|
LISINOPRIL 20MG TAB
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 00904679961
|
| Hospital Charge Code |
3300533
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$8.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Humana ChoiceCare |
$2.60
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.00
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
LITHIUM CARBONATE 150 MG CAP
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 00054852625
|
| Hospital Charge Code |
3300536
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
LITHIUM CARBONATE 150 MG CAP
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 00054852625
|
| Hospital Charge Code |
3300536
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$4.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Humana ChoiceCare |
$1.30
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.00
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
LITHIUM CARBONATE 450 MG CR TAB
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 00054002025
|
| Hospital Charge Code |
3300537
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
LITHIUM CARBONATE 450 MG CR TAB
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 00054002025
|
| Hospital Charge Code |
3300537
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$6.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Humana ChoiceCare |
$2.08
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.80
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
LITHIUM (Vitros)
|
Facility
|
OP
|
$159.00
|
|
|
Service Code
|
CPT 80178
|
| Hospital Charge Code |
2232224
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.62 |
| Max. Negotiated Rate |
$151.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$11.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$95.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$11.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$9.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6.61
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cigna Commercial |
$135.15
|
| Rate for Payer: First Health Commercial |
$143.10
|
| Rate for Payer: First Health Workers Compensation |
$11.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$143.10
|
| Rate for Payer: GEHA Commercial |
$127.20
|
| Rate for Payer: GEHA Medicare |
$6.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$143.10
|
| Rate for Payer: Humana ChoiceCare |
$7.27
|
| Rate for Payer: Humana Medicare Advantage |
$6.61
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$11.10
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$9.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6.61
|
| Rate for Payer: Multiplan All |
$144.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.24
|
| Rate for Payer: OMNI Networks Commercial |
$111.30
|
| Rate for Payer: One Health Plan PPO/POS |
$143.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$11.10
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$9.62
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6.61
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$151.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$13.22
|
| Rate for Payer: Three Rivers Provider Network All |
$119.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.48
|
| Rate for Payer: United Healthcare Commercial |
$135.15
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.61
|
| Rate for Payer: United Payors & United Providers UP&UP |
$147.87
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6.61
|
| Rate for Payer: Zelis Auto |
$63.60
|
| Rate for Payer: Zelis Medicare |
$5.62
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.93
|
| Rate for Payer: Zelis Worker's Compensation |
$8.37
|
|
|
LITHIUM (Vitros)
|
Facility
|
IP
|
$159.00
|
|
|
Service Code
|
CPT 80178
|
| Hospital Charge Code |
2232224
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.37 |
| Max. Negotiated Rate |
$151.05 |
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cigna Commercial |
$135.15
|
| Rate for Payer: First Health Commercial |
$143.10
|
| Rate for Payer: First Health Workers Compensation |
$11.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$143.10
|
| Rate for Payer: GEHA Commercial |
$111.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$143.10
|
| Rate for Payer: Multiplan All |
$144.69
|
| Rate for Payer: OMNI Networks Commercial |
$111.30
|
| Rate for Payer: One Health Plan PPO/POS |
$143.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$151.05
|
| Rate for Payer: Three Rivers Provider Network All |
$119.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$147.87
|
| Rate for Payer: Zelis Auto |
$63.60
|
| Rate for Payer: Zelis Worker's Compensation |
$8.37
|
|
|
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM)
|
Facility
|
OP
|
$6,549.86
|
|
|
Service Code
|
CPT 52317
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,044.30 |
| Max. Negotiated Rate |
$6,549.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,580.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,580.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2,044.30
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,274.93
|
| Rate for Payer: First Health Workers Compensation |
$4,214.83
|
| Rate for Payer: GEHA Medicare |
$3,274.93
|
| Rate for Payer: Humana ChoiceCare |
$3,602.42
|
| Rate for Payer: Humana Medicare Advantage |
$3,274.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,501.88
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,085.94
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,274.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,567.38
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,408.50
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,085.94
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,274.93
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,549.86
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,209.43
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,085.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,274.93
