|
MOBILIZATION OF COLON
|
Facility
|
OP
|
$387.00
|
|
|
Service Code
|
CPT 44139
|
| Hospital Charge Code |
6144139
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$96.75 |
| Max. Negotiated Rate |
$367.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$232.20
|
| Rate for Payer: Cash Price |
$232.20
|
| Rate for Payer: Cigna Commercial |
$328.95
|
| Rate for Payer: First Health Commercial |
$348.30
|
| Rate for Payer: First Health Workers Compensation |
$149.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$348.30
|
| Rate for Payer: GEHA Commercial |
$309.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$348.30
|
| Rate for Payer: Humana ChoiceCare |
$100.62
|
| Rate for Payer: Multiplan All |
$352.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$232.20
|
| Rate for Payer: OMNI Networks Commercial |
$270.90
|
| Rate for Payer: One Health Plan PPO/POS |
$348.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$367.65
|
| Rate for Payer: Three Rivers Provider Network All |
$290.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$340.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$96.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$359.91
|
| Rate for Payer: Zelis Auto |
$154.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$193.50
|
| Rate for Payer: Zelis Worker's Compensation |
$105.65
|
|
|
MODIFIED HODGE TEST
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
CPT 87184
|
| Hospital Charge Code |
22990372
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$7.76 |
| Max. Negotiated Rate |
$150.10 |
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cigna Commercial |
$134.30
|
| Rate for Payer: First Health Commercial |
$142.20
|
| Rate for Payer: First Health Workers Compensation |
$10.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$142.20
|
| Rate for Payer: GEHA Commercial |
$110.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$142.20
|
| Rate for Payer: Multiplan All |
$143.78
|
| Rate for Payer: OMNI Networks Commercial |
$110.60
|
| Rate for Payer: One Health Plan PPO/POS |
$142.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$150.10
|
| Rate for Payer: Three Rivers Provider Network All |
$118.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$146.94
|
| Rate for Payer: Zelis Auto |
$63.20
|
| Rate for Payer: Zelis Worker's Compensation |
$7.76
|
|
|
MODIFIED HODGE TEST
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
CPT 87184
|
| Hospital Charge Code |
22990372
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$6.36 |
| Max. Negotiated Rate |
$150.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$13.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$94.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$13.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$10.67
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$7.48
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cigna Commercial |
$134.30
|
| Rate for Payer: First Health Commercial |
$142.20
|
| Rate for Payer: First Health Workers Compensation |
$10.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$142.20
|
| Rate for Payer: GEHA Commercial |
$126.40
|
| Rate for Payer: GEHA Medicare |
$7.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$142.20
|
| Rate for Payer: Humana ChoiceCare |
$8.23
|
| Rate for Payer: Humana Medicare Advantage |
$7.48
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$12.57
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$10.89
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$7.48
|
| Rate for Payer: Multiplan All |
$143.78
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.72
|
| Rate for Payer: OMNI Networks Commercial |
$110.60
|
| Rate for Payer: One Health Plan PPO/POS |
$142.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$12.57
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$10.89
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$7.48
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$150.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$14.96
|
| Rate for Payer: Three Rivers Provider Network All |
$118.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.33
|
| Rate for Payer: United Healthcare Commercial |
$134.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.48
|
| Rate for Payer: United Payors & United Providers UP&UP |
$146.94
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$7.48
|
| Rate for Payer: Zelis Auto |
$63.20
|
| Rate for Payer: Zelis Medicare |
$6.36
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.98
|
| Rate for Payer: Zelis Worker's Compensation |
$7.76
|
|
|
MOD SEDAT ENDO SVC >5YRS
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
CPT G0500
|
| Hospital Charge Code |
6191088
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$14.45
|
| Rate for Payer: First Health Commercial |
$15.30
|
| Rate for Payer: First Health Workers Compensation |
$6.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15.30
|
| Rate for Payer: GEHA Commercial |
$11.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15.30
|
| Rate for Payer: Multiplan All |
$15.47
|
| Rate for Payer: OMNI Networks Commercial |
$11.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16.15
|
