| Rate for Payer: Multiplan All |
$131.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.41
|
| Rate for Payer: OMNI Networks Commercial |
$100.80
|
| Rate for Payer: One Health Plan PPO/POS |
$129.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$12.26
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$10.62
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$7.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$136.80
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$14.60
|
| Rate for Payer: Three Rivers Provider Network All |
$108.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.15
|
| Rate for Payer: United Healthcare Commercial |
$122.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.30
|
| Rate for Payer: United Payors & United Providers UP&UP |
$133.92
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$7.30
|
| Rate for Payer: Zelis Auto |
$57.60
|
| Rate for Payer: Zelis Medicare |
$6.21
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.76
|
| Rate for Payer: Zelis Worker's Compensation |
$8.37
|
|
|
antistreptolysin O (ASO) ab REF006031
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
CPT 86060
|
| Hospital Charge Code |
22990343
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.37 |
| Max. Negotiated Rate |
$136.80 |
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$122.40
|
| Rate for Payer: First Health Commercial |
$129.60
|
| Rate for Payer: First Health Workers Compensation |
$11.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$129.60
|
| Rate for Payer: GEHA Commercial |
$100.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$129.60
|
| Rate for Payer: Multiplan All |
$131.04
|
| Rate for Payer: OMNI Networks Commercial |
$100.80
|
| Rate for Payer: One Health Plan PPO/POS |
$129.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$136.80
|
| Rate for Payer: Three Rivers Provider Network All |
$108.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$133.92
|
| Rate for Payer: Zelis Auto |
$57.60
|
| Rate for Payer: Zelis Worker's Compensation |
$8.37
|
|
|
antithrombin antigen REF015057
|
Facility
|
OP
|
$341.00
|
|
|
Service Code
|
CPT 85301
|
| Hospital Charge Code |
2299188
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$9.19 |
| Max. Negotiated Rate |
$323.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$19.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$204.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$19.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$15.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$10.81
|
| Rate for Payer: Cash Price |
$204.60
|
| Rate for Payer: Cash Price |
$204.60
|
| Rate for Payer: Cigna Commercial |
$289.85
|
| Rate for Payer: First Health Commercial |
$306.90
|
| Rate for Payer: First Health Workers Compensation |
$19.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$306.90
|
| Rate for Payer: GEHA Commercial |
$272.80
|
| Rate for Payer: GEHA Medicare |
$10.81
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$306.90
|
| Rate for Payer: Humana ChoiceCare |
$11.89
|
| Rate for Payer: Humana Medicare Advantage |
$10.81
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$18.16
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$15.73
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$10.81
|
| Rate for Payer: Multiplan All |
$310.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$18.38
|
| Rate for Payer: OMNI Networks Commercial |
$238.70
|
| Rate for Payer: One Health Plan PPO/POS |
$306.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$18.16
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$15.73
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$10.81
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$323.95
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$21.62
|
| Rate for Payer: Three Rivers Provider Network All |
$255.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.59
|
| Rate for Payer: United Healthcare Commercial |
$289.85
|
| Rate for Payer: United Healthcare Managed Medicaid |
$15.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.81
|
| Rate for Payer: United Payors & United Providers UP&UP |
$317.13
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$10.81
|
| Rate for Payer: Zelis Auto |
$136.40
|
| Rate for Payer: Zelis Medicare |
$9.19
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12.97
|
| Rate for Payer: Zelis Worker's Compensation |
$14.06
|
|
|
antithrombin antigen REF015057
|
Facility
|
IP
|
$341.00
|
|
|
Service Code
|
CPT 85301
|
| Hospital Charge Code |
2299188
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$14.06 |
| Max. Negotiated Rate |
$323.95 |
| Rate for Payer: Cash Price |
$204.60
|
| Rate for Payer: Cash Price |
$204.60
|
| Rate for Payer: Cigna Commercial |
$289.85
|
| Rate for Payer: First Health Commercial |
$306.90
|
| Rate for Payer: First Health Workers Compensation |
$19.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$306.90
