|
LIGATION OF SALIVARY DUCT
|
Facility
|
IP
|
$527.00
|
|
|
Service Code
|
CPT 42665
|
| Hospital Charge Code |
6142665
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$143.87 |
| Max. Negotiated Rate |
$500.65 |
| Rate for Payer: Cash Price |
$316.20
|
| Rate for Payer: Cigna Commercial |
$447.95
|
| Rate for Payer: First Health Commercial |
$474.30
|
| Rate for Payer: First Health Workers Compensation |
$203.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$474.30
|
| Rate for Payer: GEHA Commercial |
$368.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$474.30
|
| Rate for Payer: Multiplan All |
$479.57
|
| Rate for Payer: OMNI Networks Commercial |
$368.90
|
| Rate for Payer: One Health Plan PPO/POS |
$474.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$500.65
|
| Rate for Payer: Three Rivers Provider Network All |
$395.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$490.11
|
| Rate for Payer: Zelis Auto |
$210.80
|
| Rate for Payer: Zelis Worker's Compensation |
$143.87
|
|
|
LIGATION OF SHUNT
|
Facility
|
OP
|
$905.00
|
|
|
Service Code
|
CPT 49428
|
| Hospital Charge Code |
6149428
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$226.25 |
| Max. Negotiated Rate |
$859.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$543.00
|
| Rate for Payer: Cash Price |
$543.00
|
| Rate for Payer: Cigna Commercial |
$769.25
|
| Rate for Payer: First Health Commercial |
$814.50
|
| Rate for Payer: First Health Workers Compensation |
$349.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$814.50
|
| Rate for Payer: GEHA Commercial |
$724.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$814.50
|
| Rate for Payer: Humana ChoiceCare |
$235.30
|
| Rate for Payer: Multiplan All |
$823.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$543.00
|
| Rate for Payer: OMNI Networks Commercial |
$633.50
|
| Rate for Payer: One Health Plan PPO/POS |
$814.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$859.75
|
| Rate for Payer: Three Rivers Provider Network All |
$678.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$796.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$226.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$841.65
|
| Rate for Payer: Zelis Auto |
$362.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$452.50
|
| Rate for Payer: Zelis Worker's Compensation |
$247.06
|
|
|
LIGATION OF SHUNT
|
Facility
|
IP
|
$905.00
|
|
|
Service Code
|
CPT 49428
|
| Hospital Charge Code |
6149428
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$247.06 |
| Max. Negotiated Rate |
$859.75 |
| Rate for Payer: Cash Price |
$543.00
|
| Rate for Payer: Cigna Commercial |
$769.25
|
| Rate for Payer: First Health Commercial |
$814.50
|
| Rate for Payer: First Health Workers Compensation |
$349.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$814.50
|
| Rate for Payer: GEHA Commercial |
$633.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$814.50
|
| Rate for Payer: Multiplan All |
$823.55
|
| Rate for Payer: OMNI Networks Commercial |
$633.50
|
| Rate for Payer: One Health Plan PPO/POS |
$814.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$859.75
|
| Rate for Payer: Three Rivers Provider Network All |
$678.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$841.65
|
| Rate for Payer: Zelis Auto |
$362.00
|
| Rate for Payer: Zelis Worker's Compensation |
$247.06
|
|
|
LIGATION UPPER JAW ARTERY
|
Facility
|
OP
|
$1,694.00
|
|
|
Service Code
|
CPT 30920
|
| Hospital Charge Code |
6130920
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$462.46 |
| Max. Negotiated Rate |
$5,977.36 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,686.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,016.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,686.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2,128.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$2,988.68
|
| Rate for Payer: Cash Price |
$1,016.40
|
| Rate for Payer: Cash Price |
$1,016.40
|
| Rate for Payer: Cigna Commercial |
$1,439.90
|
| Rate for Payer: First Health Commercial |
$1,524.60
|
| Rate for Payer: First Health Workers Compensation |
$654.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,524.60
|
| Rate for Payer: GEHA Commercial |
$1,355.20
|
| Rate for Payer: GEHA Medicare |
$2,988.68
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,524.60
|
| Rate for Payer: Humana ChoiceCare |
$3,287.55
|
| Rate for Payer: Humana Medicare Advantage |
$2,988.68
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,020.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,171.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$2,988.68
|
| Rate for Payer: Multiplan All |
$1,541.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,080.76
|
| Rate for Payer: OMNI Networks Commercial |
$1,185.80
|
| Rate for Payer: One Health Plan PPO/POS |
$1,524.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,507.50
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,171.67
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$2,988.68
