|
IODINE 123CAP P100MC
|
Facility
|
IP
|
$339.00
|
|
|
Service Code
|
CPT A9516
|
| Hospital Charge Code |
2410055
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$92.55 |
| Max. Negotiated Rate |
$322.05 |
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cigna Commercial |
$288.15
|
| Rate for Payer: First Health Commercial |
$305.10
|
| Rate for Payer: First Health Workers Compensation |
$130.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$305.10
|
| Rate for Payer: GEHA Commercial |
$237.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$305.10
|
| Rate for Payer: Multiplan All |
$308.49
|
| Rate for Payer: OMNI Networks Commercial |
$237.30
|
| Rate for Payer: One Health Plan PPO/POS |
$305.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$322.05
|
| Rate for Payer: Three Rivers Provider Network All |
$254.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$315.27
|
| Rate for Payer: Zelis Auto |
$135.60
|
| Rate for Payer: Zelis Worker's Compensation |
$92.55
|
|
|
IODINE 123CAP P100MC
|
Facility
|
OP
|
$339.00
|
|
|
Service Code
|
CPT A9516
|
| Hospital Charge Code |
2410055
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$84.75 |
| Max. Negotiated Rate |
$322.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$203.40
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cigna Commercial |
$288.15
|
| Rate for Payer: First Health Commercial |
$305.10
|
| Rate for Payer: First Health Workers Compensation |
$130.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$305.10
|
| Rate for Payer: GEHA Commercial |
$271.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$305.10
|
| Rate for Payer: Humana ChoiceCare |
$88.14
|
| Rate for Payer: Multiplan All |
$308.49
|
| Rate for Payer: New Mexico Health Connections Medicare |
$203.40
|
| Rate for Payer: OMNI Networks Commercial |
$237.30
|
| Rate for Payer: One Health Plan PPO/POS |
$305.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$322.05
|
| Rate for Payer: Three Rivers Provider Network All |
$254.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$298.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$84.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$315.27
|
| Rate for Payer: Zelis Auto |
$135.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$169.50
|
| Rate for Payer: Zelis Worker's Compensation |
$92.55
|
|
|
IODINE I-123 SOD IODIDE MIL
|
Facility
|
OP
|
$1,193.00
|
|
|
Service Code
|
CPT A9509
|
| Hospital Charge Code |
2495101
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$298.25 |
| Max. Negotiated Rate |
$1,133.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$715.80
|
| Rate for Payer: Cash Price |
$715.80
|
| Rate for Payer: Cigna Commercial |
$1,014.05
|
| Rate for Payer: First Health Commercial |
$1,073.70
|
| Rate for Payer: First Health Workers Compensation |
$460.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,073.70
|
| Rate for Payer: GEHA Commercial |
$954.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,073.70
|
| Rate for Payer: Humana ChoiceCare |
$310.18
|
| Rate for Payer: Multiplan All |
$1,085.63
|
| Rate for Payer: New Mexico Health Connections Medicare |
$715.80
|
| Rate for Payer: OMNI Networks Commercial |
$835.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,073.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,133.35
|
| Rate for Payer: Three Rivers Provider Network All |
$894.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,049.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$298.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,109.49
|
| Rate for Payer: Zelis Auto |
$477.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$596.50
|
| Rate for Payer: Zelis Worker's Compensation |
$325.69
|
|
|
IODINE I-123 SOD IODIDE MIL
|
Facility
|
IP
|
$1,193.00
|
|
|
Service Code
|
CPT A9509
|
| Hospital Charge Code |
2495101
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$325.69 |
| Max. Negotiated Rate |
$1,133.35 |
| Rate for Payer: Cash Price |
$715.80
|
| Rate for Payer: Cigna Commercial |
$1,014.05
|
| Rate for Payer: First Health Commercial |
$1,073.70
|
| Rate for Payer: First Health Workers Compensation |
$460.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,073.70
|
| Rate for Payer: GEHA Commercial |
$835.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,073.70
|
| Rate for Payer: Multiplan All |
$1,085.63
|
| Rate for Payer: OMNI Networks Commercial |
$835.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,073.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,133.35
|
| Rate for Payer: Three Rivers Provider Network All |
$894.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,109.49
|
| Rate for Payer: Zelis Auto |
$477.20
|
| Rate for Payer: Zelis Worker's Compensation |
$325.69
|
|
|
IODINE I-131 SOD IODIDE, THER PER mCi
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
CPT A9530
|
| Hospital Charge Code |
3303101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.76 |
| Max. Negotiated Rate |
$100.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$19.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$63.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$19.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$15.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$20.88
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$90.10