|
| Rate for Payer: GEHA Commercial |
$238.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$306.90
|
| Rate for Payer: Multiplan All |
$310.31
|
| Rate for Payer: OMNI Networks Commercial |
$238.70
|
| Rate for Payer: One Health Plan PPO/POS |
$306.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$323.95
|
| Rate for Payer: Three Rivers Provider Network All |
$255.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$317.13
|
| Rate for Payer: Zelis Auto |
$136.40
|
| Rate for Payer: Zelis Worker's Compensation |
$14.06
|
|
|
antithrombin III activity REF015040
|
Facility
|
IP
|
$249.00
|
|
|
Service Code
|
CPT 85300
|
| Hospital Charge Code |
2299187
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$15.01 |
| Max. Negotiated Rate |
$236.55 |
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$211.65
|
| Rate for Payer: First Health Commercial |
$224.10
|
| Rate for Payer: First Health Workers Compensation |
$21.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$224.10
|
| Rate for Payer: GEHA Commercial |
$174.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$224.10
|
| Rate for Payer: Multiplan All |
$226.59
|
| Rate for Payer: OMNI Networks Commercial |
$174.30
|
| Rate for Payer: One Health Plan PPO/POS |
$224.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$236.55
|
| Rate for Payer: Three Rivers Provider Network All |
$186.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$231.57
|
| Rate for Payer: Zelis Auto |
$99.60
|
| Rate for Payer: Zelis Worker's Compensation |
$15.01
|
|
|
antithrombin III activity REF015040
|
Facility
|
OP
|
$249.00
|
|
|
Service Code
|
CPT 85300
|
| Hospital Charge Code |
2299187
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$236.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$21.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$149.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$21.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.90
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$11.85
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$211.65
|
| Rate for Payer: First Health Commercial |
$224.10
|
| Rate for Payer: First Health Workers Compensation |
$21.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$224.10
|
| Rate for Payer: GEHA Commercial |
$199.20
|
| Rate for Payer: GEHA Medicare |
$11.85
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$224.10
|
| Rate for Payer: Humana ChoiceCare |
$13.04
|
| Rate for Payer: Humana Medicare Advantage |
$11.85
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$19.91
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$17.24
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$11.85
|
| Rate for Payer: Multiplan All |
$226.59
|
| Rate for Payer: New Mexico Health Connections Medicare |
$20.14
|
| Rate for Payer: OMNI Networks Commercial |
$174.30
|
| Rate for Payer: One Health Plan PPO/POS |
$224.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$19.91
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$17.24
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$11.85
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$236.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$23.70
|
| Rate for Payer: Three Rivers Provider Network All |
$186.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11.61
|
| Rate for Payer: United Healthcare Commercial |
$211.65
|
| Rate for Payer: United Healthcare Managed Medicaid |
$17.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.85
|
| Rate for Payer: United Payors & United Providers UP&UP |
$231.57
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$11.85
|
| Rate for Payer: Zelis Auto |
$99.60
|
| Rate for Payer: Zelis Medicare |
$10.07
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$14.22
|
| Rate for Payer: Zelis Worker's Compensation |
$15.01
|
|
|
anti-u3 rnp REF 520019
|
Facility
|
IP
|
$185.73
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2200823
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.72 |
| Max. Negotiated Rate |
$176.44 |
| Rate for Payer: Cash Price |
$111.44
|
| Rate for Payer: Cash Price |
$111.44
|
| Rate for Payer: Cigna Commercial |
$157.87
|
| Rate for Payer: First Health Commercial |
$167.16
|
| Rate for Payer: First Health Workers Compensation |
$29.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$167.16
|
| Rate for Payer: GEHA Commercial |
$130.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$167.16
|
| Rate for Payer: Multiplan All |
$169.01
|
| Rate for Payer: OMNI Networks Commercial |
$130.01
|
| Rate for Payer: One Health Plan PPO/POS |
$167.16
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$176.44
|
| Rate for Payer: Three Rivers Provider Network All |
$139.30
|
| Rate for Payer: United Payors & United Providers UP&UP |
$172.73
|
| Rate for Payer: Zelis Auto |
$74.29
|
| Rate for Payer: Zelis Worker's Compensation |
$20.72
|
|
|
anti-u3 rnp REF 520019
|
Facility
|
OP
|
$185.73
