|
MESH 3D MAX LARGE RIGHT
|
Facility
|
OP
|
$1,364.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7003206
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$341.00 |
| Max. Negotiated Rate |
$1,295.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$818.40
|
| Rate for Payer: Cash Price |
$818.40
|
| Rate for Payer: Cash Price |
$818.40
|
| Rate for Payer: Cigna Commercial |
$1,159.40
|
| Rate for Payer: First Health Commercial |
$1,227.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,227.60
|
| Rate for Payer: GEHA Commercial |
$1,091.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,227.60
|
| Rate for Payer: Humana ChoiceCare |
$354.64
|
| Rate for Payer: Multiplan All |
$1,241.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$818.40
|
| Rate for Payer: OMNI Networks Commercial |
$954.80
|
| Rate for Payer: One Health Plan PPO/POS |
$1,227.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,295.80
|
| Rate for Payer: Three Rivers Provider Network All |
$1,023.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,200.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$341.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,268.52
|
| Rate for Payer: Zelis Auto |
$545.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$682.00
|
|
|
MESH 3D MAX LARGE RIGHT
|
Facility
|
IP
|
$1,364.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7003206
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$545.60 |
| Max. Negotiated Rate |
$1,295.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,091.20
|
| Rate for Payer: Cash Price |
$818.40
|
| Rate for Payer: Cash Price |
$818.40
|
| Rate for Payer: Cigna Commercial |
$1,159.40
|
| Rate for Payer: First Health Commercial |
$1,227.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,227.60
|
| Rate for Payer: GEHA Commercial |
$954.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,227.60
|
| Rate for Payer: Multiplan All |
$1,241.24
|
| Rate for Payer: OMNI Networks Commercial |
$954.80
|
| Rate for Payer: One Health Plan PPO/POS |
$1,227.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,295.80
|
| Rate for Payer: Three Rivers Provider Network All |
$1,023.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,268.52
|
| Rate for Payer: Zelis Auto |
$545.60
|
|
|
MESH 3D MAX MED LEFT
|
Facility
|
OP
|
$1,296.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7006627
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$324.00 |
| Max. Negotiated Rate |
$1,231.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$777.60
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Cigna Commercial |
$1,101.60
|
| Rate for Payer: First Health Commercial |
$1,166.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,166.40
|
| Rate for Payer: GEHA Commercial |
$1,036.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,166.40
|
| Rate for Payer: Humana ChoiceCare |
$336.96
|
| Rate for Payer: Multiplan All |
$1,179.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$777.60
|
| Rate for Payer: OMNI Networks Commercial |
$907.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,166.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,231.20
|
| Rate for Payer: Three Rivers Provider Network All |
$972.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,140.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$324.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,205.28
|
| Rate for Payer: Zelis Auto |
$518.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$648.00
|
|
|
MESH 3D MAX MED LEFT
|
Facility
|
IP
|
$1,296.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7006627
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$518.40 |
| Max. Negotiated Rate |
$1,231.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,036.80
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Cigna Commercial |
$1,101.60
|
| Rate for Payer: First Health Commercial |
$1,166.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,166.40
|
| Rate for Payer: GEHA Commercial |
$907.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,166.40
|
| Rate for Payer: Multiplan All |
$1,179.36
|
| Rate for Payer: OMNI Networks Commercial |
$907.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,166.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,231.20
|
| Rate for Payer: Three Rivers Provider Network All |
$972.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,205.28
|
| Rate for Payer: Zelis Auto |
$518.40
|
|
|
MESH 3D MAX MED RIGHT
|
Facility
|
OP
|
$1,296.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7006628
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$324.00 |
| Max. Negotiated Rate |
$1,231.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$777.60
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Cigna Commercial |
$1,101.60
|
| Rate for Payer: First Health Commercial |
$1,166.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,166.40
|
| Rate for Payer: GEHA Commercial |
$1,036.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,166.40
|
| Rate for Payer: Humana ChoiceCare |
$336.96
|
| Rate for Payer: Multiplan All |
$1,179.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$777.60
|
| Rate for Payer: OMNI Networks Commercial |
$907.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,166.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,231.20
|
| Rate for Payer: Three Rivers Provider Network All |
$972.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,140.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$324.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,205.28
|
| Rate for Payer: Zelis Auto |
$518.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$648.00
|
|
|
MESH 3D MAX MED RIGHT
|
Facility
|
IP
|
$1,296.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7006628
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$518.40 |
| Max. Negotiated Rate |
$1,231.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,036.80
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Cigna Commercial |
$1,101.60
|
| Rate for Payer: First Health Commercial |
$1,166.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,166.40
|
| Rate for Payer: GEHA Commercial |
