|
LOSARTAN POTASSIUM 50MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084034711
|
| Hospital Charge Code |
3300544
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
LOSARTAN POTASSIUM 50MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084034711
|
| Hospital Charge Code |
3300544
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
LOTRISONE 15GM/LUBRIDERM
|
Facility
|
IP
|
$235.00
|
|
| Hospital Charge Code |
3300545
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.16 |
| Max. Negotiated Rate |
$223.25 |
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$199.75
|
| Rate for Payer: First Health Commercial |
$211.50
|
| Rate for Payer: First Health Workers Compensation |
$90.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$211.50
|
| Rate for Payer: GEHA Commercial |
$164.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$211.50
|
| Rate for Payer: Multiplan All |
$213.85
|
| Rate for Payer: OMNI Networks Commercial |
$164.50
|
| Rate for Payer: One Health Plan PPO/POS |
$211.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$223.25
|
| Rate for Payer: Three Rivers Provider Network All |
$176.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$218.55
|
| Rate for Payer: Zelis Auto |
$94.00
|
| Rate for Payer: Zelis Worker's Compensation |
$64.16
|
|
|
LOTRISONE 15GM/LUBRIDERM
|
Facility
|
OP
|
$235.00
|
|
| Hospital Charge Code |
3300545
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.75 |
| Max. Negotiated Rate |
$223.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$199.75
|
| Rate for Payer: First Health Commercial |
$211.50
|
| Rate for Payer: First Health Workers Compensation |
$90.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$211.50
|
| Rate for Payer: GEHA Commercial |
$188.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$211.50
|
| Rate for Payer: Humana ChoiceCare |
$61.10
|
| Rate for Payer: Multiplan All |
$213.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$141.00
|
| Rate for Payer: OMNI Networks Commercial |
$164.50
|
| Rate for Payer: One Health Plan PPO/POS |
$211.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$223.25
|
| Rate for Payer: Three Rivers Provider Network All |
$176.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$206.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$58.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$218.55
|
| Rate for Payer: Zelis Auto |
$94.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$117.50
|
| Rate for Payer: Zelis Worker's Compensation |
$64.16
|
|
|
LOVELACE REGIONAL HOSPITAL ROSWELL
|
Facility
|
OP
|
$139.00
|
|
| Hospital Charge Code |
2200170
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$34.75 |
| Max. Negotiated Rate |
$132.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$83.40
|
| Rate for Payer: Cash Price |
$83.40
|
| Rate for Payer: Cigna Commercial |
$118.15
|
| Rate for Payer: First Health Commercial |
$125.10
|
| Rate for Payer: First Health Workers Compensation |
$53.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$125.10
|
| Rate for Payer: GEHA Commercial |
$111.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$125.10
|
| Rate for Payer: Humana ChoiceCare |
$36.14
|
| Rate for Payer: Multiplan All |
$126.49
|
| Rate for Payer: New Mexico Health Connections Medicare |
$83.40
|
| Rate for Payer: OMNI Networks Commercial |
$97.30
|
| Rate for Payer: One Health Plan PPO/POS |
$125.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$132.05
|
| Rate for Payer: Three Rivers Provider Network All |
$104.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$122.32
|
| Rate for Payer: United Healthcare Commercial |
$118.15
|
| Rate for Payer: United Healthcare Managed Medicaid |
$34.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$129.27
|
| Rate for Payer: Zelis Auto |
$55.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$69.50
|
| Rate for Payer: Zelis Worker's Compensation |
$37.95
|
|
|
LOVELACE REGIONAL HOSPITAL ROSWELL
|
Facility
|
IP
|
$139.00
|
|
| Hospital Charge Code |
2200170
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$37.95 |
| Max. Negotiated Rate |
$132.05 |
| Rate for Payer: Cash Price |
$83.40
|
| Rate for Payer: Cigna Commercial |
$118.15
|
| Rate for Payer: First Health Commercial |
$125.10
|
| Rate for Payer: First Health Workers Compensation |
$53.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$125.10
|
| Rate for Payer: GEHA Commercial |
$97.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$125.10
|
| Rate for Payer: Multiplan All |
$126.49
|
| Rate for Payer: OMNI Networks Commercial |
$97.30
|
| Rate for Payer: One Health Plan PPO/POS |
$125.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$132.05
|
| Rate for Payer: Three Rivers Provider Network All |
$104.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$129.27
|
| Rate for Payer: Zelis Auto |
$55.60
|
| Rate for Payer: Zelis Worker's Compensation |
$37.95
|
|
|
LOW BACK DISK SURGERY
|
Facility
|
OP
|
$7,946.00
|
|
|
Service Code
|
CPT 62380
|
| Hospital Charge Code |
6162380
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$2,169.26 |
| Max. Negotiated Rate |