| Rate for Payer: Three Rivers Provider Network All |
$12.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15.81
|
| Rate for Payer: Zelis Auto |
$6.80
|
| Rate for Payer: Zelis Worker's Compensation |
$4.64
|
|
|
MOD SEDAT ENDO SVC >5YRS
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
CPT G0500
|
| Hospital Charge Code |
6191088
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$14.45
|
| Rate for Payer: First Health Commercial |
$15.30
|
| Rate for Payer: First Health Workers Compensation |
$6.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15.30
|
| Rate for Payer: GEHA Commercial |
$13.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15.30
|
| Rate for Payer: Humana ChoiceCare |
$4.42
|
| Rate for Payer: Multiplan All |
$15.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10.20
|
| Rate for Payer: OMNI Networks Commercial |
$11.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16.15
|
| Rate for Payer: Three Rivers Provider Network All |
$12.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15.81
|
| Rate for Payer: Zelis Auto |
$6.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.50
|
| Rate for Payer: Zelis Worker's Compensation |
$4.64
|
|
|
molecular cytogenetics dna probe ea REF
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
CPT 88271
|
| Hospital Charge Code |
2200406
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.16 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$259.25
|
| Rate for Payer: First Health Commercial |
$274.50
|
| Rate for Payer: First Health Workers Compensation |
$35.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$274.50
|
| Rate for Payer: GEHA Commercial |
$213.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$274.50
|
| Rate for Payer: Multiplan All |
$277.55
|
| Rate for Payer: OMNI Networks Commercial |
$213.50
|
| Rate for Payer: One Health Plan PPO/POS |
$274.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$289.75
|
| Rate for Payer: Three Rivers Provider Network All |
$228.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$283.65
|
| Rate for Payer: Zelis Auto |
$122.00
|
| Rate for Payer: Zelis Worker's Compensation |
$25.16
|
|
|
molecular cytogenetics dna probe ea REF
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
CPT 88271
|
| Hospital Charge Code |
2200406
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.21 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$183.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$21.42
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$259.25
|
| Rate for Payer: First Health Commercial |
$274.50
|
| Rate for Payer: First Health Workers Compensation |
$35.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$274.50
|
| Rate for Payer: GEHA Commercial |
$244.00
|
| Rate for Payer: GEHA Medicare |
$21.42
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$274.50
|
| Rate for Payer: Humana ChoiceCare |
$23.56
|
| Rate for Payer: Humana Medicare Advantage |
$21.42
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$35.99
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$21.42
|
| Rate for Payer: Multiplan All |
$277.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$36.41
|
| Rate for Payer: OMNI Networks Commercial |
$213.50
|
| Rate for Payer: One Health Plan PPO/POS |
$274.50
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$21.42
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$289.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$42.84
|
| Rate for Payer: Three Rivers Provider Network All |
$228.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$20.99
|
| Rate for Payer: United Healthcare Commercial |
$259.25
|
| Rate for Payer: United Healthcare Managed Medicaid |
$76.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.42
|
| Rate for Payer: United Payors & United Providers UP&UP |
$283.65
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$21.42
|
| Rate for Payer: Zelis Auto |
$122.00
|
| Rate for Payer: Zelis Medicare |
$18.21
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$25.70
|
| Rate for Payer: Zelis Worker's Compensation |
$25.16
|
|
|
MOMETASONE/FORMOT 100-5 MCG 13 MG/PUFF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 78206012701
|
| Hospital Charge Code |
3303053
|
|
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
|
|
|
MOMETASONE/FORMOT 100-5 MCG 13 MG/PUFF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 78206012701
|
| Hospital Charge Code |
3303053
|
|
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
|
|
|
MOMETASONE/FORMOT 100-5 MCG 8.8 GM MDI
|
Facility
|
IP
|
$473.00
|
|
|
Service Code
|
NDC 78206012702
|
| Hospital Charge Code |
3303050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$129.13 |
| Max. Negotiated Rate |
$449.35 |
| Rate for Payer: Cash Price |
$283.80
|
| Rate for Payer: Cigna Commercial |
$402.05
|
| Rate for Payer: First Health Commercial |
$425.70
|
| Rate for Payer: First Health Workers Compensation |
$182.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$425.70
|
| Rate for Payer: GEHA Commercial |
$331.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$425.70
|
| Rate for Payer: Multiplan All |
$430.43
|
| Rate for Payer: OMNI Networks Commercial |
$331.10
|
| Rate for Payer: One Health Plan PPO/POS |
