|
INDIV PHYS SUPVJ HOME/DOM/R-HOME MO 30 M
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
CPT 99340
|
| Hospital Charge Code |
8599340
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$90.09 |
| Max. Negotiated Rate |
$313.50 |
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cigna Commercial |
$280.50
|
| Rate for Payer: First Health Commercial |
$297.00
|
| Rate for Payer: First Health Workers Compensation |
$127.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$297.00
|
| Rate for Payer: GEHA Commercial |
$231.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$297.00
|
| Rate for Payer: Multiplan All |
$300.30
|
| Rate for Payer: OMNI Networks Commercial |
$231.00
|
| Rate for Payer: One Health Plan PPO/POS |
$297.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$313.50
|
| Rate for Payer: Three Rivers Provider Network All |
$247.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$306.90
|
| Rate for Payer: Zelis Auto |
$132.00
|
| Rate for Payer: Zelis Worker's Compensation |
$90.09
|
|
|
INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 3
|
Facility
|
IP
|
$170.00
|
|
|
Service Code
|
CPT 90875
|
| Hospital Charge Code |
9599244
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$46.41 |
| Max. Negotiated Rate |
$161.50 |
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$144.50
|
| Rate for Payer: First Health Commercial |
$153.00
|
| Rate for Payer: First Health Workers Compensation |
$65.64
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$153.00
|
| Rate for Payer: GEHA Commercial |
$119.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$153.00
|
| Rate for Payer: Multiplan All |
$154.70
|
| Rate for Payer: OMNI Networks Commercial |
$119.00
|
| Rate for Payer: One Health Plan PPO/POS |
$153.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$161.50
|
| Rate for Payer: Three Rivers Provider Network All |
$127.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$158.10
|
| Rate for Payer: Zelis Auto |
$68.00
|
| Rate for Payer: Zelis Worker's Compensation |
$46.41
|
|
|
INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 3
|
Facility
|
IP
|
$170.00
|
|
|
Service Code
|
CPT 90875
|
| Hospital Charge Code |
8499242
|
|
Hospital Revenue Code
|
513
|
| Min. Negotiated Rate |
$46.41 |
| Max. Negotiated Rate |
$161.50 |
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$144.50
|
| Rate for Payer: First Health Commercial |
$153.00
|
| Rate for Payer: First Health Workers Compensation |
$65.64
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$153.00
|
| Rate for Payer: GEHA Commercial |
$119.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$153.00
|
| Rate for Payer: Multiplan All |
$154.70
|
| Rate for Payer: OMNI Networks Commercial |
$119.00
|
| Rate for Payer: One Health Plan PPO/POS |
$153.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$161.50
|
| Rate for Payer: Three Rivers Provider Network All |
$127.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$158.10
|
| Rate for Payer: Zelis Auto |
$68.00
|
| Rate for Payer: Zelis Worker's Compensation |
$46.41
|
|
|
INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 3
|
Facility
|
OP
|
$170.00
|
|
|
Service Code
|
CPT 90875
|
| Hospital Charge Code |
9599244
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$42.50 |
| Max. Negotiated Rate |
$161.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$102.00
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$144.50
|
| Rate for Payer: First Health Commercial |
$153.00
|
| Rate for Payer: First Health Workers Compensation |
$65.64
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$153.00
|
| Rate for Payer: GEHA Commercial |
$136.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$153.00
|
| Rate for Payer: Humana ChoiceCare |
$44.20
|
| Rate for Payer: Multiplan All |
$154.70
|
| Rate for Payer: New Mexico Health Connections Medicare |
$102.00
|
| Rate for Payer: OMNI Networks Commercial |
$119.00
|
| Rate for Payer: One Health Plan PPO/POS |
$153.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$161.50
|
| Rate for Payer: Three Rivers Provider Network All |
$127.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$149.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$42.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$158.10
|
| Rate for Payer: Zelis Auto |
$68.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$85.00
|
| Rate for Payer: Zelis Worker's Compensation |
$46.41
|
|
|
INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 3
|
Facility
|
OP
|
$170.00
|
|
|
Service Code
|
CPT 90875
|
| Hospital Charge Code |
8499242
|
|
Hospital Revenue Code
|
513
|
| Min. Negotiated Rate |
$42.50 |
| Max. Negotiated Rate |
$161.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$102.00
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$144.50
|
| Rate for Payer: First Health Commercial |
$153.00
|
| Rate for Payer: First Health Workers Compensation |
$65.64
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$153.00
|
| Rate for Payer: GEHA Commercial |
$136.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$153.00
|
| Rate for Payer: Humana ChoiceCare |
$44.20
|
| Rate for Payer: Multiplan All |
$154.70
|
| Rate for Payer: New Mexico Health Connections Medicare |
$102.00
|
| Rate for Payer: OMNI Networks Commercial |
$119.00
|
| Rate for Payer: One Health Plan PPO/POS |
$153.00
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$80.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$161.50
|
| Rate for Payer: Three Rivers Provider Network All |
$127.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$149.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$42.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$158.10
|
| Rate for Payer: Zelis Auto |