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2200823
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.24 |
| Max. Negotiated Rate |
$176.44 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$32.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$111.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$32.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$25.57
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$17.93
|
| Rate for Payer: Cash Price |
$111.44
|
| Rate for Payer: Cash Price |
$111.44
|
| Rate for Payer: Cigna Commercial |
$157.87
|
| Rate for Payer: First Health Commercial |
$167.16
|
| Rate for Payer: First Health Workers Compensation |
$29.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$167.16
|
| Rate for Payer: GEHA Commercial |
$148.58
|
| Rate for Payer: GEHA Medicare |
$17.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$167.16
|
| Rate for Payer: Humana ChoiceCare |
$19.72
|
| Rate for Payer: Humana Medicare Advantage |
$17.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$30.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$26.09
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$17.93
|
| Rate for Payer: Multiplan All |
$169.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.48
|
| Rate for Payer: OMNI Networks Commercial |
$130.01
|
| Rate for Payer: One Health Plan PPO/POS |
$167.16
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$30.13
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$26.09
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$17.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$176.44
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$35.86
|
| Rate for Payer: Three Rivers Provider Network All |
$139.30
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17.57
|
| Rate for Payer: United Healthcare Commercial |
$157.87
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$172.73
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$17.93
|
| Rate for Payer: Zelis Auto |
$74.29
|
| Rate for Payer: Zelis Medicare |
$15.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.52
|
| Rate for Payer: Zelis Worker's Compensation |
$20.72
|
|
|
APAP-ASA-CAFF 250 MG-250 MG-65 MG EXT ST
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00536132601
|
| Hospital Charge Code |
3302910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
APAP-ASA-CAFF 250 MG-250 MG-65 MG EXT ST
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00536132601
|
| Hospital Charge Code |
3302910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
APEX PIN 5 X150
|
Facility
|
IP
|
$719.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006438
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$287.60 |
| Max. Negotiated Rate |
$683.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$575.20
|
| Rate for Payer: Cash Price |
$431.40
|
| Rate for Payer: Cash Price |
$431.40
|
| Rate for Payer: Cigna Commercial |
$611.15
|
| Rate for Payer: First Health Commercial |
$647.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$647.10
|
| Rate for Payer: GEHA Commercial |
$503.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$647.10
|
| Rate for Payer: Multiplan All |
$654.29
|
| Rate for Payer: OMNI Networks Commercial |
$503.30
|
| Rate for Payer: One Health Plan PPO/POS |
$647.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$683.05
|
| Rate for Payer: Three Rivers Provider Network All |
$539.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$668.67
|
| Rate for Payer: Zelis Auto |
$287.60
|
|
|
APEX PIN 5 X150
|
Facility
|
OP
|
$719.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006438
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$179.75 |
| Max. Negotiated Rate |
$683.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$431.40
|
| Rate for Payer: Cash Price |
$431.40
|
| Rate for Payer: Cash Price |
$431.40
|
| Rate for Payer: Cigna Commercial |
$611.15
|
| Rate for Payer: First Health Commercial |
$647.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$647.10
|
| Rate for Payer: GEHA Commercial |
$575.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$647.10
|
| Rate for Payer: Humana ChoiceCare |
$186.94
|
| Rate for Payer: Multiplan All |
$654.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$431.40
|
| Rate for Payer: OMNI Networks Commercial |
$503.30
|
| Rate for Payer: One Health Plan PPO/POS |
$647.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$683.05
|
| Rate for Payer: Three Rivers Provider Network All |
$539.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$632.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$179.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$668.67
|
| Rate for Payer: Zelis Auto |
$287.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$359.50
|
|
|
a. phagocytophylum PCR REF138172
|
Facility
|
OP
|
$335.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
2200468
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.83 |