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,609.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$5,977.36
|
| Rate for Payer: Three Rivers Provider Network All |
$1,270.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,928.91
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,171.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,988.68
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,575.42
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$2,988.68
|
| Rate for Payer: Zelis Auto |
$677.60
|
| Rate for Payer: Zelis Medicare |
$2,540.38
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,586.42
|
| Rate for Payer: Zelis Worker's Compensation |
$462.46
|
|
|
LIGATION UPPER JAW ARTERY
|
Facility
|
IP
|
$1,694.00
|
|
|
Service Code
|
CPT 30920
|
| Hospital Charge Code |
6130920
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$462.46 |
| Max. Negotiated Rate |
$1,609.30 |
| Rate for Payer: Cash Price |
$1,016.40
|
| Rate for Payer: Cigna Commercial |
$1,439.90
|
| Rate for Payer: First Health Commercial |
$1,524.60
|
| Rate for Payer: First Health Workers Compensation |
$654.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,524.60
|
| Rate for Payer: GEHA Commercial |
$1,185.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,524.60
|
| Rate for Payer: Multiplan All |
$1,541.54
|
| Rate for Payer: OMNI Networks Commercial |
$1,185.80
|
| Rate for Payer: One Health Plan PPO/POS |
$1,524.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,609.30
|
| Rate for Payer: Three Rivers Provider Network All |
$1,270.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,575.42
|
| Rate for Payer: Zelis Auto |
$677.60
|
| Rate for Payer: Zelis Worker's Compensation |
$462.46
|
|
|
LIMB NERVE SURGERY ADD-ON
|
Facility
|
IP
|
$573.00
|
|
|
Service Code
|
CPT 64783
|
| Hospital Charge Code |
6164783
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$156.43 |
| Max. Negotiated Rate |
$544.35 |
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Cigna Commercial |
$487.05
|
| Rate for Payer: First Health Commercial |
$515.70
|
| Rate for Payer: First Health Workers Compensation |
$221.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$515.70
|
| Rate for Payer: GEHA Commercial |
$401.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$515.70
|
| Rate for Payer: Multiplan All |
$521.43
|
| Rate for Payer: OMNI Networks Commercial |
$401.10
|
| Rate for Payer: One Health Plan PPO/POS |
$515.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$544.35
|
| Rate for Payer: Three Rivers Provider Network All |
$429.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$532.89
|
| Rate for Payer: Zelis Auto |
$229.20
|
| Rate for Payer: Zelis Worker's Compensation |
$156.43
|
|
|
LIMB NERVE SURGERY ADD-ON
|
Facility
|
OP
|
$573.00
|
|
|
Service Code
|
CPT 64783
|
| Hospital Charge Code |
6164783
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$148.98 |
| Max. Negotiated Rate |
$1,892.76 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,892.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$343.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,892.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,499.44
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Cigna Commercial |
$487.05
|
| Rate for Payer: First Health Commercial |
$515.70
|
| Rate for Payer: First Health Workers Compensation |
$221.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$515.70
|
| Rate for Payer: GEHA Commercial |
$458.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$515.70
|
| Rate for Payer: Humana ChoiceCare |
$148.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,529.98
|
| Rate for Payer: Multiplan All |
$521.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$343.80
|
| Rate for Payer: OMNI Networks Commercial |
$401.10
|
| Rate for Payer: One Health Plan PPO/POS |
$515.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,766.58
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,529.98
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$544.35
|
| Rate for Payer: Three Rivers Provider Network All |
$429.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$504.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,529.98
|
| Rate for Payer: United Payors & United Providers UP&UP |
$532.89
|
| Rate for Payer: Zelis Auto |
$229.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$286.50
|
| Rate for Payer: Zelis Worker's Compensation |
$156.43
|
|
|
LINACLOTIDE 145 MCG CAP
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
NDC 00456120130
|
| Hospital Charge Code |
3300530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.74 |
| Max. Negotiated Rate |
$51.30 |
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$45.90
|
| Rate for Payer: First Health Commercial |
$48.60
|
| Rate for Payer: First Health Workers Compensation |
$20.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$48.60
|
| Rate for Payer: GEHA Commercial |
$37.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$48.60
|
| Rate for Payer: Multiplan All |
$49.14
|
| Rate for Payer: OMNI Networks Commercial |
$37.80
|
| Rate for Payer: One Health Plan PPO/POS |