|
| Rate for Payer: First Health Commercial |
$95.40
|
| Rate for Payer: First Health Workers Compensation |
$40.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$95.40
|
| Rate for Payer: GEHA Commercial |
$84.80
|
| Rate for Payer: GEHA Medicare |
$20.88
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$95.40
|
| Rate for Payer: Humana ChoiceCare |
$22.97
|
| Rate for Payer: Humana Medicare Advantage |
$20.88
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$35.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$16.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$20.88
|
| Rate for Payer: Multiplan All |
$96.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$35.50
|
| Rate for Payer: OMNI Networks Commercial |
$74.20
|
| Rate for Payer: One Health Plan PPO/POS |
$95.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$18.56
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$16.08
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$20.88
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$100.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$41.76
|
| Rate for Payer: Three Rivers Provider Network All |
$79.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$20.46
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.88
|
| Rate for Payer: United Payors & United Providers UP&UP |
$98.58
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$20.88
|
| Rate for Payer: Zelis Auto |
$42.40
|
| Rate for Payer: Zelis Medicare |
$17.75
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$25.06
|
| Rate for Payer: Zelis Worker's Compensation |
$28.94
|
|
|
IODINE I-131 SOD IODIDE, THER PER mCi
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
CPT A9530
|
| Hospital Charge Code |
3303101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.94 |
| Max. Negotiated Rate |
$100.70 |
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$90.10
|
| Rate for Payer: First Health Commercial |
$95.40
|
| Rate for Payer: First Health Workers Compensation |
$40.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$95.40
|
| Rate for Payer: GEHA Commercial |
$74.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$95.40
|
| Rate for Payer: Multiplan All |
$96.46
|
| Rate for Payer: OMNI Networks Commercial |
$74.20
|
| Rate for Payer: One Health Plan PPO/POS |
$95.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$100.70
|
| Rate for Payer: Three Rivers Provider Network All |
$79.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$98.58
|
| Rate for Payer: Zelis Auto |
$42.40
|
| Rate for Payer: Zelis Worker's Compensation |
$28.94
|
|
|
iodine REF070034
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT 83789
|
| Hospital Charge Code |
2200211
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.89 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$30.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$152.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Worker's Compensation |
$21.89
|
|
|
iodine REF070034
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT 83789
|
| Hospital Charge Code |
2200211
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.49 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$43.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$43.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$34.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$24.11
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$30.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$174.40
|
| Rate for Payer: GEHA Medicare |
$24.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Humana ChoiceCare |
$26.52
|
| Rate for Payer: Humana Medicare Advantage |
$24.11
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$40.50
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$35.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$24.11
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$40.99
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$40.50
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$35.08
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$24.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$48.22
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$23.63
|
| Rate for Payer: United Healthcare Commercial |
$185.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$35.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$24.11
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Medicare |
$20.49
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$28.93
|
| Rate for Payer: Zelis Worker's Compensation |
$21.89
|
|
|
IODOSORB 0.9% GEL
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
NDC 40565012256
|
| Hospital Charge Code |
3300132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.78 |
| Max. Negotiated Rate |
$176.70 |
| Rate for Payer: Cash Price |
$111.60
|
| Rate for Payer: Cigna Commercial |
$158.10
|
| Rate for Payer: First Health Commercial |
$167.40
|
| Rate for Payer: First Health Workers Compensation |
$71.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$167.40
|
| Rate for Payer: GEHA Commercial |
$130.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$167.40
|
| Rate for Payer: Multiplan All |
$169.26
|
| Rate for Payer: OMNI Networks Commercial |
$130.20
|
| Rate for Payer: One Health Plan PPO/POS |
$167.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$176.70