| Max. Negotiated Rate |
$318.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$63.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$201.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$63.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$50.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$35.09
|
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cigna Commercial |
$284.75
|
| Rate for Payer: First Health Commercial |
$301.50
|
| Rate for Payer: First Health Workers Compensation |
$55.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$301.50
|
| Rate for Payer: GEHA Commercial |
$268.00
|
| Rate for Payer: GEHA Medicare |
$35.09
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$301.50
|
| Rate for Payer: Humana ChoiceCare |
$38.60
|
| Rate for Payer: Humana Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$58.95
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$51.06
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$35.09
|
| Rate for Payer: Multiplan All |
$304.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$59.65
|
| Rate for Payer: OMNI Networks Commercial |
$234.50
|
| Rate for Payer: One Health Plan PPO/POS |
$301.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$58.95
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$51.06
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$35.09
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$318.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$70.18
|
| Rate for Payer: Three Rivers Provider Network All |
$251.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$34.39
|
| Rate for Payer: United Healthcare Commercial |
$284.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$51.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Payors & United Providers UP&UP |
$311.55
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$35.09
|
| Rate for Payer: Zelis Auto |
$134.00
|
| Rate for Payer: Zelis Medicare |
$29.83
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$42.11
|
| Rate for Payer: Zelis Worker's Compensation |
$39.21
|
|
|
a. phagocytophylum PCR REF138172
|
Facility
|
IP
|
$335.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
2200468
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.21 |
| Max. Negotiated Rate |
$318.25 |
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cigna Commercial |
$284.75
|
| Rate for Payer: First Health Commercial |
$301.50
|
| Rate for Payer: First Health Workers Compensation |
$55.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$301.50
|
| Rate for Payer: GEHA Commercial |
$234.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$301.50
|
| Rate for Payer: Multiplan All |
$304.85
|
| Rate for Payer: OMNI Networks Commercial |
$234.50
|
| Rate for Payer: One Health Plan PPO/POS |
$301.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$318.25
|
| Rate for Payer: Three Rivers Provider Network All |
$251.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$311.55
|
| Rate for Payer: Zelis Auto |
$134.00
|
| Rate for Payer: Zelis Worker's Compensation |
$39.21
|
|
|
APIXABAN 2.5 MG ORAL TABLET
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
NDC 00003089321
|
| Hospital Charge Code |
330284
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.74 |
| Max. Negotiated Rate |
$51.30 |
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$45.90
|
| Rate for Payer: First Health Commercial |
$48.60
|
| Rate for Payer: First Health Workers Compensation |
$20.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$48.60
|
| Rate for Payer: GEHA Commercial |
$37.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$48.60
|
| Rate for Payer: Multiplan All |
$49.14
|
| Rate for Payer: OMNI Networks Commercial |
$37.80
|
| Rate for Payer: One Health Plan PPO/POS |
$48.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$51.30
|
| Rate for Payer: Three Rivers Provider Network All |
$40.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$50.22
|
| Rate for Payer: Zelis Auto |
$21.60
|
| Rate for Payer: Zelis Worker's Compensation |
$14.74
|
|
|
APIXABAN 5 MG TABLET
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
NDC 00003089421
|
| Hospital Charge Code |
3302674
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.74 |
| Max. Negotiated Rate |
$51.30 |
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$45.90
|
| Rate for Payer: First Health Commercial |
$48.60
|
| Rate for Payer: First Health Workers Compensation |
$20.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$48.60
|
| Rate for Payer: GEHA Commercial |
$37.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$48.60
|
| Rate for Payer: Multiplan All |
$49.14
|
| Rate for Payer: OMNI Networks Commercial |
$37.80
|
| Rate for Payer: One Health Plan PPO/POS |
$48.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$51.30
|
| Rate for Payer: Three Rivers Provider Network All |
$40.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$50.22
|