$48.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$51.30
|
| Rate for Payer: Three Rivers Provider Network All |
$40.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$50.22
|
| Rate for Payer: Zelis Auto |
$21.60
|
| Rate for Payer: Zelis Worker's Compensation |
$14.74
|
|
|
LINACLOTIDE 145 MCG CAP
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
NDC 00456120130
|
| Hospital Charge Code |
3300530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$51.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$45.90
|
| Rate for Payer: First Health Commercial |
$48.60
|
| Rate for Payer: First Health Workers Compensation |
$20.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$48.60
|
| Rate for Payer: GEHA Commercial |
$43.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$48.60
|
| Rate for Payer: Humana ChoiceCare |
$14.04
|
| Rate for Payer: Multiplan All |
$49.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$32.40
|
| Rate for Payer: OMNI Networks Commercial |
$37.80
|
| Rate for Payer: One Health Plan PPO/POS |
$48.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$51.30
|
| Rate for Payer: Three Rivers Provider Network All |
$40.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$47.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$50.22
|
| Rate for Payer: Zelis Auto |
$21.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$27.00
|
| Rate for Payer: Zelis Worker's Compensation |
$14.74
|
|
|
LINER ACETABULAR 32MM 54MM
|
Facility
|
OP
|
$11,608.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006426
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,902.00 |
| Max. Negotiated Rate |
$11,027.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,964.80
|
| Rate for Payer: Cash Price |
$6,964.80
|
| Rate for Payer: Cash Price |
$6,964.80
|
| Rate for Payer: Cigna Commercial |
$9,866.80
|
| Rate for Payer: First Health Commercial |
$10,447.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,447.20
|
| Rate for Payer: GEHA Commercial |
$9,286.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,447.20
|
| Rate for Payer: Humana ChoiceCare |
$3,018.08
|
| Rate for Payer: Multiplan All |
$10,563.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,964.80
|
| Rate for Payer: OMNI Networks Commercial |
$8,125.60
|
| Rate for Payer: One Health Plan PPO/POS |
$10,447.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,027.60
|
| Rate for Payer: Three Rivers Provider Network All |
$8,706.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10,215.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,902.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,795.44
|
| Rate for Payer: Zelis Auto |
$4,643.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,804.00
|
|
|
LINER ACETABULAR 32MM 54MM
|
Facility
|
IP
|
$11,608.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006426
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,643.20 |
| Max. Negotiated Rate |
$11,027.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9,286.40
|
| Rate for Payer: Cash Price |
$6,964.80
|
| Rate for Payer: Cash Price |
$6,964.80
|
| Rate for Payer: Cigna Commercial |
$9,866.80
|
| Rate for Payer: First Health Commercial |
$10,447.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,447.20
|
| Rate for Payer: GEHA Commercial |
$8,125.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,447.20
|
| Rate for Payer: Multiplan All |
$10,563.28
|
| Rate for Payer: OMNI Networks Commercial |
$8,125.60
|
| Rate for Payer: One Health Plan PPO/POS |
$10,447.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,027.60
|
| Rate for Payer: Three Rivers Provider Network All |
$8,706.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,795.44
|
| Rate for Payer: Zelis Auto |
$4,643.20
|
|
|
LINER,ACETABULAR 36MM,SIZE24
|
Facility
|
OP
|
$5,661.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002247
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,415.25 |
| Max. Negotiated Rate |
$5,377.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,396.60
|
| Rate for Payer: Cash Price |
$3,396.60
|
| Rate for Payer: Cash Price |
$3,396.60
|
| Rate for Payer: Cigna Commercial |
$4,811.85
|
| Rate for Payer: First Health Commercial |
$5,094.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,094.90
|
| Rate for Payer: GEHA Commercial |
$4,528.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,094.90
|
| Rate for Payer: Humana ChoiceCare |
$1,471.86
|
| Rate for Payer: Multiplan All |
$5,151.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,396.60
|
| Rate for Payer: OMNI Networks Commercial |
$3,962.70
|
| Rate for Payer: One Health Plan PPO/POS |
$5,094.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,377.95
|
| Rate for Payer: Three Rivers Provider Network All |
$4,245.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,981.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,415.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,264.73
|
| Rate for Payer: Zelis Auto |
$2,264.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,830.50
|
|
|