|
| Rate for Payer: Three Rivers Provider Network All |
$139.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$172.98
|
| Rate for Payer: Zelis Auto |
$74.40
|
| Rate for Payer: Zelis Worker's Compensation |
$50.78
|
|
|
IODOSORB 0.9% GEL
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
NDC 40565012256
|
| Hospital Charge Code |
3300132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$176.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$111.60
|
| Rate for Payer: Cash Price |
$111.60
|
| Rate for Payer: Cigna Commercial |
$158.10
|
| Rate for Payer: First Health Commercial |
$167.40
|
| Rate for Payer: First Health Workers Compensation |
$71.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$167.40
|
| Rate for Payer: GEHA Commercial |
$148.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$167.40
|
| Rate for Payer: Humana ChoiceCare |
$48.36
|
| Rate for Payer: Multiplan All |
$169.26
|
| Rate for Payer: New Mexico Health Connections Medicare |
$111.60
|
| Rate for Payer: OMNI Networks Commercial |
$130.20
|
| Rate for Payer: One Health Plan PPO/POS |
$167.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$176.70
|
| Rate for Payer: Three Rivers Provider Network All |
$139.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$163.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$46.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$172.98
|
| Rate for Payer: Zelis Auto |
$74.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$93.00
|
| Rate for Payer: Zelis Worker's Compensation |
$50.78
|
|
|
IO GA N-STIM SUBSQ W/REPR
|
Facility
|
IP
|
$440.00
|
|
|
Service Code
|
CPT 95982
|
| Hospital Charge Code |
21695982
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$120.12 |
| Max. Negotiated Rate |
$418.00 |
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cigna Commercial |
$374.00
|
| Rate for Payer: First Health Commercial |
$396.00
|
| Rate for Payer: First Health Workers Compensation |
$169.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$396.00
|
| Rate for Payer: GEHA Commercial |
$308.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$396.00
|
| Rate for Payer: Multiplan All |
$400.40
|
| Rate for Payer: OMNI Networks Commercial |
$308.00
|
| Rate for Payer: One Health Plan PPO/POS |
$396.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$418.00
|
| Rate for Payer: Three Rivers Provider Network All |
$330.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$409.20
|
| Rate for Payer: Zelis Auto |
$176.00
|
| Rate for Payer: Zelis Worker's Compensation |
$120.12
|
|
|
IO GA N-STIM SUBSQ W/REPR
|
Facility
|
OP
|
$440.00
|
|
|
Service Code
|
CPT 95982
|
| Hospital Charge Code |
21695982
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$30.10 |
| Max. Negotiated Rate |
$418.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$52.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$264.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$52.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$41.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$35.41
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cigna Commercial |
$374.00
|
| Rate for Payer: First Health Commercial |
$396.00
|
| Rate for Payer: First Health Workers Compensation |
$169.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$396.00
|
| Rate for Payer: GEHA Commercial |
$352.00
|
| Rate for Payer: GEHA Medicare |
$35.41
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$396.00
|
| Rate for Payer: Humana ChoiceCare |
$38.95
|
| Rate for Payer: Humana Medicare Advantage |
$35.41
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$59.49
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$42.61
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$35.41
|
| Rate for Payer: Multiplan All |
$400.40
|
| Rate for Payer: New Mexico Health Connections Medicare |
$60.20
|
| Rate for Payer: OMNI Networks Commercial |
$308.00
|
| Rate for Payer: One Health Plan PPO/POS |
$396.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$49.20
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$42.61
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$35.41
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$418.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$70.82
|
| Rate for Payer: Three Rivers Provider Network All |
$330.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$34.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$42.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.41
|
| Rate for Payer: United Payors & United Providers UP&UP |
$409.20
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$35.41
|
| Rate for Payer: Zelis Auto |
$176.00
|
| Rate for Payer: Zelis Medicare |
$30.10
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$42.49
|
| Rate for Payer: Zelis Worker's Compensation |
$120.12
|
|
|
IO GA N-STIM SUBSQ W/REPR
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
CPT 95982
|
| Hospital Charge Code |
8595982
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$40.95 |
| Max. Negotiated Rate |
$142.50 |
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$127.50
|
| Rate for Payer: First Health Commercial |
$135.00
|
| Rate for Payer: First Health Workers Compensation |
$57.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$135.00
|