| Rate for Payer: Zelis Auto |
$21.60
|
| Rate for Payer: Zelis Worker's Compensation |
$14.74
|
|
|
APIXABAN 5 MG TABLET
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
NDC 00003089421
|
| Hospital Charge Code |
3302674
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$51.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$45.90
|
| Rate for Payer: First Health Commercial |
$48.60
|
| Rate for Payer: First Health Workers Compensation |
$20.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$48.60
|
| Rate for Payer: GEHA Commercial |
$43.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$48.60
|
| Rate for Payer: Humana ChoiceCare |
$14.04
|
| Rate for Payer: Multiplan All |
$49.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$32.40
|
| Rate for Payer: OMNI Networks Commercial |
$37.80
|
| Rate for Payer: One Health Plan PPO/POS |
$48.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$51.30
|
| Rate for Payer: Three Rivers Provider Network All |
$40.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$47.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$50.22
|
| Rate for Payer: Zelis Auto |
$21.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$27.00
|
| Rate for Payer: Zelis Worker's Compensation |
$14.74
|
|
|
APLIGRAF 44 SQ CM
|
Facility
|
OP
|
$4,705.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
7002458
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.25 |
| Max. Negotiated Rate |
$4,469.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,823.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$36.22
|
| Rate for Payer: Cash Price |
$2,823.00
|
| Rate for Payer: Cash Price |
$2,823.00
|
| Rate for Payer: Cigna Commercial |
$3,999.25
|
| Rate for Payer: First Health Commercial |
$4,234.50
|
| Rate for Payer: First Health Workers Compensation |
$1,816.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,234.50
|
| Rate for Payer: GEHA Commercial |
$33.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,234.50
|
| Rate for Payer: Humana ChoiceCare |
$1,223.30
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$36.96
|
| Rate for Payer: Multiplan All |
$4,281.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,823.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,293.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4,234.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$42.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$36.96
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,469.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3,528.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,140.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$36.96
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,375.65
|
| Rate for Payer: Zelis Auto |
$1,882.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,352.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1,284.46
|
|
|
APLIGRAF 44 SQ CM
|
Facility
|
IP
|
$4,705.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
7002458
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,284.46 |
| Max. Negotiated Rate |
$4,469.75 |
| Rate for Payer: Cash Price |
$2,823.00
|
| Rate for Payer: Cigna Commercial |
$3,999.25
|
| Rate for Payer: First Health Commercial |
$4,234.50
|
| Rate for Payer: First Health Workers Compensation |
$1,816.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,234.50
|
| Rate for Payer: GEHA Commercial |
$3,293.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,234.50
|
| Rate for Payer: Multiplan All |
$4,281.55
|
| Rate for Payer: OMNI Networks Commercial |
$3,293.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4,234.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,469.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3,528.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,375.65
|
| Rate for Payer: Zelis Auto |
$1,882.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,284.46
|
|
|
APLIGRAF 5X5
|
Facility
|
IP
|
$103.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
1999337
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.12 |
| Max. Negotiated Rate |
$97.85 |
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$87.55
|
| Rate for Payer: First Health Commercial |
$92.70
|
| Rate for Payer: First Health Workers Compensation |
$39.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$92.70
|
| Rate for Payer: GEHA Commercial |
$72.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$92.70
|
| Rate for Payer: Multiplan All |
$93.73
|
| Rate for Payer: OMNI Networks Commercial |
$72.10
|
| Rate for Payer: One Health Plan PPO/POS |
$92.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$97.85
|
| Rate for Payer: Three Rivers Provider Network All |
$77.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$95.79
|
| Rate for Payer: Zelis Auto |
$41.20
|
| Rate for Payer: Zelis Worker's Compensation |
$28.12
|
|
|
APLIGRAF 5X5
|
Facility
|
OP
|
$103.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