LINER,ACETABULAR 36MM,SIZE24
|
Facility
|
IP
|
$5,661.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002247
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,264.40 |
| Max. Negotiated Rate |
$5,377.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,528.80
|
| Rate for Payer: Cash Price |
$3,396.60
|
| Rate for Payer: Cash Price |
$3,396.60
|
| Rate for Payer: Cigna Commercial |
$4,811.85
|
| Rate for Payer: First Health Commercial |
$5,094.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,094.90
|
| Rate for Payer: GEHA Commercial |
$3,962.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,094.90
|
| Rate for Payer: Multiplan All |
$5,151.51
|
| Rate for Payer: OMNI Networks Commercial |
$3,962.70
|
| Rate for Payer: One Health Plan PPO/POS |
$5,094.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,377.95
|
| Rate for Payer: Three Rivers Provider Network All |
$4,245.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,264.73
|
| Rate for Payer: Zelis Auto |
$2,264.40
|
|
|
LINER,TAPERLOC 36MM
|
Facility
|
OP
|
$6,471.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
70090042
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,617.75 |
| Max. Negotiated Rate |
$6,147.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,882.60
|
| Rate for Payer: Cash Price |
$3,882.60
|
| Rate for Payer: Cash Price |
$3,882.60
|
| Rate for Payer: Cigna Commercial |
$5,500.35
|
| Rate for Payer: First Health Commercial |
$5,823.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,823.90
|
| Rate for Payer: GEHA Commercial |
$5,176.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,823.90
|
| Rate for Payer: Humana ChoiceCare |
$1,682.46
|
| Rate for Payer: Multiplan All |
$5,888.61
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,882.60
|
| Rate for Payer: OMNI Networks Commercial |
$4,529.70
|
| Rate for Payer: One Health Plan PPO/POS |
$5,823.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,147.45
|
| Rate for Payer: Three Rivers Provider Network All |
$4,853.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,694.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,617.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,018.03
|
| Rate for Payer: Zelis Auto |
$2,588.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,235.50
|
|
|
LINER,TAPERLOC 36MM
|
Facility
|
OP
|
$6,181.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
70090041
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,545.25 |
| Max. Negotiated Rate |
$5,871.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,708.60
|
| Rate for Payer: Cash Price |
$3,708.60
|
| Rate for Payer: Cash Price |
$3,708.60
|
| Rate for Payer: Cigna Commercial |
$5,253.85
|
| Rate for Payer: First Health Commercial |
$5,562.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,562.90
|
| Rate for Payer: GEHA Commercial |
$4,944.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,562.90
|
| Rate for Payer: Humana ChoiceCare |
$1,607.06
|
| Rate for Payer: Multiplan All |
$5,624.71
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,708.60
|
| Rate for Payer: OMNI Networks Commercial |
$4,326.70
|
| Rate for Payer: One Health Plan PPO/POS |
$5,562.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,871.95
|
| Rate for Payer: Three Rivers Provider Network All |
$4,635.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,439.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,545.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,748.33
|
| Rate for Payer: Zelis Auto |
$2,472.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,090.50
|
|
|
LINER,TAPERLOC 36MM
|
Facility
|
IP
|
$6,471.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
70090042
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,588.40 |
| Max. Negotiated Rate |
$6,147.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,176.80
|
| Rate for Payer: Cash Price |
$3,882.60
|
| Rate for Payer: Cash Price |
$3,882.60
|
| Rate for Payer: Cigna Commercial |
$5,500.35
|
| Rate for Payer: First Health Commercial |
$5,823.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,823.90
|
| Rate for Payer: GEHA Commercial |
$4,529.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,823.90
|
| Rate for Payer: Multiplan All |
$5,888.61
|
| Rate for Payer: OMNI Networks Commercial |
$4,529.70
|
| Rate for Payer: One Health Plan PPO/POS |
$5,823.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,147.45
|
| Rate for Payer: Three Rivers Provider Network All |
$4,853.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,018.03
|
| Rate for Payer: Zelis Auto |
$2,588.40
|
|
|
LINER,TAPERLOC 36MM
|
Facility
|
IP
|
$6,181.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
70090041
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,472.40 |
| Max. Negotiated Rate |
$5,871.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,944.80
|
| Rate for Payer: Cash Price |
$3,708.60
|
| Rate for Payer: Cash Price |
$3,708.60
|
| Rate for Payer: Cigna Commercial |
$5,253.85
|
| Rate for Payer: First Health Commercial |
$5,562.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,562.90