$13,566.52 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$7,829.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,767.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$7,829.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$6,202.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6,783.26
|
| Rate for Payer: Cash Price |
$4,767.60
|
| Rate for Payer: Cash Price |
$4,767.60
|
| Rate for Payer: Cigna Commercial |
$6,754.10
|
| Rate for Payer: First Health Commercial |
$7,151.40
|
| Rate for Payer: First Health Workers Compensation |
$3,067.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,151.40
|
| Rate for Payer: GEHA Commercial |
$6,356.80
|
| Rate for Payer: GEHA Medicare |
$6,783.26
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,151.40
|
| Rate for Payer: Humana ChoiceCare |
$7,461.59
|
| Rate for Payer: Humana Medicare Advantage |
$6,783.26
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$11,395.88
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$6,328.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6,783.26
|
| Rate for Payer: Multiplan All |
$7,230.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11,531.54
|
| Rate for Payer: OMNI Networks Commercial |
$5,562.20
|
| Rate for Payer: One Health Plan PPO/POS |
$7,151.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$7,307.10
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$6,328.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6,783.26
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,548.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$13,566.52
|
| Rate for Payer: Three Rivers Provider Network All |
$5,959.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,647.59
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6,328.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,783.26
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,389.78
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6,783.26
|
| Rate for Payer: Zelis Auto |
$3,178.40
|
| Rate for Payer: Zelis Medicare |
$5,765.77
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8,139.91
|
| Rate for Payer: Zelis Worker's Compensation |
$2,169.26
|
|
|
LOW BACK DISK SURGERY
|
Facility
|
IP
|
$7,946.00
|
|
|
Service Code
|
CPT 62380
|
| Hospital Charge Code |
6162380
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$2,169.26 |
| Max. Negotiated Rate |
$7,548.70 |
| Rate for Payer: Cash Price |
$4,767.60
|
| Rate for Payer: Cigna Commercial |
$6,754.10
|
| Rate for Payer: First Health Commercial |
$7,151.40
|
| Rate for Payer: First Health Workers Compensation |
$3,067.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,151.40
|
| Rate for Payer: GEHA Commercial |
$5,562.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,151.40
|
| Rate for Payer: Multiplan All |
$7,230.86
|
| Rate for Payer: OMNI Networks Commercial |
$5,562.20
|
| Rate for Payer: One Health Plan PPO/POS |
$7,151.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,548.70
|
| Rate for Payer: Three Rivers Provider Network All |
$5,959.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,389.78
|
| Rate for Payer: Zelis Auto |
$3,178.40
|
| Rate for Payer: Zelis Worker's Compensation |
$2,169.26
|
|
|
LOWER ENDO SCREENING
|
Facility
|
IP
|
$4,060.00
|
|
| Hospital Charge Code |
6180046
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$1,108.38 |
| Max. Negotiated Rate |
$3,857.00 |
| Rate for Payer: Cash Price |
$2,436.00
|
| Rate for Payer: Cigna Commercial |
$3,451.00
|
| Rate for Payer: First Health Commercial |
$3,654.00
|
| Rate for Payer: First Health Workers Compensation |
$1,567.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,654.00
|
| Rate for Payer: GEHA Commercial |
$2,842.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,654.00
|
| Rate for Payer: Multiplan All |
$3,694.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,842.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,654.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,857.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,045.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,775.80
|
| Rate for Payer: Zelis Auto |
$1,624.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,108.38
|
|
|
LOWER ENDO SCREENING
|
Facility
|
OP
|
$4,060.00
|
|
| Hospital Charge Code |
6180046
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$1,015.00 |
| Max. Negotiated Rate |
$3,857.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,436.00
|
| Rate for Payer: Cash Price |
$2,436.00
|
| Rate for Payer: Cigna Commercial |
$3,451.00
|
| Rate for Payer: First Health Commercial |
$3,654.00
|
| Rate for Payer: First Health Workers Compensation |
$1,567.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,654.00
|
| Rate for Payer: GEHA Commercial |
$3,248.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,654.00
|
| Rate for Payer: Humana ChoiceCare |
$1,055.60
|
| Rate for Payer: Multiplan All |
$3,694.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,436.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,842.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,654.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,857.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,045.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,572.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,015.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,775.80
