|
LABETALOL HCL 100MG TAB
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 51079092820
|
| Hospital Charge Code |
3300487
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$6.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
LABETALOL HCL 100MG TAB
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 51079092820
|
| Hospital Charge Code |
3300487
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$7.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Humana ChoiceCare |
$2.34
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5.40
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.50
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
LABETALOL HCL 20 MG/4 ML IV PUSH
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00409233934
|
| Hospital Charge Code |
3300486
|
|
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
|
|
|
LABETALOL HCL 20 MG/4 ML IV PUSH
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 00409233934
|
| Hospital Charge Code |
3300486
|
|
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
|
|
|
LAB HANDLING FEE
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
CPT 99001
|
| Hospital Charge Code |
2299615
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.25 |
| Max. Negotiated Rate |
$57.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$36.60
|
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Cigna Commercial |
$51.85
|
| Rate for Payer: First Health Commercial |
$54.90
|
| Rate for Payer: First Health Workers Compensation |
$23.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$54.90
|
| Rate for Payer: GEHA Commercial |
$48.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$54.90
|
| Rate for Payer: Humana ChoiceCare |
$15.86
|
| Rate for Payer: Multiplan All |
$55.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$36.60
|
| Rate for Payer: OMNI Networks Commercial |
$42.70
|
| Rate for Payer: One Health Plan PPO/POS |
$54.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$57.95
|
| Rate for Payer: Three Rivers Provider Network All |
$45.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$53.68
|
| Rate for Payer: United Healthcare Commercial |
$51.85
|
| Rate for Payer: United Healthcare Managed Medicaid |
$15.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$56.73
|
| Rate for Payer: Zelis Auto |
$24.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$30.50
|
| Rate for Payer: Zelis Worker's Compensation |
$16.65
|
|
|
LAB HANDLING FEE
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
CPT 99001
|
| Hospital Charge Code |
2299615
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.65 |
| Max. Negotiated Rate |
$57.95 |
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Cigna Commercial |
$51.85
|
| Rate for Payer: First Health Commercial |
$54.90
|
| Rate for Payer: First Health Workers Compensation |
$23.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$54.90
|
| Rate for Payer: GEHA Commercial |
$42.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$54.90
|
| Rate for Payer: Multiplan All |
$55.51
|
| Rate for Payer: OMNI Networks Commercial |
$42.70
|
| Rate for Payer: One Health Plan PPO/POS |
$54.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$57.95
|
| Rate for Payer: Three Rivers Provider Network All |
$45.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$56.73
|
| Rate for Payer: Zelis Auto |
$24.40
|
| Rate for Payer: Zelis Worker's Compensation |
$16.65
|
|
|
LAB test for HIT (Vitros)
|
Facility
|
OP
|
$409.00
|
|
|
Service Code
|
CPT 80053
|
| Hospital Charge Code |
2233999
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.98 |
| Max. Negotiated Rate |
$388.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$19.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$245.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$19.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$15.06
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$10.56
|
| Rate for Payer: Cash Price |
$245.40
|
| Rate for Payer: Cash Price |
$245.40
|
| Rate for Payer: Cigna Commercial |
$347.65
|
| Rate for Payer: First Health Commercial |
$368.10
|
| Rate for Payer: First Health Workers Compensation |
$18.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$368.10
|
| Rate for Payer: GEHA Commercial |
$327.20
|
| Rate for Payer: GEHA Medicare |
$10.56
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$368.10
|
| Rate for Payer: Humana ChoiceCare |
$11.62
|
| Rate for Payer: Humana Medicare Advantage |
$10.56
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$17.74
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$15.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$10.56
|
| Rate for Payer: Multiplan All |
$372.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$17.95
|
| Rate for Payer: OMNI Networks Commercial |
$286.30
|
| Rate for Payer: One Health Plan PPO/POS |
$368.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$17.74
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$15.36
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$10.56
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$388.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$21.12