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,274.93
|
| Rate for Payer: Zelis Medicare |
$2,783.69
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,929.92
|
| Rate for Payer: Zelis Worker's Compensation |
$2,980.19
|
|
|
LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE
|
Facility
|
OP
|
$6,549.86
|
|
|
Service Code
|
CPT 50590
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,783.69 |
| Max. Negotiated Rate |
$6,549.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$4,182.14
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$4,182.14
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3,313.09
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,274.93
|
| Rate for Payer: First Health Workers Compensation |
$4,214.83
|
| Rate for Payer: GEHA Medicare |
$3,274.93
|
| Rate for Payer: Humana ChoiceCare |
$3,602.42
|
| Rate for Payer: Humana Medicare Advantage |
$3,274.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,501.88
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,380.56
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,274.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,567.38
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$3,903.33
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3,380.56
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,274.93
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,549.86
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,209.43
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,380.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,274.93
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,274.93
|
| Rate for Payer: Zelis Medicare |
$2,783.69
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,929.92
|
| Rate for Payer: Zelis Worker's Compensation |
$2,980.19
|
|
|
liver kidney microsomal(lkm)absREF163980
|
Facility
|
OP
|
$145.00
|
|
|
Service Code
|
CPT 86376
|
| Hospital Charge Code |
22990820
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.37 |
| Max. Negotiated Rate |
$137.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$87.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$20.75
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.55
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$123.25
|
| Rate for Payer: First Health Commercial |
$130.50
|
| Rate for Payer: First Health Workers Compensation |
$28.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$130.50
|
| Rate for Payer: GEHA Commercial |
$116.00
|
| Rate for Payer: GEHA Medicare |
$14.55
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$130.50
|
| Rate for Payer: Humana ChoiceCare |
$16.00
|
| Rate for Payer: Humana Medicare Advantage |
$14.55
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$24.44
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.17
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.55
|
| Rate for Payer: Multiplan All |
$131.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.73
|
| Rate for Payer: OMNI Networks Commercial |
$101.50
|
| Rate for Payer: One Health Plan PPO/POS |
$130.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$24.44
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.17
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$137.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.10
|
| Rate for Payer: Three Rivers Provider Network All |
$108.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.26
|
| Rate for Payer: United Healthcare Commercial |
$123.25
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$134.85
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.55
|
| Rate for Payer: Zelis Auto |
$58.00
|
| Rate for Payer: Zelis Medicare |
$12.37
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.46
|
| Rate for Payer: Zelis Worker's Compensation |
$19.81
|
|
|
liver kidney microsomal(lkm)absREF163980
|
Facility
|
IP
|
$145.00
|
|
|
Service Code
|
CPT 86376
|
| Hospital Charge Code |
22990820
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$19.81 |
| Max. Negotiated Rate |
$137.75 |
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$123.25
|
| Rate for Payer: First Health Commercial |
$130.50
|
| Rate for Payer: First Health Workers Compensation |
$28.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$130.50
|
| Rate for Payer: GEHA Commercial |
$101.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$130.50
|
| Rate for Payer: Multiplan All |
$131.95
|
| Rate for Payer: OMNI Networks Commercial |
$101.50
|
| Rate for Payer: One Health Plan PPO/POS |
$130.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$137.75
|
| Rate for Payer: Three Rivers Provider Network All |
$108.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$134.85
|
| Rate for Payer: Zelis Auto |
$58.00
|
| Rate for Payer: Zelis Worker's Compensation |
$19.81
|
|
|
LIVER PROFILE (Vitros)
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
CPT 80076
|
| Hospital Charge Code |
2232206
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.93 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$255.00
|
| Rate for Payer: First Health Commercial |
$270.00
|
| Rate for Payer: First Health Workers Compensation |
$14.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.00
|
| Rate for Payer: GEHA Commercial |
$210.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.00
|
| Rate for Payer: Multiplan All |
$273.00
|
| Rate for Payer: OMNI Networks Commercial |
$210.00
|
| Rate for Payer: One Health Plan PPO/POS |
$270.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.00
|
| Rate for Payer: Three Rivers Provider Network All |
$225.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.00
|
| Rate for Payer: Zelis Auto |
$120.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.93
|
|
|
LIVER PROFILE (Vitros)
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
CPT 80076
|
| Hospital Charge Code |
2232206
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.94 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$14.70
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$180.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$14.70