$907.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,166.40
|
| Rate for Payer: Multiplan All |
$1,179.36
|
| Rate for Payer: OMNI Networks Commercial |
$907.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,166.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,231.20
|
| Rate for Payer: Three Rivers Provider Network All |
$972.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,205.28
|
| Rate for Payer: Zelis Auto |
$518.40
|
|
|
MESH PHASIX ST CIRCLE
|
Facility
|
OP
|
$6,943.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7008020
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,735.75 |
| Max. Negotiated Rate |
$6,595.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,165.80
|
| Rate for Payer: Cash Price |
$4,165.80
|
| Rate for Payer: Cash Price |
$4,165.80
|
| Rate for Payer: Cigna Commercial |
$5,901.55
|
| Rate for Payer: First Health Commercial |
$6,248.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,248.70
|
| Rate for Payer: GEHA Commercial |
$5,554.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,248.70
|
| Rate for Payer: Humana ChoiceCare |
$1,805.18
|
| Rate for Payer: Multiplan All |
$6,318.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,165.80
|
| Rate for Payer: OMNI Networks Commercial |
$4,860.10
|
| Rate for Payer: One Health Plan PPO/POS |
$6,248.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,595.85
|
| Rate for Payer: Three Rivers Provider Network All |
$5,207.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,109.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,735.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,456.99
|
| Rate for Payer: Zelis Auto |
$2,777.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,471.50
|
|
|
MESH PHASIX ST CIRCLE
|
Facility
|
IP
|
$6,943.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7008020
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,777.20 |
| Max. Negotiated Rate |
$6,595.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,554.40
|
| Rate for Payer: Cash Price |
$4,165.80
|
| Rate for Payer: Cash Price |
$4,165.80
|
| Rate for Payer: Cigna Commercial |
$5,901.55
|
| Rate for Payer: First Health Commercial |
$6,248.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,248.70
|
| Rate for Payer: GEHA Commercial |
$4,860.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,248.70
|
| Rate for Payer: Multiplan All |
$6,318.13
|
| Rate for Payer: OMNI Networks Commercial |
$4,860.10
|
| Rate for Payer: One Health Plan PPO/POS |
$6,248.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,595.85
|
| Rate for Payer: Three Rivers Provider Network All |
$5,207.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,456.99
|
| Rate for Payer: Zelis Auto |
$2,777.20
|
|
|
MESH VENTRIO ST 19.6X24.6CM
|
Facility
|
OP
|
$5,344.00
|
|
| Hospital Charge Code |
90061630
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,336.00 |
| Max. Negotiated Rate |
$5,076.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,206.40
|
| Rate for Payer: Cash Price |
$3,206.40
|
| Rate for Payer: Cash Price |
$3,206.40
|
| Rate for Payer: Cigna Commercial |
$4,542.40
|
| Rate for Payer: First Health Commercial |
$4,809.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,809.60
|
| Rate for Payer: GEHA Commercial |
$4,275.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,809.60
|
| Rate for Payer: Humana ChoiceCare |
$1,389.44
|
| Rate for Payer: Multiplan All |
$4,863.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,206.40
|
| Rate for Payer: OMNI Networks Commercial |
$3,740.80
|
| Rate for Payer: One Health Plan PPO/POS |
$4,809.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,076.80
|
| Rate for Payer: Three Rivers Provider Network All |
$4,008.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,702.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,336.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,969.92
|
| Rate for Payer: Zelis Auto |
$2,137.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,672.00
|
|
|
MESH VENTRIO ST 19.6X24.6CM
|
Facility
|
IP
|
$5,344.00
|
|
| Hospital Charge Code |
90061630
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,137.60 |
| Max. Negotiated Rate |
$5,076.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,275.20
|
| Rate for Payer: Cash Price |
$3,206.40
|
| Rate for Payer: Cash Price |
$3,206.40
|
| Rate for Payer: Cigna Commercial |
$4,542.40
|
| Rate for Payer: First Health Commercial |
$4,809.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,809.60
|
| Rate for Payer: GEHA Commercial |
$3,740.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,809.60
|
| Rate for Payer: Multiplan All |
$4,863.04
|
| Rate for Payer: OMNI Networks Commercial |
$3,740.80
|
| Rate for Payer: One Health Plan PPO/POS |
$4,809.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,076.80
|
| Rate for Payer: Three Rivers Provider Network All |
$4,008.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,969.92
|
| Rate for Payer: Zelis Auto |
$2,137.60
|
|
|
mesquite IgE REF602932
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2200724
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.22
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: GEHA Medicare |
$5.22
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.22
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.76
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.59
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.22
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10.44
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.12
|
| Rate for Payer: United Healthcare Commercial |
$47.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.22
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Medicare |
$4.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.26
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
mesquite IgE REF602932
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2200724
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
METAMUCIL PACKET
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 37000002404
|
| Hospital Charge Code |
3301366
|
|