$425.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$449.35
|
| Rate for Payer: Three Rivers Provider Network All |
$354.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$439.89
|
| Rate for Payer: Zelis Auto |
$189.20
|
| Rate for Payer: Zelis Worker's Compensation |
$129.13
|
|
|
MOMETASONE/FORMOT 100-5 MCG 8.8 GM MDI
|
Facility
|
OP
|
$473.00
|
|
|
Service Code
|
NDC 78206012702
|
| Hospital Charge Code |
3303050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$118.25 |
| Max. Negotiated Rate |
$449.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$283.80
|
| Rate for Payer: Cash Price |
$283.80
|
| Rate for Payer: Cigna Commercial |
$402.05
|
| Rate for Payer: First Health Commercial |
$425.70
|
| Rate for Payer: First Health Workers Compensation |
$182.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$425.70
|
| Rate for Payer: GEHA Commercial |
$378.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$425.70
|
| Rate for Payer: Humana ChoiceCare |
$122.98
|
| Rate for Payer: Multiplan All |
$430.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$283.80
|
| Rate for Payer: OMNI Networks Commercial |
$331.10
|
| Rate for Payer: One Health Plan PPO/POS |
$425.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$449.35
|
| Rate for Payer: Three Rivers Provider Network All |
$354.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$416.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$118.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$439.89
|
| Rate for Payer: Zelis Auto |
$189.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$236.50
|
| Rate for Payer: Zelis Worker's Compensation |
$129.13
|
|
|
MOMETASONE/FORMOT 200-5 MCG 13 MG/PUFF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 78206012601
|
| Hospital Charge Code |
3303054
|
|
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
|
|
|
MOMETASONE/FORMOT 200-5 MCG 13 MG/PUFF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 78206012601
|
| Hospital Charge Code |
3303054
|
|
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
|
|
|
MOMETASONE/FORMOT 200-5 MCG 8.8 GM MDI
|
Facility
|
IP
|
$473.00
|
|
|
Service Code
|
NDC 78206012602
|
| Hospital Charge Code |
3303051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$129.13 |
| Max. Negotiated Rate |
$449.35 |
| Rate for Payer: Cash Price |
$283.80
|
| Rate for Payer: Cigna Commercial |
$402.05
|
| Rate for Payer: First Health Commercial |
$425.70
|
| Rate for Payer: First Health Workers Compensation |
$182.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$425.70
|
| Rate for Payer: GEHA Commercial |
$331.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$425.70
|
| Rate for Payer: Multiplan All |
$430.43
|
| Rate for Payer: OMNI Networks Commercial |
$331.10
|
| Rate for Payer: One Health Plan PPO/POS |
$425.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$449.35
|
| Rate for Payer: Three Rivers Provider Network All |
$354.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$439.89
|
| Rate for Payer: Zelis Auto |
$189.20
|
| Rate for Payer: Zelis Worker's Compensation |
$129.13
|
|
|
MOMETASONE/FORMOT 200-5 MCG 8.8 GM MDI
|
Facility
|
OP
|
$473.00
|
|
|
Service Code
|
NDC 78206012602
|
| Hospital Charge Code |
3303051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$118.25 |
| Max. Negotiated Rate |
$449.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$283.80
|
| Rate for Payer: Cash Price |
$283.80
|
| Rate for Payer: Cigna Commercial |
$402.05
|
| Rate for Payer: First Health Commercial |
$425.70
|
| Rate for Payer: First Health Workers Compensation |
$182.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$425.70
|
| Rate for Payer: GEHA Commercial |
$378.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$425.70
|
| Rate for Payer: Humana ChoiceCare |
$122.98
|
| Rate for Payer: Multiplan All |
$430.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$283.80
|
| Rate for Payer: OMNI Networks Commercial |
$331.10
|
| Rate for Payer: One Health Plan PPO/POS |
$425.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$449.35
|
| Rate for Payer: Three Rivers Provider Network All |
$354.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$416.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$118.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$439.89
|
| Rate for Payer: Zelis Auto |
$189.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$236.50
|
| Rate for Payer: Zelis Worker's Compensation |
$129.13
|
|
|
MOMETASONE/FORMOT 50-5 MCG MDI
|
Facility
|
IP
|
$626.00
|
|
|
Service Code
|
NDC 00085222301
|
| Hospital Charge Code |
3303052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$170.90 |
| Max. Negotiated Rate |
$594.70 |
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$532.10
|
| Rate for Payer: First Health Commercial |
$563.40
|
| Rate for Payer: First Health Workers Compensation |
$241.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$563.40
|
| Rate for Payer: GEHA Commercial |
$438.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$563.40
|
| Rate for Payer: Multiplan All |
$569.66
|
| Rate for Payer: OMNI Networks Commercial |
$438.20
|
| Rate for Payer: One Health Plan PPO/POS |
$563.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$594.70