|
| Rate for Payer: GEHA Commercial |
$4,326.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,562.90
|
| Rate for Payer: Multiplan All |
$5,624.71
|
| Rate for Payer: OMNI Networks Commercial |
$4,326.70
|
| Rate for Payer: One Health Plan PPO/POS |
$5,562.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,871.95
|
| Rate for Payer: Three Rivers Provider Network All |
$4,635.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,748.33
|
| Rate for Payer: Zelis Auto |
$2,472.40
|
|
|
LINEZOLID 600MG/300ML
|
Facility
|
OP
|
$346.00
|
|
|
Service Code
|
NDC 57664068331
|
| Hospital Charge Code |
3301833
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$86.50 |
| Max. Negotiated Rate |
$328.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$207.60
|
| Rate for Payer: Cash Price |
$207.60
|
| Rate for Payer: Cigna Commercial |
$294.10
|
| Rate for Payer: First Health Commercial |
$311.40
|
| Rate for Payer: First Health Workers Compensation |
$133.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$311.40
|
| Rate for Payer: GEHA Commercial |
$276.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$311.40
|
| Rate for Payer: Humana ChoiceCare |
$89.96
|
| Rate for Payer: Multiplan All |
$314.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$207.60
|
| Rate for Payer: OMNI Networks Commercial |
$242.20
|
| Rate for Payer: One Health Plan PPO/POS |
$311.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$328.70
|
| Rate for Payer: Three Rivers Provider Network All |
$259.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$304.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$86.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$321.78
|
| Rate for Payer: Zelis Auto |
$138.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$173.00
|
| Rate for Payer: Zelis Worker's Compensation |
$94.46
|
|
|
LINEZOLID 600MG/300ML
|
Facility
|
IP
|
$346.00
|
|
|
Service Code
|
NDC 57664068331
|
| Hospital Charge Code |
3301833
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.46 |
| Max. Negotiated Rate |
$328.70 |
| Rate for Payer: Cash Price |
$207.60
|
| Rate for Payer: Cigna Commercial |
$294.10
|
| Rate for Payer: First Health Commercial |
$311.40
|
| Rate for Payer: First Health Workers Compensation |
$133.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$311.40
|
| Rate for Payer: GEHA Commercial |
$242.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$311.40
|
| Rate for Payer: Multiplan All |
$314.86
|
| Rate for Payer: OMNI Networks Commercial |
$242.20
|
| Rate for Payer: One Health Plan PPO/POS |
$311.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$328.70
|
| Rate for Payer: Three Rivers Provider Network All |
$259.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$321.78
|
| Rate for Payer: Zelis Auto |
$138.40
|
| Rate for Payer: Zelis Worker's Compensation |
$94.46
|
|
|
LINEZOLID (ZYVOX) 600MG TAB
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
NDC 00904655304
|
| Hospital Charge Code |
3302378
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.74 |
| Max. Negotiated Rate |
$40.85 |
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$36.55
|
| Rate for Payer: First Health Commercial |
$38.70
|
| Rate for Payer: First Health Workers Compensation |
$16.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$38.70
|
| Rate for Payer: GEHA Commercial |
$30.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$38.70
|
| Rate for Payer: Multiplan All |
$39.13
|
| Rate for Payer: OMNI Networks Commercial |
$30.10
|
| Rate for Payer: One Health Plan PPO/POS |
$38.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$40.85
|
| Rate for Payer: Three Rivers Provider Network All |
$32.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$39.99
|
| Rate for Payer: Zelis Auto |
$17.20
|
| Rate for Payer: Zelis Worker's Compensation |
$11.74
|
|
|
LINEZOLID (ZYVOX) 600MG TAB
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
NDC 00904655304
|
| Hospital Charge Code |
3302378
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.75 |
| Max. Negotiated Rate |
$40.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$25.80
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$36.55
|
| Rate for Payer: First Health Commercial |
$38.70
|
| Rate for Payer: First Health Workers Compensation |
$16.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$38.70
|
| Rate for Payer: GEHA Commercial |
$34.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$38.70
|
| Rate for Payer: Humana ChoiceCare |
$11.18
|
| Rate for Payer: Multiplan All |
$39.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.80
|
| Rate for Payer: OMNI Networks Commercial |
$30.10
|
| Rate for Payer: One Health Plan PPO/POS |
$38.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$40.85
|
| Rate for Payer: Three Rivers Provider Network All |
$32.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$37.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$39.99
|
| Rate for Payer: Zelis Auto |
$17.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.50
|
| Rate for Payer: Zelis Worker's Compensation |