$68.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$85.00
|
| Rate for Payer: Zelis Worker's Compensation |
$46.41
|
|
|
INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 4
|
Facility
|
OP
|
$221.00
|
|
|
Service Code
|
CPT 90876
|
| Hospital Charge Code |
9599245
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$55.25 |
| Max. Negotiated Rate |
$209.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$132.60
|
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cigna Commercial |
$187.85
|
| Rate for Payer: First Health Commercial |
$198.90
|
| Rate for Payer: First Health Workers Compensation |
$85.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$198.90
|
| Rate for Payer: GEHA Commercial |
$176.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$198.90
|
| Rate for Payer: Humana ChoiceCare |
$57.46
|
| Rate for Payer: Multiplan All |
$201.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$132.60
|
| Rate for Payer: OMNI Networks Commercial |
$154.70
|
| Rate for Payer: One Health Plan PPO/POS |
$198.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$209.95
|
| Rate for Payer: Three Rivers Provider Network All |
$165.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$194.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$55.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$205.53
|
| Rate for Payer: Zelis Auto |
$88.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$110.50
|
| Rate for Payer: Zelis Worker's Compensation |
$60.33
|
|
|
INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 4
|
Facility
|
IP
|
$221.00
|
|
|
Service Code
|
CPT 90876
|
| Hospital Charge Code |
9599245
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$60.33 |
| Max. Negotiated Rate |
$209.95 |
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cigna Commercial |
$187.85
|
| Rate for Payer: First Health Commercial |
$198.90
|
| Rate for Payer: First Health Workers Compensation |
$85.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$198.90
|
| Rate for Payer: GEHA Commercial |
$154.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$198.90
|
| Rate for Payer: Multiplan All |
$201.11
|
| Rate for Payer: OMNI Networks Commercial |
$154.70
|
| Rate for Payer: One Health Plan PPO/POS |
$198.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$209.95
|
| Rate for Payer: Three Rivers Provider Network All |
$165.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$205.53
|
| Rate for Payer: Zelis Auto |
$88.40
|
| Rate for Payer: Zelis Worker's Compensation |
$60.33
|
|
|
INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 4
|
Facility
|
IP
|
$221.00
|
|
|
Service Code
|
CPT 90876
|
| Hospital Charge Code |
8499243
|
|
Hospital Revenue Code
|
513
|
| Min. Negotiated Rate |
$60.33 |
| Max. Negotiated Rate |
$209.95 |
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cigna Commercial |
$187.85
|
| Rate for Payer: First Health Commercial |
$198.90
|
| Rate for Payer: First Health Workers Compensation |
$85.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$198.90
|
| Rate for Payer: GEHA Commercial |
$154.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$198.90
|
| Rate for Payer: Multiplan All |
$201.11
|
| Rate for Payer: OMNI Networks Commercial |
$154.70
|
| Rate for Payer: One Health Plan PPO/POS |
$198.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$209.95
|
| Rate for Payer: Three Rivers Provider Network All |
$165.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$205.53
|
| Rate for Payer: Zelis Auto |
$88.40
|
| Rate for Payer: Zelis Worker's Compensation |
$60.33
|
|
|
INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 4
|
Facility
|
OP
|
$221.00
|
|
|
Service Code
|
CPT 90876
|
| Hospital Charge Code |
8499243
|
|
Hospital Revenue Code
|
513
|
| Min. Negotiated Rate |
$55.25 |
| Max. Negotiated Rate |
$209.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$132.60
|
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cigna Commercial |
$187.85
|
| Rate for Payer: First Health Commercial |
$198.90
|
| Rate for Payer: First Health Workers Compensation |
$85.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$198.90
|
| Rate for Payer: GEHA Commercial |
$176.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$198.90
|
| Rate for Payer: Humana ChoiceCare |
$57.46
|
| Rate for Payer: Multiplan All |
$201.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$132.60
|
| Rate for Payer: OMNI Networks Commercial |
$154.70
|
| Rate for Payer: One Health Plan PPO/POS |
$198.90
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$80.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$209.95
|
| Rate for Payer: Three Rivers Provider Network All |
$165.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$194.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$55.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$205.53
|
| Rate for Payer: Zelis Auto |
$88.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$110.50
|
| Rate for Payer: Zelis Worker's Compensation |
$60.33
|
|
|
INDOCYANINE GREEN 25MG - FOR SURGERY
|
Facility
|
IP
|
$534.00
|
|
|
Service Code
|
NDC 17238042406
|
| Hospital Charge Code |
3305029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$145.78 |
| Max. Negotiated Rate |
$507.30 |
| Rate for Payer: Cash Price |
$320.40
|
| Rate for Payer: Cigna Commercial |
$453.90
|
| Rate for Payer: First Health Commercial |
$480.60
|
| Rate for Payer: First Health Workers Compensation |
$206.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$480.60
|
| Rate for Payer: GEHA Commercial |
$373.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$480.60
|
| Rate for Payer: Multiplan All |
$485.94
|
| Rate for Payer: OMNI Networks Commercial |
$373.80
|
| Rate for Payer: One Health Plan PPO/POS |
$480.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$507.30