|
| Rate for Payer: Zelis Auto |
$1,624.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,030.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,108.38
|
|
|
LOWER ENDO WITH PROCEDURE
|
Facility
|
IP
|
$5,684.00
|
|
| Hospital Charge Code |
6180048
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$1,551.73 |
| Max. Negotiated Rate |
$5,399.80 |
| Rate for Payer: Cash Price |
$3,410.40
|
| Rate for Payer: Cigna Commercial |
$4,831.40
|
| Rate for Payer: First Health Commercial |
$5,115.60
|
| Rate for Payer: First Health Workers Compensation |
$2,194.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,115.60
|
| Rate for Payer: GEHA Commercial |
$3,978.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,115.60
|
| Rate for Payer: Multiplan All |
$5,172.44
|
| Rate for Payer: OMNI Networks Commercial |
$3,978.80
|
| Rate for Payer: One Health Plan PPO/POS |
$5,115.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,399.80
|
| Rate for Payer: Three Rivers Provider Network All |
$4,263.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,286.12
|
| Rate for Payer: Zelis Auto |
$2,273.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1,551.73
|
|
|
LOWER ENDO WITH PROCEDURE
|
Facility
|
OP
|
$5,684.00
|
|
| Hospital Charge Code |
6180048
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$1,421.00 |
| Max. Negotiated Rate |
$5,399.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,410.40
|
| Rate for Payer: Cash Price |
$3,410.40
|
| Rate for Payer: Cigna Commercial |
$4,831.40
|
| Rate for Payer: First Health Commercial |
$5,115.60
|
| Rate for Payer: First Health Workers Compensation |
$2,194.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,115.60
|
| Rate for Payer: GEHA Commercial |
$4,547.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,115.60
|
| Rate for Payer: Humana ChoiceCare |
$1,477.84
|
| Rate for Payer: Multiplan All |
$5,172.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,410.40
|
| Rate for Payer: OMNI Networks Commercial |
$3,978.80
|
| Rate for Payer: One Health Plan PPO/POS |
$5,115.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,399.80
|
| Rate for Payer: Three Rivers Provider Network All |
$4,263.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,001.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,421.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,286.12
|
| Rate for Payer: Zelis Auto |
$2,273.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,842.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,551.73
|
|
|
LOW FREQUENCY NON-THERMAL ULTRASOUND PER
|
Facility
|
IP
|
$423.00
|
|
|
Service Code
|
CPT 97610
|
| Hospital Charge Code |
1999258
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$115.48 |
| Max. Negotiated Rate |
$401.85 |
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cigna Commercial |
$359.55
|
| Rate for Payer: First Health Commercial |
$380.70
|
| Rate for Payer: First Health Workers Compensation |
$163.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$380.70
|
| Rate for Payer: GEHA Commercial |
$296.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$380.70
|
| Rate for Payer: Multiplan All |
$384.93
|
| Rate for Payer: OMNI Networks Commercial |
$296.10
|
| Rate for Payer: One Health Plan PPO/POS |
$380.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$401.85
|
| Rate for Payer: Three Rivers Provider Network All |
$317.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$393.39
|
| Rate for Payer: Zelis Auto |
$169.20
|
| Rate for Payer: Zelis Worker's Compensation |
$115.48
|
|
|
LOW FREQUENCY NON-THERMAL ULTRASOUND PER
|
Facility
|
OP
|
$423.00
|
|
|
Service Code
|
CPT 97610
|
| Hospital Charge Code |
1999258
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$92.30 |
| Max. Negotiated Rate |
$401.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$116.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$253.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$116.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$92.30
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$188.67
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cigna Commercial |
$359.55
|
| Rate for Payer: First Health Commercial |
$380.70
|
| Rate for Payer: First Health Workers Compensation |
$163.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$380.70
|
| Rate for Payer: GEHA Commercial |
$338.40
|
| Rate for Payer: GEHA Medicare |
$188.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$380.70
|
| Rate for Payer: Humana ChoiceCare |
$207.54
|
| Rate for Payer: Humana Medicare Advantage |
$188.67
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$316.97
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$94.17
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$188.67
|
| Rate for Payer: Multiplan All |
$384.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$320.74
|
| Rate for Payer: OMNI Networks Commercial |
$296.10
|
| Rate for Payer: One Health Plan PPO/POS |
$380.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$108.74
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$94.17
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$188.67
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$401.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$377.34