|
| Rate for Payer: Three Rivers Provider Network All |
$469.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$582.18
|
| Rate for Payer: Zelis Auto |
$250.40
|
| Rate for Payer: Zelis Worker's Compensation |
$170.90
|
|
|
MOMETASONE/FORMOT 50-5 MCG MDI
|
Facility
|
OP
|
$626.00
|
|
|
Service Code
|
NDC 00085222301
|
| Hospital Charge Code |
3303052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$156.50 |
| Max. Negotiated Rate |
$594.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$375.60
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Cigna Commercial |
$532.10
|
| Rate for Payer: First Health Commercial |
$563.40
|
| Rate for Payer: First Health Workers Compensation |
$241.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$563.40
|
| Rate for Payer: GEHA Commercial |
$500.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$563.40
|
| Rate for Payer: Humana ChoiceCare |
$162.76
|
| Rate for Payer: Multiplan All |
$569.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$375.60
|
| Rate for Payer: OMNI Networks Commercial |
$438.20
|
| Rate for Payer: One Health Plan PPO/POS |
$563.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$594.70
|
| Rate for Payer: Three Rivers Provider Network All |
$469.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$550.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$156.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$582.18
|
| Rate for Payer: Zelis Auto |
$250.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$313.00
|
| Rate for Payer: Zelis Worker's Compensation |
$170.90
|
|
|
MOMETASONE/FORMOT 50-5 MCG PER PUFF
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 00085222301
|
| Hospital Charge Code |
3303055
|
|
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
|
|
|
MOMETASONE/FORMOT 50-5 MCG PER PUFF
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 00085222301
|
| Hospital Charge Code |
3303055
|
|
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
|
|
|
MOMETASONE FUROATE NASAL 50MCG/ACT
|
Facility
|
OP
|
$603.00
|
|
| Hospital Charge Code |
3300611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$150.75 |
| Max. Negotiated Rate |
$572.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$361.80
|
| Rate for Payer: Cash Price |
$361.80
|
| Rate for Payer: Cigna Commercial |
$512.55
|
| Rate for Payer: First Health Commercial |
$542.70
|
| Rate for Payer: First Health Workers Compensation |
$232.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$542.70
|
| Rate for Payer: GEHA Commercial |
$482.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$542.70
|
| Rate for Payer: Humana ChoiceCare |
$156.78
|
| Rate for Payer: Multiplan All |
$548.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$361.80
|
| Rate for Payer: OMNI Networks Commercial |
$422.10
|
| Rate for Payer: One Health Plan PPO/POS |
$542.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$572.85
|
| Rate for Payer: Three Rivers Provider Network All |
$452.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$530.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$150.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$560.79
|
| Rate for Payer: Zelis Auto |
$241.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$301.50
|
| Rate for Payer: Zelis Worker's Compensation |
$164.62
|
|
|
MOMETASONE FUROATE NASAL 50MCG/ACT
|
Facility
|
IP
|
$603.00
|
|
| Hospital Charge Code |
3300611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$164.62 |
| Max. Negotiated Rate |
$572.85 |
| Rate for Payer: Cash Price |
$361.80
|
| Rate for Payer: Cigna Commercial |
$512.55
|
| Rate for Payer: First Health Commercial |
$542.70
|
| Rate for Payer: First Health Workers Compensation |
$232.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$542.70
|
| Rate for Payer: GEHA Commercial |
$422.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$542.70
|
| Rate for Payer: Multiplan All |
$548.73
|
| Rate for Payer: OMNI Networks Commercial |
$422.10
|
| Rate for Payer: One Health Plan PPO/POS |
$542.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$572.85
|
| Rate for Payer: Three Rivers Provider Network All |
$452.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$560.79
|
| Rate for Payer: Zelis Auto |
$241.20
|
| Rate for Payer: Zelis Worker's Compensation |
$164.62
|
|
|
monkeypox dna-pcr REF140230
|
Facility
|
IP
|
$335.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
2200806
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.21 |
| Max. Negotiated Rate |
$318.25 |
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cigna Commercial |
$284.75
|
| Rate for Payer: First Health Commercial |
$301.50
|
| Rate for Payer: First Health Workers Compensation |
$55.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$301.50
|
| Rate for Payer: GEHA Commercial |
$234.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$301.50
|
| Rate for Payer: Multiplan All |
$304.85
|
| Rate for Payer: OMNI Networks Commercial |
$234.50
|
| Rate for Payer: One Health Plan PPO/POS |
$301.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$318.25
|
| Rate for Payer: Three Rivers Provider Network All |
$251.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$311.55