| Rate for Payer: GEHA Commercial |
$105.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$135.00
|
| Rate for Payer: Multiplan All |
$136.50
|
| Rate for Payer: OMNI Networks Commercial |
$105.00
|
| Rate for Payer: One Health Plan PPO/POS |
$135.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$142.50
|
| Rate for Payer: Three Rivers Provider Network All |
$112.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$139.50
|
| Rate for Payer: Zelis Auto |
$60.00
|
| Rate for Payer: Zelis Worker's Compensation |
$40.95
|
|
|
IO GA N-STIM SUBSQ W/REPR
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
CPT 95982
|
| Hospital Charge Code |
8595982
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$30.10 |
| Max. Negotiated Rate |
$142.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$52.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$90.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$52.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$41.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$35.41
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$127.50
|
| Rate for Payer: First Health Commercial |
$135.00
|
| Rate for Payer: First Health Workers Compensation |
$57.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$135.00
|
| Rate for Payer: GEHA Commercial |
$120.00
|
| Rate for Payer: GEHA Medicare |
$35.41
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$135.00
|
| Rate for Payer: Humana ChoiceCare |
$38.95
|
| Rate for Payer: Humana Medicare Advantage |
$35.41
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$59.49
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$42.61
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$35.41
|
| Rate for Payer: Multiplan All |
$136.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$60.20
|
| Rate for Payer: OMNI Networks Commercial |
$105.00
|
| Rate for Payer: One Health Plan PPO/POS |
$135.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$49.20
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$42.61
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$35.41
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$142.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$70.82
|
| Rate for Payer: Three Rivers Provider Network All |
$112.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$34.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$42.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.41
|
| Rate for Payer: United Payors & United Providers UP&UP |
$139.50
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$35.41
|
| Rate for Payer: Zelis Auto |
$60.00
|
| Rate for Payer: Zelis Medicare |
$30.10
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$42.49
|
| Rate for Payer: Zelis Worker's Compensation |
$40.95
|
|
|
IOHEXOL 300 MGI/ML 50 ML
|
Facility
|
IP
|
$353.00
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
3302862
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.37 |
| Max. Negotiated Rate |
$335.35 |
| Rate for Payer: Cash Price |
$211.80
|
| Rate for Payer: Cigna Commercial |
$300.05
|
| Rate for Payer: First Health Commercial |
$317.70
|
| Rate for Payer: First Health Workers Compensation |
$136.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$317.70
|
| Rate for Payer: GEHA Commercial |
$247.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$317.70
|
| Rate for Payer: Multiplan All |
$321.23
|
| Rate for Payer: OMNI Networks Commercial |
$247.10
|
| Rate for Payer: One Health Plan PPO/POS |
$317.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$335.35
|
| Rate for Payer: Three Rivers Provider Network All |
$264.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$328.29
|
| Rate for Payer: Zelis Auto |
$141.20
|
| Rate for Payer: Zelis Worker's Compensation |
$96.37
|
|
|
IOHEXOL 300 MGI/ML 50 ML
|
Facility
|
OP
|
$353.00
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
3302862
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$335.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$211.80
|
| Rate for Payer: Cash Price |
$211.80
|
| Rate for Payer: Cash Price |
$211.80
|
| Rate for Payer: Cigna Commercial |
$300.05
|
| Rate for Payer: First Health Commercial |
$317.70
|
| Rate for Payer: First Health Workers Compensation |
$136.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$317.70
|
| Rate for Payer: GEHA Commercial |
$0.17
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$317.70
|
| Rate for Payer: Humana ChoiceCare |
$91.78
|
| Rate for Payer: Multiplan All |
$321.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$211.80
|
| Rate for Payer: OMNI Networks Commercial |
$247.10
|
| Rate for Payer: One Health Plan PPO/POS |
$317.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$335.35
|
| Rate for Payer: Three Rivers Provider Network All |
$264.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$310.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$88.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$328.29
|
| Rate for Payer: Zelis Auto |
$141.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$176.50
|
| Rate for Payer: Zelis Worker's Compensation |
$96.37
|
|
|
IOHEXOL INJ 240 MGI/ML 10 ML
|
Facility
|
IP
|
$336.00
|
|
|
Service Code
|
CPT Q9966
|
| Hospital Charge Code |
3302861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.73 |
| Max. Negotiated Rate |