|
| Rate for Payer: Three Rivers Provider Network All |
$400.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$496.62
|
| Rate for Payer: Zelis Auto |
$213.60
|
| Rate for Payer: Zelis Worker's Compensation |
$145.78
|
|
|
INDOCYANINE GREEN 25MG - FOR SURGERY
|
Facility
|
OP
|
$534.00
|
|
|
Service Code
|
NDC 17238042406
|
| Hospital Charge Code |
3305029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$133.50 |
| Max. Negotiated Rate |
$507.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$320.40
|
| Rate for Payer: Cash Price |
$320.40
|
| Rate for Payer: Cigna Commercial |
$453.90
|
| Rate for Payer: First Health Commercial |
$480.60
|
| Rate for Payer: First Health Workers Compensation |
$206.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$480.60
|
| Rate for Payer: GEHA Commercial |
$427.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$480.60
|
| Rate for Payer: Humana ChoiceCare |
$138.84
|
| Rate for Payer: Multiplan All |
$485.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$320.40
|
| Rate for Payer: OMNI Networks Commercial |
$373.80
|
| Rate for Payer: One Health Plan PPO/POS |
$480.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$507.30
|
| Rate for Payer: Three Rivers Provider Network All |
$400.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$469.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$133.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$496.62
|
| Rate for Payer: Zelis Auto |
$213.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$267.00
|
| Rate for Payer: Zelis Worker's Compensation |
$145.78
|
|
|
INDOMETHACIN CAP 25MG
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
3300449
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$4.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
INDOMETHACIN CAP 25MG
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
3300449
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Humana ChoiceCare |
$1.82
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.20
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
INDWLL CATH; 2-WAY LATEX W/COAT EA
|
Facility
|
IP
|
$362.00
|
|
|
Service Code
|
CPT A4338
|
| Hospital Charge Code |
8504338
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.83 |
| Max. Negotiated Rate |
$343.90 |
| Rate for Payer: Cash Price |
$217.20
|
| Rate for Payer: Cigna Commercial |
$307.70
|
| Rate for Payer: First Health Commercial |
$325.80
|
| Rate for Payer: First Health Workers Compensation |
$139.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$325.80
|
| Rate for Payer: GEHA Commercial |
$253.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$325.80
|
| Rate for Payer: Multiplan All |
$329.42
|
| Rate for Payer: OMNI Networks Commercial |
$253.40
|
| Rate for Payer: One Health Plan PPO/POS |
$325.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$343.90
|
| Rate for Payer: Three Rivers Provider Network All |
$271.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$336.66
|
| Rate for Payer: Zelis Auto |
$144.80
|
| Rate for Payer: Zelis Worker's Compensation |
$98.83
|
|
|
INDWLL CATH; 2-WAY LATEX W/COAT EA
|
Facility
|
OP
|
$362.00
|
|
|
Service Code
|
CPT A4338
|
| Hospital Charge Code |
8504338
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.37 |
| Max. Negotiated Rate |
$343.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$32.02
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$217.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$32.02
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$25.37
|
| Rate for Payer: Cash Price |
$217.20
|
| Rate for Payer: Cash Price |
$217.20
|
| Rate for Payer: Cigna Commercial |
$307.70
|
| Rate for Payer: First Health Commercial |
$325.80
|
| Rate for Payer: First Health Workers Compensation |
$139.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$325.80
|
| Rate for Payer: GEHA Commercial |
$289.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$325.80
|
| Rate for Payer: Humana ChoiceCare |
$94.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$25.89
|
| Rate for Payer: Multiplan All |
$329.42
|
| Rate for Payer: New Mexico Health Connections Medicare |
$217.20
|
| Rate for Payer: OMNI Networks Commercial |
$253.40
|
| Rate for Payer: One Health Plan PPO/POS |
$325.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$29.89
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$25.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$343.90
|
| Rate for Payer: Three Rivers Provider Network All |
$271.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$318.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$25.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$336.66
|
| Rate for Payer: Zelis Auto |
$144.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$181.00
|
| Rate for Payer: Zelis Worker's Compensation |
$98.83
|
|
|
INFANT (0-1YR0)
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
CPT 99381
|
| Hospital Charge Code |
7299381
|
|
Hospital Revenue Code
|
517
|
| 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
|
|
|
INFANT (0-1YR0)
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
CPT 99381
|
| Hospital Charge Code |
7299381
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$51.74 |
| Max. Negotiated Rate |
$189.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| 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 |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| 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 |
$159.20
|
| 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 |
$137.55
|
| 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 |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| 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 |
$137.55
|