|
| Rate for Payer: Three Rivers Provider Network All |
$317.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$184.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$94.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$188.67
|
| Rate for Payer: United Payors & United Providers UP&UP |
$393.39
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$188.67
|
| Rate for Payer: Zelis Auto |
$169.20
|
| Rate for Payer: Zelis Medicare |
$160.37
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$226.40
|
| Rate for Payer: Zelis Worker's Compensation |
$115.48
|
|
|
LOW PROFILE LIGAMENT STAPLE
|
Facility
|
OP
|
$553.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008017
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$138.25 |
| Max. Negotiated Rate |
$525.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$331.80
|
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cigna Commercial |
$470.05
|
| Rate for Payer: First Health Commercial |
$497.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$497.70
|
| Rate for Payer: GEHA Commercial |
$442.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$497.70
|
| Rate for Payer: Humana ChoiceCare |
$143.78
|
| Rate for Payer: Multiplan All |
$503.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$331.80
|
| Rate for Payer: OMNI Networks Commercial |
$387.10
|
| Rate for Payer: One Health Plan PPO/POS |
$497.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$525.35
|
| Rate for Payer: Three Rivers Provider Network All |
$414.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$486.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$138.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$514.29
|
| Rate for Payer: Zelis Auto |
$221.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$276.50
|
|
|
LOW PROFILE LIGAMENT STAPLE
|
Facility
|
IP
|
$553.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008018
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$221.20 |
| Max. Negotiated Rate |
$525.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$442.40
|
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cigna Commercial |
$470.05
|
| Rate for Payer: First Health Commercial |
$497.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$497.70
|
| Rate for Payer: GEHA Commercial |
$387.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$497.70
|
| Rate for Payer: Multiplan All |
$503.23
|
| Rate for Payer: OMNI Networks Commercial |
$387.10
|
| Rate for Payer: One Health Plan PPO/POS |
$497.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$525.35
|
| Rate for Payer: Three Rivers Provider Network All |
$414.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$514.29
|
| Rate for Payer: Zelis Auto |
$221.20
|
|
|
LOW PROFILE LIGAMENT STAPLE
|
Facility
|
OP
|
$553.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008018
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$138.25 |
| Max. Negotiated Rate |
$525.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$331.80
|
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cigna Commercial |
$470.05
|
| Rate for Payer: First Health Commercial |
$497.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$497.70
|
| Rate for Payer: GEHA Commercial |
$442.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$497.70
|
| Rate for Payer: Humana ChoiceCare |
$143.78
|
| Rate for Payer: Multiplan All |
$503.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$331.80
|
| Rate for Payer: OMNI Networks Commercial |
$387.10
|
| Rate for Payer: One Health Plan PPO/POS |
$497.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$525.35
|
| Rate for Payer: Three Rivers Provider Network All |
$414.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$486.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$138.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$514.29
|
| Rate for Payer: Zelis Auto |
$221.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$276.50
|
|
|
LOW PROFILE LIGAMENT STAPLE
|
Facility
|
OP
|
$553.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008019
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$138.25 |
| Max. Negotiated Rate |
$525.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$331.80
|
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cigna Commercial |
$470.05
|
| Rate for Payer: First Health Commercial |
$497.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$497.70
|
| Rate for Payer: GEHA Commercial |
$442.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$497.70
|
| Rate for Payer: Humana ChoiceCare |
$143.78
|
| Rate for Payer: Multiplan All |
$503.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$331.80
|
| Rate for Payer: OMNI Networks Commercial |
$387.10
|
| Rate for Payer: One Health Plan PPO/POS |
$497.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$525.35
|
| Rate for Payer: Three Rivers Provider Network All |
$414.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$486.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$138.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$514.29
|
| Rate for Payer: Zelis Auto |
$221.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$276.50
|
|
|
LOW PROFILE LIGAMENT STAPLE
|
Facility
|
IP
|