$319.20 |
| Rate for Payer: Cash Price |
$201.60
|
| Rate for Payer: Cigna Commercial |
$285.60
|
| Rate for Payer: First Health Commercial |
$302.40
|
| Rate for Payer: First Health Workers Compensation |
$129.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$302.40
|
| Rate for Payer: GEHA Commercial |
$235.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$302.40
|
| Rate for Payer: Multiplan All |
$305.76
|
| Rate for Payer: OMNI Networks Commercial |
$235.20
|
| Rate for Payer: One Health Plan PPO/POS |
$302.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$319.20
|
| Rate for Payer: Three Rivers Provider Network All |
$252.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$312.48
|
| Rate for Payer: Zelis Auto |
$134.40
|
| Rate for Payer: Zelis Worker's Compensation |
$91.73
|
|
|
IOHEXOL INJ 240 MGI/ML 10 ML
|
Facility
|
OP
|
$336.00
|
|
|
Service Code
|
CPT Q9966
|
| Hospital Charge Code |
3302861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$319.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$201.60
|
| Rate for Payer: Cash Price |
$201.60
|
| Rate for Payer: Cash Price |
$201.60
|
| Rate for Payer: Cigna Commercial |
$285.60
|
| Rate for Payer: First Health Commercial |
$302.40
|
| Rate for Payer: First Health Workers Compensation |
$129.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$302.40
|
| Rate for Payer: GEHA Commercial |
$0.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$302.40
|
| Rate for Payer: Humana ChoiceCare |
$87.36
|
| Rate for Payer: Multiplan All |
$305.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$201.60
|
| Rate for Payer: OMNI Networks Commercial |
$235.20
|
| Rate for Payer: One Health Plan PPO/POS |
$302.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$319.20
|
| Rate for Payer: Three Rivers Provider Network All |
$252.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$295.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$84.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$312.48
|
| Rate for Payer: Zelis Auto |
$134.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$168.00
|
| Rate for Payer: Zelis Worker's Compensation |
$91.73
|
|
|
IOHEXOL INJ 350MGI/ML 100 ML
|
Facility
|
OP
|
$664.00
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
3302863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$630.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$398.40
|
| Rate for Payer: Cash Price |
$398.40
|
| Rate for Payer: Cash Price |
$398.40
|
| Rate for Payer: Cigna Commercial |
$564.40
|
| Rate for Payer: First Health Commercial |
$597.60
|
| Rate for Payer: First Health Workers Compensation |
$256.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$597.60
|
| Rate for Payer: GEHA Commercial |
$0.17
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$597.60
|
| Rate for Payer: Humana ChoiceCare |
$172.64
|
| Rate for Payer: Multiplan All |
$604.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$398.40
|
| Rate for Payer: OMNI Networks Commercial |
$464.80
|
| Rate for Payer: One Health Plan PPO/POS |
$597.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$630.80
|
| Rate for Payer: Three Rivers Provider Network All |
$498.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$584.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$166.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$617.52
|
| Rate for Payer: Zelis Auto |
$265.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$332.00
|
| Rate for Payer: Zelis Worker's Compensation |
$181.27
|
|
|
IOHEXOL INJ 350MGI/ML 100 ML
|
Facility
|
IP
|
$664.00
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
3302863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.27 |
| Max. Negotiated Rate |
$630.80 |
| Rate for Payer: Cash Price |
$398.40
|
| Rate for Payer: Cigna Commercial |
$564.40
|
| Rate for Payer: First Health Commercial |
$597.60
|
| Rate for Payer: First Health Workers Compensation |
$256.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$597.60
|
| Rate for Payer: GEHA Commercial |
$464.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$597.60
|
| Rate for Payer: Multiplan All |
$604.24
|
| Rate for Payer: OMNI Networks Commercial |
$464.80
|
| Rate for Payer: One Health Plan PPO/POS |
$597.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$630.80
|
| Rate for Payer: Three Rivers Provider Network All |
$498.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$617.52
|
| Rate for Payer: Zelis Auto |
$265.60
|
| Rate for Payer: Zelis Worker's Compensation |
$181.27
|
|
|
IOHEXOL INJ 350 MGI/ML 125 ML
|
Facility
|
OP
|
$740.00
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
3302865
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$703.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$444.00
|
| Rate for Payer: Cash Price |
$444.00
|
| Rate for Payer: Cash Price |
$444.00
|
| Rate for Payer: Cigna Commercial |
$629.00
|
| Rate for Payer: First Health Commercial |
$666.00
|
| Rate for Payer: First Health Workers Compensation |
$285.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$666.00
|
| Rate for Payer: GEHA Commercial |
$0.17
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$666.00
|
| Rate for Payer: Humana ChoiceCare |
$192.40
|
| Rate for Payer: Multiplan All |
$673.40
|
| Rate for Payer: New Mexico Health Connections Medicare |