$11.74
|
|
|
LIOTHYRONINE 5 MCG TAB
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 60793011501
|
| Hospital Charge Code |
3303022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.75 |
| Max. Negotiated Rate |
$18.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$11.40
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: First Health Commercial |
$17.10
|
| Rate for Payer: First Health Workers Compensation |
$7.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$17.10
|
| Rate for Payer: GEHA Commercial |
$15.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17.10
|
| Rate for Payer: Humana ChoiceCare |
$4.94
|
| Rate for Payer: Multiplan All |
$17.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.40
|
| Rate for Payer: OMNI Networks Commercial |
$13.30
|
| Rate for Payer: One Health Plan PPO/POS |
$17.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18.05
|
| Rate for Payer: Three Rivers Provider Network All |
$14.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17.67
|
| Rate for Payer: Zelis Auto |
$7.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$9.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.19
|
|
|
LIOTHYRONINE 5 MCG TAB
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 60793011501
|
| Hospital Charge Code |
3303022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.19 |
| Max. Negotiated Rate |
$18.05 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: First Health Commercial |
$17.10
|
| Rate for Payer: First Health Workers Compensation |
$7.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$17.10
|
| Rate for Payer: GEHA Commercial |
$13.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17.10
|
| Rate for Payer: Multiplan All |
$17.29
|
| Rate for Payer: OMNI Networks Commercial |
$13.30
|
| Rate for Payer: One Health Plan PPO/POS |
$17.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18.05
|
| Rate for Payer: Three Rivers Provider Network All |
$14.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17.67
|
| Rate for Payer: Zelis Auto |
$7.60
|
| Rate for Payer: Zelis Worker's Compensation |
$5.19
|
|
|
LIPASE (Vitros)
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
CPT 83690
|
| Hospital Charge Code |
2232223
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.86 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$12.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$91.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$12.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$9.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6.89
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$129.20
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: First Health Workers Compensation |
$13.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$136.80
|
| Rate for Payer: GEHA Commercial |
$121.60
|
| Rate for Payer: GEHA Medicare |
$6.89
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$136.80
|
| Rate for Payer: Humana ChoiceCare |
$7.58
|
| Rate for Payer: Humana Medicare Advantage |
$6.89
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$11.58
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$10.03
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6.89
|
| Rate for Payer: Multiplan All |
$138.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.71
|
| Rate for Payer: OMNI Networks Commercial |
$106.40
|
| Rate for Payer: One Health Plan PPO/POS |
$136.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$11.58
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$10.03
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$144.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$13.78
|
| Rate for Payer: Three Rivers Provider Network All |
$114.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.75
|
| Rate for Payer: United Healthcare Commercial |
$129.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$141.36
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6.89
|
| Rate for Payer: Zelis Auto |
$60.80
|
| Rate for Payer: Zelis Medicare |
$5.86
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.27
|
| Rate for Payer: Zelis Worker's Compensation |
$9.23
|
|
|
LIPASE (Vitros)
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
CPT 83690
|
| Hospital Charge Code |
2232223
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.23 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$129.20
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: First Health Workers Compensation |
$13.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$136.80
|
| Rate for Payer: GEHA Commercial |
$106.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$136.80
|
| Rate for Payer: Multiplan All |
$138.32
|
| Rate for Payer: OMNI Networks Commercial |
$106.40
|
| Rate for Payer: One Health Plan PPO/POS |
$136.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$144.40
|
| Rate for Payer: Three Rivers Provider Network All |
$114.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$141.36
|
| Rate for Payer: Zelis Auto |
$60.80
|
| Rate for Payer: Zelis Worker's Compensation |
$9.23
|
|