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
|
|
|
METAMUCIL PACKET
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 37000002404
|
| Hospital Charge Code |
3301366
|
|
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
|
|
|
metanephrines frac 24hr urine REF004234
|
Facility
|
IP
|
$412.00
|
|
|
Service Code
|
CPT 83835
|
| Hospital Charge Code |
22990740
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.43 |
| Max. Negotiated Rate |
$391.40 |
| Rate for Payer: Cash Price |
$247.20
|
| Rate for Payer: Cash Price |
$247.20
|
| Rate for Payer: Cigna Commercial |
$350.20
|
| Rate for Payer: First Health Commercial |
$370.80
|
| Rate for Payer: First Health Workers Compensation |
$30.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$370.80
|
| Rate for Payer: GEHA Commercial |
$288.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$370.80
|
| Rate for Payer: Multiplan All |
$374.92
|
| Rate for Payer: OMNI Networks Commercial |
$288.40
|
| Rate for Payer: One Health Plan PPO/POS |
$370.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$391.40
|
| Rate for Payer: Three Rivers Provider Network All |
$309.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$383.16
|
| Rate for Payer: Zelis Auto |
$164.80
|
| Rate for Payer: Zelis Worker's Compensation |
$21.43
|
|
|
metanephrines frac 24hr urine REF004234
|
Facility
|
OP
|
$412.00
|
|
|
Service Code
|
CPT 83835
|
| Hospital Charge Code |
22990740
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$391.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$30.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$247.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$30.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$24.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$16.94
|
| Rate for Payer: Cash Price |
$247.20
|
| Rate for Payer: Cash Price |
$247.20
|
| Rate for Payer: Cigna Commercial |
$350.20
|
| Rate for Payer: First Health Commercial |
$370.80
|
| Rate for Payer: First Health Workers Compensation |
$30.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$370.80
|
| Rate for Payer: GEHA Commercial |
$329.60
|
| Rate for Payer: GEHA Medicare |
$16.94
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$370.80
|
| Rate for Payer: Humana ChoiceCare |
$18.63
|
| Rate for Payer: Humana Medicare Advantage |
$16.94
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$28.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$24.65
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$16.94
|
| Rate for Payer: Multiplan All |
$374.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$28.80
|
| Rate for Payer: OMNI Networks Commercial |
$288.40
|
| Rate for Payer: One Health Plan PPO/POS |
$370.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$28.46
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$24.65
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$16.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$391.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$33.88
|
| Rate for Payer: Three Rivers Provider Network All |
$309.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16.60
|
| Rate for Payer: United Healthcare Commercial |
$350.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$24.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$383.16
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$16.94
|
| Rate for Payer: Zelis Auto |
$164.80
|
| Rate for Payer: Zelis Medicare |
$14.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.33
|
| Rate for Payer: Zelis Worker's Compensation |
$21.43
|
|
|
metanephrines,fractionated,freeREF121806
|
Facility
|
OP
|
$412.00
|
|
|
Service Code
|
CPT 83835
|
| Hospital Charge Code |
22990739
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$391.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$30.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$247.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$30.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$24.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$16.94
|
| Rate for Payer: Cash Price |
$247.20
|
| Rate for Payer: Cash Price |
$247.20
|
| Rate for Payer: Cigna Commercial |
$350.20
|
| Rate for Payer: First Health Commercial |
$370.80
|
| Rate for Payer: First Health Workers Compensation |
$30.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$370.80
|
| Rate for Payer: GEHA Commercial |
$329.60
|
| Rate for Payer: GEHA Medicare |
$16.94
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$370.80
|
| Rate for Payer: Humana ChoiceCare |
$18.63
|
| Rate for Payer: Humana Medicare Advantage |
$16.94
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$28.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$24.65
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$16.94
|
| Rate for Payer: Multiplan All |
$374.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$28.80
|
| Rate for Payer: OMNI Networks Commercial |
$288.40
|
| Rate for Payer: One Health Plan PPO/POS |
$370.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$28.46
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$24.65
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$16.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$391.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$33.88
|
| Rate for Payer: Three Rivers Provider Network All |
$309.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16.60
|
| Rate for Payer: United Healthcare Commercial |
$350.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$24.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$383.16
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$16.94
|
| Rate for Payer: Zelis Auto |
$164.80
|
| Rate for Payer: Zelis Medicare |
$14.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.33
|
| Rate for Payer: Zelis Worker's Compensation |
$21.43
|
|
|
metanephrines,fractionated,freeREF121806
|
Facility
|
IP
|
$412.00
|
|
|
Service Code
|
CPT 83835
|
| Hospital Charge Code |
22990739
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.43 |
| Max. Negotiated Rate |
$391.40 |
| Rate for Payer: Cash Price |
$247.20
|
| Rate for Payer: Cash Price |
$247.20
|
| Rate for Payer: Cigna Commercial |