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$11.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$8.17
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$255.00
|
| Rate for Payer: First Health Commercial |
$270.00
|
| Rate for Payer: First Health Workers Compensation |
$14.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.00
|
| Rate for Payer: GEHA Commercial |
$240.00
|
| Rate for Payer: GEHA Medicare |
$8.17
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.00
|
| Rate for Payer: Humana ChoiceCare |
$8.99
|
| Rate for Payer: Humana Medicare Advantage |
$8.17
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$13.73
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$11.88
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$8.17
|
| Rate for Payer: Multiplan All |
$273.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$13.89
|
| Rate for Payer: OMNI Networks Commercial |
$210.00
|
| Rate for Payer: One Health Plan PPO/POS |
$270.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$13.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$11.88
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$8.17
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$16.34
|
| Rate for Payer: Three Rivers Provider Network All |
$225.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8.01
|
| Rate for Payer: United Healthcare Commercial |
$255.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.17
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.00
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$8.17
|
| Rate for Payer: Zelis Auto |
$120.00
|
| Rate for Payer: Zelis Medicare |
$6.94
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$9.80
|
| Rate for Payer: Zelis Worker's Compensation |
$9.93
|
|
|
LO ANAL GAST N-STIM INIT
|
Facility
|
OP
|
$312.00
|
|
|
Service Code
|
CPT 95981
|
| Hospital Charge Code |
8595981
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$47.94 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$142.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$187.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$142.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$112.81
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$56.40
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$249.60
|
| Rate for Payer: GEHA Medicare |
$56.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Humana ChoiceCare |
$62.04
|
| Rate for Payer: Humana Medicare Advantage |
$56.40
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$94.75
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$115.10
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$56.40
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$95.88
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$132.90
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$115.10
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$56.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$112.80
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$55.27
|
| Rate for Payer: United Healthcare Managed Medicaid |
$115.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$56.40
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$56.40
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Medicare |
$47.94
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$67.68
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
LO ANAL GAST N-STIM INIT
|
Facility
|
IP
|
$312.00
|
|
|
Service Code
|
CPT 95981
|
| Hospital Charge Code |
8595981
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$85.18 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$218.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
LOCAL FACILITY ANESTHESIA
|
Facility
|
IP
|
$914.00
|
|
| Hospital Charge Code |
3701999
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$249.52 |
| Max. Negotiated Rate |
$868.30 |
| Rate for Payer: Cash Price |
$548.40
|
| Rate for Payer: Cigna Commercial |
$776.90
|
| Rate for Payer: First Health Commercial |
$822.60
|
| Rate for Payer: First Health Workers Compensation |
$352.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$822.60
|
| Rate for Payer: GEHA Commercial |
$639.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$822.60
|
| Rate for Payer: Multiplan All |
$831.74
|
| Rate for Payer: OMNI Networks Commercial |
$639.80
|
| Rate for Payer: One Health Plan PPO/POS |
$822.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$868.30
|
| Rate for Payer: Three Rivers Provider Network All |
$685.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$850.02
|
| Rate for Payer: Zelis Auto |
$365.60
|
| Rate for Payer: Zelis Worker's Compensation |
$249.52
|
|
|
LOCAL FACILITY ANESTHESIA
|
Facility
|
OP
|
$914.00
|
|
| Hospital Charge Code |
3701999
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$228.50 |
| Max. Negotiated Rate |
$868.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$548.40
|
| Rate for Payer: Cash Price |
$548.40
|
| Rate for Payer: Cigna Commercial |
$776.90
|
| Rate for Payer: First Health Commercial |
$822.60
|
| Rate for Payer: First Health Workers Compensation |
$352.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$822.60
|
| Rate for Payer: GEHA Commercial |
$731.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$822.60
|
| Rate for Payer: Humana ChoiceCare |
$237.64
|
| Rate for Payer: Multiplan All |
$831.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$548.40
|
| Rate for Payer: OMNI Networks Commercial |
$639.80
|
| Rate for Payer: One Health Plan PPO/POS |
$822.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$868.30
|
| Rate for Payer: Three Rivers Provider Network All |
$685.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$804.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$228.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$850.02
|
| Rate for Payer: Zelis Auto |
$365.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$457.00
|
| Rate for Payer: Zelis Worker's Compensation |
$249.52
|
|
|