$444.00
|
| Rate for Payer: OMNI Networks Commercial |
$518.00
|
| Rate for Payer: One Health Plan PPO/POS |
$666.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$703.00
|
| Rate for Payer: Three Rivers Provider Network All |
$555.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$651.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$185.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$688.20
|
| Rate for Payer: Zelis Auto |
$296.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$370.00
|
| Rate for Payer: Zelis Worker's Compensation |
$202.02
|
|
|
IOHEXOL INJ 350 MGI/ML 125 ML
|
Facility
|
IP
|
$740.00
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
3302865
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$202.02 |
| Max. Negotiated Rate |
$703.00 |
| Rate for Payer: Cash Price |
$444.00
|
| Rate for Payer: Cigna Commercial |
$629.00
|
| Rate for Payer: First Health Commercial |
$666.00
|
| Rate for Payer: First Health Workers Compensation |
$285.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$666.00
|
| Rate for Payer: GEHA Commercial |
$518.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$666.00
|
| Rate for Payer: Multiplan All |
$673.40
|
| Rate for Payer: OMNI Networks Commercial |
$518.00
|
| Rate for Payer: One Health Plan PPO/POS |
$666.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$703.00
|
| Rate for Payer: Three Rivers Provider Network All |
$555.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$688.20
|
| Rate for Payer: Zelis Auto |
$296.00
|
| Rate for Payer: Zelis Worker's Compensation |
$202.02
|
|
|
IOHEXOL INJ 350 MGI/ML 150 ML
|
Facility
|
IP
|
$859.00
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
3302864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$234.51 |
| Max. Negotiated Rate |
$816.05 |
| Rate for Payer: Cash Price |
$515.40
|
| Rate for Payer: Cigna Commercial |
$730.15
|
| Rate for Payer: First Health Commercial |
$773.10
|
| Rate for Payer: First Health Workers Compensation |
$331.66
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$773.10
|
| Rate for Payer: GEHA Commercial |
$601.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$773.10
|
| Rate for Payer: Multiplan All |
$781.69
|
| Rate for Payer: OMNI Networks Commercial |
$601.30
|
| Rate for Payer: One Health Plan PPO/POS |
$773.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$816.05
|
| Rate for Payer: Three Rivers Provider Network All |
$644.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$798.87
|
| Rate for Payer: Zelis Auto |
$343.60
|
| Rate for Payer: Zelis Worker's Compensation |
$234.51
|
|
|
IOHEXOL INJ 350 MGI/ML 150 ML
|
Facility
|
OP
|
$859.00
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
3302864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$816.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$515.40
|
| Rate for Payer: Cash Price |
$515.40
|
| Rate for Payer: Cash Price |
$515.40
|
| Rate for Payer: Cigna Commercial |
$730.15
|
| Rate for Payer: First Health Commercial |
$773.10
|
| Rate for Payer: First Health Workers Compensation |
$331.66
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$773.10
|
| Rate for Payer: GEHA Commercial |
$0.17
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$773.10
|
| Rate for Payer: Humana ChoiceCare |
$223.34
|
| Rate for Payer: Multiplan All |
$781.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$515.40
|
| Rate for Payer: OMNI Networks Commercial |
$601.30
|
| Rate for Payer: One Health Plan PPO/POS |
$773.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$816.05
|
| Rate for Payer: Three Rivers Provider Network All |
$644.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$755.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$214.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$798.87
|
| Rate for Payer: Zelis Auto |
$343.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$429.50
|
| Rate for Payer: Zelis Worker's Compensation |
$234.51
|
|
|
IOHEXOL INJ 350MGI/ML 50ML
|
Facility
|
OP
|
$408.00
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
3302860
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$387.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$244.80
|
| Rate for Payer: Cash Price |
$244.80
|
| Rate for Payer: Cash Price |
$244.80
|
| Rate for Payer: Cigna Commercial |
$346.80
|
| Rate for Payer: First Health Commercial |
$367.20
|
| Rate for Payer: First Health Workers Compensation |
$157.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$367.20
|
| Rate for Payer: GEHA Commercial |
$0.17
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$367.20
|
| Rate for Payer: Humana ChoiceCare |
$106.08
|
| Rate for Payer: Multiplan All |
$371.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$244.80
|
| Rate for Payer: OMNI Networks Commercial |
$285.60
|
| Rate for Payer: One Health Plan PPO/POS |
$367.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$387.60
|
| Rate for Payer: Three Rivers Provider Network All |
$306.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$359.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$102.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$379.44
|
| Rate for Payer: Zelis Auto |
$163.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$204.00
|
| Rate for Payer: Zelis Worker's Compensation |
$111.38
|
|