$350.20
|
| Rate for Payer: First Health Commercial |
$370.80
|
| Rate for Payer: First Health Workers Compensation |
$30.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$370.80
|
| Rate for Payer: GEHA Commercial |
$288.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$370.80
|
| Rate for Payer: Multiplan All |
$374.92
|
| Rate for Payer: OMNI Networks Commercial |
$288.40
|
| Rate for Payer: One Health Plan PPO/POS |
$370.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$391.40
|
| Rate for Payer: Three Rivers Provider Network All |
$309.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$383.16
|
| Rate for Payer: Zelis Auto |
$164.80
|
| Rate for Payer: Zelis Worker's Compensation |
$21.43
|
|
|
METATARSAL PAD
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
CPT L3080
|
| Hospital Charge Code |
8230077
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$62.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$57.75
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$39.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$57.75
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$45.75
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$56.10
|
| Rate for Payer: First Health Commercial |
$59.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$59.40
|
| Rate for Payer: GEHA Commercial |
$52.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$59.40
|
| Rate for Payer: Humana ChoiceCare |
$17.16
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$46.68
|
| Rate for Payer: Multiplan All |
$60.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$39.60
|
| Rate for Payer: OMNI Networks Commercial |
$46.20
|
| Rate for Payer: One Health Plan PPO/POS |
$59.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$53.90
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$46.68
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$62.70
|
| Rate for Payer: Three Rivers Provider Network All |
$49.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$58.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$46.68
|
| Rate for Payer: United Payors & United Providers UP&UP |
$61.38
|
| Rate for Payer: Zelis Auto |
$26.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.00
|
|
|
METATARSAL PAD
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
CPT L3080
|
| Hospital Charge Code |
8800019
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$62.70 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$56.10
|
| Rate for Payer: First Health Commercial |
$59.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$59.40
|
| Rate for Payer: GEHA Commercial |
$46.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$59.40
|
| Rate for Payer: Multiplan All |
$60.06
|
| Rate for Payer: OMNI Networks Commercial |
$46.20
|
| Rate for Payer: One Health Plan PPO/POS |
$59.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$62.70
|
| Rate for Payer: Three Rivers Provider Network All |
$49.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$61.38
|
| Rate for Payer: Zelis Auto |
$26.40
|
|
|
METATARSAL PAD
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
CPT L3080
|
| Hospital Charge Code |
8800019
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$62.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$57.75
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$39.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$57.75
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$45.75
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$56.10
|
| Rate for Payer: First Health Commercial |
$59.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$59.40
|
| Rate for Payer: GEHA Commercial |
$52.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$59.40
|
| Rate for Payer: Humana ChoiceCare |
$17.16
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$46.68
|
| Rate for Payer: Multiplan All |
$60.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$39.60
|
| Rate for Payer: OMNI Networks Commercial |
$46.20
|
| Rate for Payer: One Health Plan PPO/POS |
$59.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$53.90
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$46.68
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$62.70
|
| Rate for Payer: Three Rivers Provider Network All |
$49.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$58.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$46.68
|
| Rate for Payer: United Payors & United Providers UP&UP |
$61.38
|
| Rate for Payer: Zelis Auto |
$26.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.00
|
|
|
METATARSAL PAD
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
CPT L3080
|
| Hospital Charge Code |
8230077
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$62.70 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$56.10
|
| Rate for Payer: First Health Commercial |
$59.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$59.40
|
| Rate for Payer: GEHA Commercial |
$46.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$59.40
|
| Rate for Payer: Multiplan All |
$60.06
|
| Rate for Payer: OMNI Networks Commercial |
$46.20
|
| Rate for Payer: One Health Plan PPO/POS |
$59.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$62.70
|
| Rate for Payer: Three Rivers Provider Network All |
$49.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$61.38
|
| Rate for Payer: Zelis Auto |
$26.40
|
|
|
MetFORMIN ER 500 MG TAB
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 68180033607
|
| Hospital Charge Code |
3300573
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$9.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Humana ChoiceCare |
$3.12
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.20
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
MetFORMIN ER 500 MG TAB
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 68180033607
|
| Hospital Charge Code |
3300573
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$8.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
MetFORMIN HCL 500 MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 51079017220
|
| Hospital Charge Code |
3300571
|
|
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
|
|