1999337
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.78 |
| Max. Negotiated Rate |
$97.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$61.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$36.22
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$87.55
|
| Rate for Payer: First Health Commercial |
$92.70
|
| Rate for Payer: First Health Workers Compensation |
$39.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$92.70
|
| Rate for Payer: GEHA Commercial |
$33.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$92.70
|
| Rate for Payer: Humana ChoiceCare |
$26.78
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$36.96
|
| Rate for Payer: Multiplan All |
$93.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$61.80
|
| Rate for Payer: OMNI Networks Commercial |
$72.10
|
| Rate for Payer: One Health Plan PPO/POS |
$92.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$42.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$36.96
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$97.85
|
| Rate for Payer: Three Rivers Provider Network All |
$77.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$90.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$36.96
|
| Rate for Payer: United Payors & United Providers UP&UP |
$95.79
|
| Rate for Payer: Zelis Auto |
$41.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$51.50
|
| Rate for Payer: Zelis Worker's Compensation |
$28.12
|
|
|
APLIGRAF PER SQUAR CENTIMETER
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
1905279
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.33 |
| Max. Negotiated Rate |
$189.05 |
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$169.15
|
| Rate for Payer: First Health Commercial |
$179.10
|
| Rate for Payer: First Health Workers Compensation |
$76.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$179.10
|
| Rate for Payer: GEHA Commercial |
$139.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$179.10
|
| Rate for Payer: Multiplan All |
$181.09
|
| Rate for Payer: OMNI Networks Commercial |
$139.30
|
| Rate for Payer: One Health Plan PPO/POS |
$179.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$189.05
|
| Rate for Payer: Three Rivers Provider Network All |
$149.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$185.07
|
| Rate for Payer: Zelis Auto |
$79.60
|
| Rate for Payer: Zelis Worker's Compensation |
$54.33
|
|
|
APLIGRAF PER SQUAR CENTIMETER
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
1905279
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.25 |
| Max. Negotiated Rate |
$189.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$119.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$36.22
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$169.15
|
| Rate for Payer: First Health Commercial |
$179.10
|
| Rate for Payer: First Health Workers Compensation |
$76.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$179.10
|
| Rate for Payer: GEHA Commercial |
$33.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$179.10
|
| Rate for Payer: Humana ChoiceCare |
$51.74
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$36.96
|
| Rate for Payer: Multiplan All |
$181.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$119.40
|
| Rate for Payer: OMNI Networks Commercial |
$139.30
|
| Rate for Payer: One Health Plan PPO/POS |
$179.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$42.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$36.96
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$189.05
|
| Rate for Payer: Three Rivers Provider Network All |
$149.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$175.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$36.96
|
| Rate for Payer: United Payors & United Providers UP&UP |
$185.07
|
| Rate for Payer: Zelis Auto |
$79.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$99.50
|
| Rate for Payer: Zelis Worker's Compensation |
$54.33
|
|
|
APLIGRAFT 44 SQ CM
|
Facility
|
IP
|
$1,314.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
1999234
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$358.72 |
| Max. Negotiated Rate |
$1,248.30 |
| Rate for Payer: Cash Price |
$788.40
|
| Rate for Payer: Cigna Commercial |
$1,116.90
|
| Rate for Payer: First Health Commercial |
$1,182.60
|
| Rate for Payer: First Health Workers Compensation |
$507.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,182.60
|
| Rate for Payer: GEHA Commercial |
$919.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,182.60
|
| Rate for Payer: Multiplan All |
$1,195.74
|
| Rate for Payer: OMNI Networks Commercial |
$919.80
|
| Rate for Payer: One Health Plan PPO/POS |
$1,182.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,248.30
|
| Rate for Payer: Three Rivers Provider Network All |
$985.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,222.02
|
| Rate for Payer: Zelis Auto |
$525.60
|
| Rate for Payer: Zelis Worker's Compensation |
$358.72
|
|