LONG ARM CAST, ADULT (11+YRS)
|
Facility
|
IP
|
$91.00
|
|
|
Service Code
|
CPT Q4006
|
| Hospital Charge Code |
8804006
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.84 |
| Max. Negotiated Rate |
$86.45 |
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$77.35
|
| Rate for Payer: First Health Commercial |
$81.90
|
| Rate for Payer: First Health Workers Compensation |
$35.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.90
|
| Rate for Payer: GEHA Commercial |
$63.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.90
|
| Rate for Payer: Multiplan All |
$82.81
|
| Rate for Payer: OMNI Networks Commercial |
$63.70
|
| Rate for Payer: One Health Plan PPO/POS |
$81.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$86.45
|
| Rate for Payer: Three Rivers Provider Network All |
$68.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$84.63
|
| Rate for Payer: Zelis Auto |
$36.40
|
| Rate for Payer: Zelis Worker's Compensation |
$24.84
|
|
|
LONG ARM CAST, ADULT (11+YRS)
|
Facility
|
IP
|
$91.00
|
|
|
Service Code
|
CPT Q4006
|
| Hospital Charge Code |
8204006
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.84 |
| Max. Negotiated Rate |
$86.45 |
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$77.35
|
| Rate for Payer: First Health Commercial |
$81.90
|
| Rate for Payer: First Health Workers Compensation |
$35.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.90
|
| Rate for Payer: GEHA Commercial |
$63.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.90
|
| Rate for Payer: Multiplan All |
$82.81
|
| Rate for Payer: OMNI Networks Commercial |
$63.70
|
| Rate for Payer: One Health Plan PPO/POS |
$81.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$86.45
|
| Rate for Payer: Three Rivers Provider Network All |
$68.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$84.63
|
| Rate for Payer: Zelis Auto |
$36.40
|
| Rate for Payer: Zelis Worker's Compensation |
$24.84
|
|
|
LONG ARM CAST, ADULT (11+YRS)
|
Facility
|
OP
|
$91.00
|
|
|
Service Code
|
CPT Q4006
|
| Hospital Charge Code |
8804006
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$86.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$77.35
|
| Rate for Payer: First Health Commercial |
$81.90
|
| Rate for Payer: First Health Workers Compensation |
$35.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.90
|
| Rate for Payer: GEHA Commercial |
$72.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.90
|
| Rate for Payer: Humana ChoiceCare |
$23.66
|
| Rate for Payer: Multiplan All |
$82.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$54.60
|
| Rate for Payer: OMNI Networks Commercial |
$63.70
|
| Rate for Payer: One Health Plan PPO/POS |
$81.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$86.45
|
| Rate for Payer: Three Rivers Provider Network All |
$68.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$80.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$22.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$84.63
|
| Rate for Payer: Zelis Auto |
$36.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$45.50
|
| Rate for Payer: Zelis Worker's Compensation |
$24.84
|
|
|
LONG ARM CAST, ADULT (11+YRS)
|
Facility
|
OP
|
$91.00
|
|
|
Service Code
|
CPT Q4006
|
| Hospital Charge Code |
8204006
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$86.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$77.35
|
| Rate for Payer: First Health Commercial |
$81.90
|
| Rate for Payer: First Health Workers Compensation |
$35.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.90
|
| Rate for Payer: GEHA Commercial |
$72.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.90
|
| Rate for Payer: Humana ChoiceCare |
$23.66
|
| Rate for Payer: Multiplan All |
$82.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$54.60
|
| Rate for Payer: OMNI Networks Commercial |
$63.70
|
| Rate for Payer: One Health Plan PPO/POS |
$81.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$86.45
|
| Rate for Payer: Three Rivers Provider Network All |
$68.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$80.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$22.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$84.63
|
| Rate for Payer: Zelis Auto |
$36.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$45.50
|
| Rate for Payer: Zelis Worker's Compensation |
$24.84
|
|
|
LONG ARM CAST, PED (0-10 YRS)
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT Q4008
|
| Hospital Charge Code |
8204008
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.56 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$32.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
LONG ARM CAST, PED (0-10 YRS)
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT Q4008
|
| Hospital Charge Code |
8204008
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.50 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$36.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Humana ChoiceCare |
$11.96
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.60
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$40.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$23.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
LONG ARM CAST, PED (0-10 YRS)
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT Q4008
|
| Hospital Charge Code |
8804008
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.50 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$36.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Humana ChoiceCare |
$11.96
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.60
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$40.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$23.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
LONG ARM CAST, PED (0-10 YRS)
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT Q4008
|
| Hospital Charge Code |
8804008
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.56 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$32.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