|
| Rate for Payer: Three Rivers Provider Network All |
$306.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.35
|
| Rate for Payer: United Healthcare Commercial |
$347.65
|
| Rate for Payer: United Healthcare Managed Medicaid |
$15.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.56
|
| Rate for Payer: United Payors & United Providers UP&UP |
$380.37
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$10.56
|
| Rate for Payer: Zelis Auto |
$163.60
|
| Rate for Payer: Zelis Medicare |
$8.98
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12.67
|
| Rate for Payer: Zelis Worker's Compensation |
$13.03
|
|
|
LAB test for HIT (Vitros)
|
Facility
|
IP
|
$409.00
|
|
|
Service Code
|
CPT 80053
|
| Hospital Charge Code |
2233999
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.03 |
| Max. Negotiated Rate |
$388.55 |
| Rate for Payer: Cash Price |
$245.40
|
| Rate for Payer: Cash Price |
$245.40
|
| Rate for Payer: Cigna Commercial |
$347.65
|
| Rate for Payer: First Health Commercial |
$368.10
|
| Rate for Payer: First Health Workers Compensation |
$18.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$368.10
|
| Rate for Payer: GEHA Commercial |
$286.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$368.10
|
| Rate for Payer: Multiplan All |
$372.19
|
| Rate for Payer: OMNI Networks Commercial |
$286.30
|
| Rate for Payer: One Health Plan PPO/POS |
$368.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$388.55
|
| Rate for Payer: Three Rivers Provider Network All |
$306.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$380.37
|
| Rate for Payer: Zelis Auto |
$163.60
|
| Rate for Payer: Zelis Worker's Compensation |
$13.03
|
|
|
lacosamide REF007012
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
CPT 80339
|
| Hospital Charge Code |
2200412
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$27.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$134.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Humana ChoiceCare |
$43.68
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$100.80
|
| Rate for Payer: OMNI Networks Commercial |
$117.60
|
| Rate for Payer: One Health Plan PPO/POS |
$151.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$147.84
|
| Rate for Payer: United Healthcare Commercial |
$142.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$84.00
|
| Rate for Payer: Zelis Worker's Compensation |
$19.29
|
|
|
lacosamide REF007012
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
CPT 80339
|
| Hospital Charge Code |
2200412
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$27.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$117.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: OMNI Networks Commercial |
$117.60
|
| Rate for Payer: One Health Plan PPO/POS |
$151.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Worker's Compensation |
$19.29
|
|
|
LAC REP BODY INTERMED >30CM
|
Facility
|
IP
|
$5,140.00
|
|
| Hospital Charge Code |
8112037
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,403.22 |
| Max. Negotiated Rate |
$4,883.00 |
| Rate for Payer: Cash Price |
$3,084.00
|
| Rate for Payer: Cigna Commercial |
$4,369.00
|
| Rate for Payer: First Health Commercial |
$4,626.00
|
| Rate for Payer: First Health Workers Compensation |
$1,984.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,626.00
|
| Rate for Payer: GEHA Commercial |
$3,598.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,626.00
|
| Rate for Payer: Multiplan All |
$4,677.40
|
| Rate for Payer: OMNI Networks Commercial |
$3,598.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,626.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,883.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,855.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,780.20
|
| Rate for Payer: Zelis Auto |
$2,056.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,403.22
|
|
|
LAC REP BODY INTERMED >30CM
|
Facility
|
OP
|
$5,140.00
|
|
| Hospital Charge Code |
8112037
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,285.00 |
| Max. Negotiated Rate |
$4,883.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,084.00
|
| Rate for Payer: Cash Price |
$3,084.00
|
| Rate for Payer: Cigna Commercial |
$4,369.00
|
| Rate for Payer: First Health Commercial |
$4,626.00
|
| Rate for Payer: First Health Workers Compensation |
$1,984.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,626.00
|
| Rate for Payer: GEHA Commercial |
$4,112.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,626.00
|
| Rate for Payer: Humana ChoiceCare |
$1,336.40
|
| Rate for Payer: Multiplan All |
$4,677.40
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,084.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,598.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,626.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,883.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,855.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,523.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,285.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,780.20
|
| Rate for Payer: Zelis Auto |