$553.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008019
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$221.20 |
| Max. Negotiated Rate |
$525.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$442.40
|
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cigna Commercial |
$470.05
|
| Rate for Payer: First Health Commercial |
$497.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$497.70
|
| Rate for Payer: GEHA Commercial |
$387.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$497.70
|
| Rate for Payer: Multiplan All |
$503.23
|
| Rate for Payer: OMNI Networks Commercial |
$387.10
|
| Rate for Payer: One Health Plan PPO/POS |
$497.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$525.35
|
| Rate for Payer: Three Rivers Provider Network All |
$414.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$514.29
|
| Rate for Payer: Zelis Auto |
$221.20
|
|
|
LOW PROFILE LIGAMENT STAPLE
|
Facility
|
IP
|
$553.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008017
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$221.20 |
| Max. Negotiated Rate |
$525.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$442.40
|
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cigna Commercial |
$470.05
|
| Rate for Payer: First Health Commercial |
$497.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$497.70
|
| Rate for Payer: GEHA Commercial |
$387.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$497.70
|
| Rate for Payer: Multiplan All |
$503.23
|
| Rate for Payer: OMNI Networks Commercial |
$387.10
|
| Rate for Payer: One Health Plan PPO/POS |
$497.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$525.35
|
| Rate for Payer: Three Rivers Provider Network All |
$414.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$514.29
|
| Rate for Payer: Zelis Auto |
$221.20
|
|
|
LTA KIT 4% - 4ML (OR)
|
Facility
|
IP
|
$156.00
|
|
|
Service Code
|
NDC 76329630005
|
| Hospital Charge Code |
3300519
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.59 |
| Max. Negotiated Rate |
$148.20 |
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cigna Commercial |
$132.60
|
| Rate for Payer: First Health Commercial |
$140.40
|
| Rate for Payer: First Health Workers Compensation |
$60.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$140.40
|
| Rate for Payer: GEHA Commercial |
$109.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$140.40
|
| Rate for Payer: Multiplan All |
$141.96
|
| Rate for Payer: OMNI Networks Commercial |
$109.20
|
| Rate for Payer: One Health Plan PPO/POS |
$140.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$148.20
|
| Rate for Payer: Three Rivers Provider Network All |
$117.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$145.08
|
| Rate for Payer: Zelis Auto |
$62.40
|
| Rate for Payer: Zelis Worker's Compensation |
$42.59
|
|
|
LTA KIT 4% - 4ML (OR)
|
Facility
|
OP
|
$156.00
|
|
|
Service Code
|
NDC 76329630005
|
| Hospital Charge Code |
3300519
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.00 |
| Max. Negotiated Rate |
$148.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$93.60
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cigna Commercial |
$132.60
|
| Rate for Payer: First Health Commercial |
$140.40
|
| Rate for Payer: First Health Workers Compensation |
$60.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$140.40
|
| Rate for Payer: GEHA Commercial |
$124.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$140.40
|
| Rate for Payer: Humana ChoiceCare |
$40.56
|
| Rate for Payer: Multiplan All |
$141.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$93.60
|
| Rate for Payer: OMNI Networks Commercial |
$109.20
|
| Rate for Payer: One Health Plan PPO/POS |
$140.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$148.20
|
| Rate for Payer: Three Rivers Provider Network All |
$117.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$137.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$39.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$145.08
|
| Rate for Payer: Zelis Auto |
$62.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$78.00
|
| Rate for Payer: Zelis Worker's Compensation |
$42.59
|
|
|
LUBIPROSTONE CAP 24MCG
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
NDC 64764024060
|
| Hospital Charge Code |
3300547
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$25.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
LUBIPROSTONE CAP 24MCG
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
NDC 64764024060
|
| Hospital Charge Code |
3300547
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.25 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22.20
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$29.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Humana ChoiceCare |
$9.62
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.20
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$32.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$18.50
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
LUBRICANT EYE OINTMENT TUBE
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 70000051301
|
| Hospital Charge Code |
3301975
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$14.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