| 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
|
|
|
INFANT (0-1YR0)
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
CPT 99381
|
| Hospital Charge Code |
8599381
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
|
INFANT (0-1YR0)
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
CPT 99381
|
| Hospital Charge Code |
8599381
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$51.74 |
| Max. Negotiated Rate |
$189.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| 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 |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| 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 |
$159.20
|
| 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 |
$137.55
|
| 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 |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| 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 |
$137.55
|
| 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
|
|
|
INFeD 100MG VIAL
|
Facility
|
OP
|
$206.00
|
|
|
Service Code
|
CPT J1750
|
| Hospital Charge Code |
3301943
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$195.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$18.18
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$123.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$18.18
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$14.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$18.11
|
| Rate for Payer: Cash Price |
$123.60
|
| Rate for Payer: Cash Price |
$123.60
|
| Rate for Payer: Cigna Commercial |
$175.10
|
| Rate for Payer: First Health Commercial |
$185.40
|
| Rate for Payer: First Health Workers Compensation |
$79.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$185.40
|
| Rate for Payer: GEHA Commercial |
$19.92
|
| Rate for Payer: GEHA Medicare |
$18.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$185.40
|
| Rate for Payer: Humana ChoiceCare |
$19.92
|
| Rate for Payer: Humana Medicare Advantage |
$18.11
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$30.42
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$14.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$18.11
|
| Rate for Payer: Multiplan All |
$187.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.79
|
| Rate for Payer: OMNI Networks Commercial |
$144.20
|
| Rate for Payer: One Health Plan PPO/POS |
$185.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$16.97
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$14.70
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$18.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$195.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$36.22
|
| Rate for Payer: Three Rivers Provider Network All |
$154.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$191.58
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$18.11
|
| Rate for Payer: Zelis Auto |
$82.40
|
| Rate for Payer: Zelis Medicare |
$15.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.73
|
| Rate for Payer: Zelis Worker's Compensation |
$56.24
|
|
|
INFeD 100MG VIAL
|
Facility
|
IP
|
$206.00
|
|
|
Service Code
|
CPT J1750
|
| Hospital Charge Code |
3301943
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.24 |
| Max. Negotiated Rate |
$195.70 |
| Rate for Payer: Cash Price |
$123.60
|
| Rate for Payer: Cigna Commercial |
$175.10
|
| Rate for Payer: First Health Commercial |
$185.40
|
| Rate for Payer: First Health Workers Compensation |
$79.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$185.40
|
| Rate for Payer: GEHA Commercial |
$144.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$185.40
|
| Rate for Payer: Multiplan All |
$187.46
|
| Rate for Payer: OMNI Networks Commercial |
$144.20
|
| Rate for Payer: One Health Plan PPO/POS |
$185.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$195.70
|
| Rate for Payer: Three Rivers Provider Network All |
$154.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$191.58
|
| Rate for Payer: Zelis Auto |
$82.40
|
| Rate for Payer: Zelis Worker's Compensation |
$56.24
|
|
|
INFLIXIMAB-AXXQ 100 MG VIAL PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT Q5121
|
| Hospital Charge Code |
3303206
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
INFLIXIMAB-AXXQ 100 MG VIAL PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT Q5121
|
| Hospital Charge Code |
3303206
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$40.82 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$20.41
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$22.45
|
| Rate for Payer: GEHA Medicare |
$20.41
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$22.45
|
| Rate for Payer: Humana Medicare Advantage |
$20.41
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$34.29
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$20.41
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$34.70
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$20.41
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$40.82
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$20.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.41
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$20.41
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Medicare |
$17.35
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$24.49
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
INFLIXIMAB-DYYB 1000 MG/NS 250 ML PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3303221
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
INFLIXIMAB-DYYB 1000 MG/NS 250 ML PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3303221
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.00
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.01
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.01
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