|
| Rate for Payer: Zelis Auto |
$134.00
|
| Rate for Payer: Zelis Worker's Compensation |
$39.21
|
|
|
monkeypox dna-pcr REF140230
|
Facility
|
OP
|
$335.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
2200806
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.83 |
| Max. Negotiated Rate |
$318.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$63.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$201.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$63.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$50.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$35.09
|
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cigna Commercial |
$284.75
|
| Rate for Payer: First Health Commercial |
$301.50
|
| Rate for Payer: First Health Workers Compensation |
$55.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$301.50
|
| Rate for Payer: GEHA Commercial |
$268.00
|
| Rate for Payer: GEHA Medicare |
$35.09
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$301.50
|
| Rate for Payer: Humana ChoiceCare |
$38.60
|
| Rate for Payer: Humana Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$58.95
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$51.06
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$35.09
|
| Rate for Payer: Multiplan All |
$304.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$59.65
|
| Rate for Payer: OMNI Networks Commercial |
$234.50
|
| Rate for Payer: One Health Plan PPO/POS |
$301.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$58.95
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$51.06
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$35.09
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$318.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$70.18
|
| Rate for Payer: Three Rivers Provider Network All |
$251.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$34.39
|
| Rate for Payer: United Healthcare Commercial |
$284.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$51.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Payors & United Providers UP&UP |
$311.55
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$35.09
|
| Rate for Payer: Zelis Auto |
$134.00
|
| Rate for Payer: Zelis Medicare |
$29.83
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$42.11
|
| Rate for Payer: Zelis Worker's Compensation |
$39.21
|
|
|
MONO TEST AGH
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
CPT 86308
|
| Hospital Charge Code |
2206003
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$96.90 |
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$86.70
|
| Rate for Payer: First Health Commercial |
$91.80
|
| Rate for Payer: First Health Workers Compensation |
$8.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$91.80
|
| Rate for Payer: GEHA Commercial |
$71.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$91.80
|
| Rate for Payer: Multiplan All |
$92.82
|
| Rate for Payer: OMNI Networks Commercial |
$71.40
|
| Rate for Payer: One Health Plan PPO/POS |
$91.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$96.90
|
| Rate for Payer: Three Rivers Provider Network All |
$76.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$94.86
|
| Rate for Payer: Zelis Auto |
$40.80
|
| Rate for Payer: Zelis Worker's Compensation |
$5.78
|
|
|
MONO TEST AGH
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
CPT 86308
|
| Hospital Charge Code |
2206003
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.40 |
| Max. Negotiated Rate |
$96.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$61.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.18
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$86.70
|
| Rate for Payer: First Health Commercial |
$91.80
|
| Rate for Payer: First Health Workers Compensation |
$8.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$91.80
|
| Rate for Payer: GEHA Commercial |
$81.60
|
| Rate for Payer: GEHA Medicare |
$5.18
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$91.80
|
| Rate for Payer: Humana ChoiceCare |
$5.70
|
| Rate for Payer: Humana Medicare Advantage |
$5.18
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.54
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.18
|
| Rate for Payer: Multiplan All |
$92.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.81
|
| Rate for Payer: OMNI Networks Commercial |
$71.40
|
| Rate for Payer: One Health Plan PPO/POS |
$91.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.71
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.54
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.18
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$96.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10.36
|
| Rate for Payer: Three Rivers Provider Network All |
$76.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.08
|
| Rate for Payer: United Healthcare Commercial |
$86.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.18
|
| Rate for Payer: United Payors & United Providers UP&UP |
$94.86
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.18
|
| Rate for Payer: Zelis Auto |
$40.80
|
| Rate for Payer: Zelis Medicare |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.22
|
| Rate for Payer: Zelis Worker's Compensation |
$5.78
|
|