$2,056.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,570.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,403.22
|
|
|
LAC REP BODY SIMPLE >30CM
|
Facility
|
OP
|
$1,149.00
|
|
| Hospital Charge Code |
8112007
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$287.25 |
| Max. Negotiated Rate |
$1,091.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$689.40
|
| Rate for Payer: Cash Price |
$689.40
|
| Rate for Payer: Cigna Commercial |
$976.65
|
| Rate for Payer: First Health Commercial |
$1,034.10
|
| Rate for Payer: First Health Workers Compensation |
$443.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,034.10
|
| Rate for Payer: GEHA Commercial |
$919.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,034.10
|
| Rate for Payer: Humana ChoiceCare |
$298.74
|
| Rate for Payer: Multiplan All |
$1,045.59
|
| Rate for Payer: New Mexico Health Connections Medicare |
$689.40
|
| Rate for Payer: OMNI Networks Commercial |
$804.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,034.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,091.55
|
| Rate for Payer: Three Rivers Provider Network All |
$861.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,011.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$287.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,068.57
|
| Rate for Payer: Zelis Auto |
$459.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$574.50
|
| Rate for Payer: Zelis Worker's Compensation |
$313.68
|
|
|
LAC REP BODY SIMPLE >30CM
|
Facility
|
IP
|
$1,149.00
|
|
| Hospital Charge Code |
8112007
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$313.68 |
| Max. Negotiated Rate |
$1,091.55 |
| Rate for Payer: Cash Price |
$689.40
|
| Rate for Payer: Cigna Commercial |
$976.65
|
| Rate for Payer: First Health Commercial |
$1,034.10
|
| Rate for Payer: First Health Workers Compensation |
$443.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,034.10
|
| Rate for Payer: GEHA Commercial |
$804.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,034.10
|
| Rate for Payer: Multiplan All |
$1,045.59
|
| Rate for Payer: OMNI Networks Commercial |
$804.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,034.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,091.55
|
| Rate for Payer: Three Rivers Provider Network All |
$861.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,068.57
|
| Rate for Payer: Zelis Auto |
$459.60
|
| Rate for Payer: Zelis Worker's Compensation |
$313.68
|
|
|
LAC REP FACE INTERMED 20.1-30CM
|
Facility
|
OP
|
$1,819.00
|
|
| Hospital Charge Code |
8112056
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$454.75 |
| Max. Negotiated Rate |
$1,728.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,091.40
|
| Rate for Payer: Cash Price |
$1,091.40
|
| Rate for Payer: Cigna Commercial |
$1,546.15
|
| Rate for Payer: First Health Commercial |
$1,637.10
|
| Rate for Payer: First Health Workers Compensation |
$702.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,637.10
|
| Rate for Payer: GEHA Commercial |
$1,455.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,637.10
|
| Rate for Payer: Humana ChoiceCare |
$472.94
|
| Rate for Payer: Multiplan All |
$1,655.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,091.40
|
| Rate for Payer: OMNI Networks Commercial |
$1,273.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,637.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,728.05
|
| Rate for Payer: Three Rivers Provider Network All |
$1,364.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,600.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$454.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,691.67
|
| Rate for Payer: Zelis Auto |
$727.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$909.50
|
| Rate for Payer: Zelis Worker's Compensation |
$496.59
|
|
|
LAC REP FACE INTERMED 20.1-30CM
|
Facility
|
IP
|
$1,819.00
|
|
| Hospital Charge Code |
8112056
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$496.59 |
| Max. Negotiated Rate |
$1,728.05 |
| Rate for Payer: Cash Price |
$1,091.40
|
| Rate for Payer: Cigna Commercial |
$1,546.15
|
| Rate for Payer: First Health Commercial |
$1,637.10
|
| Rate for Payer: First Health Workers Compensation |
$702.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,637.10
|
| Rate for Payer: GEHA Commercial |
$1,273.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,637.10
|
| Rate for Payer: Multiplan All |
$1,655.29
|
| Rate for Payer: OMNI Networks Commercial |
$1,273.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,637.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,728.05
|
| Rate for Payer: Three Rivers Provider Network All |
$1,364.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,691.67
|
| Rate for Payer: Zelis Auto |
$727.60
|
| Rate for Payer: Zelis Worker's Compensation |
$496.59
|
|
|
LAC REP FACE INTERMED >30CM
|
Facility
|
OP
|
$1,526.00
|
|
| Hospital Charge Code |
8112057
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$381.50 |
| Max. Negotiated Rate |
$1,449.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$915.60
|
| Rate for Payer: Cash Price |
$915.60
|
| Rate for Payer: Cigna Commercial |
$1,297.10
|
| Rate for Payer: First Health Commercial |
$1,373.40
|
| Rate for Payer: First Health Workers Compensation |
$589.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,373.40
|
| Rate for Payer: GEHA Commercial |
$1,220.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,373.40
|
| Rate for Payer: Humana ChoiceCare |
$396.76
|
| Rate for Payer: Multiplan All |
$1,388.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$915.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,068.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,373.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,449.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,144.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,342.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$381.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,419.18
|
| Rate for Payer: Zelis Auto |
$610.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$763.00
|
| Rate for Payer: Zelis Worker's Compensation |
$416.60
|
|
|
LAC REP FACE INTERMED >30CM
|
Facility
|
IP
|
$1,526.00
|
|
| Hospital Charge Code |
8112057
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$416.60 |
| Max. Negotiated Rate |
$1,449.70 |
| Rate for Payer: Cash Price |
$915.60
|
| Rate for Payer: Cigna Commercial |
$1,297.10
|
| Rate for Payer: First Health Commercial |
$1,373.40
|
| Rate for Payer: First Health Workers Compensation |
$589.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,373.40
|
| Rate for Payer: GEHA Commercial |
$1,068.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,373.40
|
| Rate for Payer: Multiplan All |
$1,388.66
|
| Rate for Payer: OMNI Networks Commercial |
$1,068.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,373.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,449.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,144.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,419.18
|
| Rate for Payer: Zelis Auto |
$610.40
|
| Rate for Payer: Zelis Worker's Compensation |
$416.60
|
|
|
LAC REP FACE SIMPLE 20.1-30CM
|
Facility
|
OP
|
$843.00
|
|
| Hospital Charge Code |
8112017
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$210.75 |
| Max. Negotiated Rate |
$800.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$505.80
|
| Rate for Payer: Cash Price |
$505.80
|
| Rate for Payer: Cigna Commercial |
$716.55
|
| Rate for Payer: First Health Commercial |
$758.70
|
| Rate for Payer: First Health Workers Compensation |
$325.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$758.70
|
| Rate for Payer: GEHA Commercial |
$674.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$758.70
|
| Rate for Payer: Humana ChoiceCare |
$219.18
|
| Rate for Payer: Multiplan All |
$767.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$505.80
|
| Rate for Payer: OMNI Networks Commercial |
$590.10
|
| Rate for Payer: One Health Plan PPO/POS |
$758.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$800.85
|
| Rate for Payer: Three Rivers Provider Network All |
$632.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$741.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$210.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$783.99
|
| Rate for Payer: Zelis Auto |
$337.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$421.50
|
| Rate for Payer: Zelis Worker's Compensation |
$230.14
|
|
|
LAC REP FACE SIMPLE 20.1-30CM
|
Facility
|
IP
|
$843.00
|
|
| Hospital Charge Code |
8112017
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$230.14 |
| Max. Negotiated Rate |
$800.85 |
| Rate for Payer: Cash Price |
$505.80
|
| Rate for Payer: Cigna Commercial |
$716.55
|
| Rate for Payer: First Health Commercial |
$758.70
|
| Rate for Payer: First Health Workers Compensation |
$325.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$758.70
|
| Rate for Payer: GEHA Commercial |
$590.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$758.70
|
| Rate for Payer: Multiplan All |
$767.13
|
| Rate for Payer: OMNI Networks Commercial |
$590.10
|
| Rate for Payer: One Health Plan PPO/POS |
$758.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$800.85
|
| Rate for Payer: Three Rivers Provider Network All |
$632.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$783.99
|
| Rate for Payer: Zelis Auto |
$337.20
|
| Rate for Payer: Zelis Worker's Compensation |
$230.14
|
|
|
LAC REP FACE SIMPLE >30CM
|
Facility
|
IP
|
$2,025.00
|
|
| Hospital Charge Code |
8112036
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$552.83 |
| Max. Negotiated Rate |
$1,923.75 |
| Rate for Payer: Cash Price |
$1,215.00
|
| Rate for Payer: Cigna Commercial |
$1,721.25
|
| Rate for Payer: First Health Commercial |
$1,822.50
|
| Rate for Payer: First Health Workers Compensation |
$781.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,822.50
|
| Rate for Payer: GEHA Commercial |
$1,417.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,822.50
|
| Rate for Payer: Multiplan All |
$1,842.75
|
| Rate for Payer: OMNI Networks Commercial |
$1,417.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,822.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,923.75
|
| Rate for Payer: Three Rivers Provider Network All |
$1,518.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,883.25
|
| Rate for Payer: Zelis Auto |
$810.00
|
| Rate for Payer: Zelis Worker's Compensation |
$552.83
|
|
|
LAC REP FACE SIMPLE >30CM
|
Facility
|
IP
|
$907.00
|
|
| Hospital Charge Code |
8112018
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$247.61 |
| Max. Negotiated Rate |
$861.65 |
| Rate for Payer: Cash Price |
$544.20
|
| Rate for Payer: Cigna Commercial |
$770.95
|
| Rate for Payer: First Health Commercial |
$816.30
|
| Rate for Payer: First Health Workers Compensation |
$350.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$816.30
|
| Rate for Payer: GEHA Commercial |
$634.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$816.30
|
| Rate for Payer: Multiplan All |
$825.37
|
| Rate for Payer: OMNI Networks Commercial |
$634.90
|
| Rate for Payer: One Health Plan PPO/POS |
$816.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$861.65
|
| Rate for Payer: Three Rivers Provider Network All |
$680.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$843.51
|
| Rate for Payer: Zelis Auto |
$362.80
|
| Rate for Payer: Zelis Worker's Compensation |
$247.61
|
|
|
LAC REP FACE SIMPLE >30CM
|
Facility
|
OP
|
$2,025.00
|
|
| Hospital Charge Code |
8112036
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$506.25 |
| Max. Negotiated Rate |
$1,923.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,215.00
|
| Rate for Payer: Cash Price |
$1,215.00
|
| Rate for Payer: Cigna Commercial |
$1,721.25
|
| Rate for Payer: First Health Commercial |
$1,822.50
|
| Rate for Payer: First Health Workers Compensation |
$781.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,822.50
|
| Rate for Payer: GEHA Commercial |
$1,620.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,822.50
|
| Rate for Payer: Humana ChoiceCare |
$526.50
|
| Rate for Payer: Multiplan All |
$1,842.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,215.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,417.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,822.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,923.75
|
| Rate for Payer: Three Rivers Provider Network All |
$1,518.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,782.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$506.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,883.25
|
| Rate for Payer: Zelis Auto |
$810.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,012.50
|
| Rate for Payer: Zelis Worker's Compensation |
$552.83
|
|
|
LAC REP FACE SIMPLE >30CM
|
Facility
|
OP
|
$907.00
|
|
| Hospital Charge Code |
8112018
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$226.75 |
| Max. Negotiated Rate |
$861.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$544.20
|
| Rate for Payer: Cash Price |
$544.20
|
| Rate for Payer: Cigna Commercial |
$770.95
|
| Rate for Payer: First Health Commercial |
$816.30
|
| Rate for Payer: First Health Workers Compensation |
$350.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$816.30
|
| Rate for Payer: GEHA Commercial |
$725.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$816.30
|
| Rate for Payer: Humana ChoiceCare |
$235.82
|
| Rate for Payer: Multiplan All |
$825.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$544.20
|
| Rate for Payer: OMNI Networks Commercial |
$634.90
|
| Rate for Payer: One Health Plan PPO/POS |
$816.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$861.65
|
| Rate for Payer: Three Rivers Provider Network All |
$680.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$798.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$226.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$843.51
|
| Rate for Payer: Zelis Auto |
$362.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$453.50
|
| Rate for Payer: Zelis Worker's Compensation |
$247.61
|
|
|
LAC REP MOUTH OVER 2.5CM OR COMPLEX
|
Facility
|
OP
|
$2,679.00
|
|
| Hospital Charge Code |
8140831
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$669.75 |
| Max. Negotiated Rate |
$2,545.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,607.40
|
| Rate for Payer: Cash Price |
$1,607.40
|
| Rate for Payer: Cigna Commercial |
$2,277.15
|
| Rate for Payer: First Health Commercial |
$2,411.10
|
| Rate for Payer: First Health Workers Compensation |
$1,034.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,411.10
|
| Rate for Payer: GEHA Commercial |
$2,143.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,411.10
|
| Rate for Payer: Humana ChoiceCare |
$696.54
|
| Rate for Payer: Multiplan All |
$2,437.89
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,607.40
|
| Rate for Payer: OMNI Networks Commercial |
$1,875.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,411.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,545.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,009.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,357.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$669.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,491.47
|
| Rate for Payer: Zelis Auto |
$1,071.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,339.50
|
| Rate for Payer: Zelis Worker's Compensation |
$731.37
|
|
