|
MULTIPLE VITAMIN PLUS MIN TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904053061
|
| Hospital Charge Code |
3300624
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
MULTIPLE VITAMIN PLUS MIN TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904053061
|
| Hospital Charge Code |
3300624
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
MULTI-VITE + MIN 15 ML UDC
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 17856001002
|
| Hospital Charge Code |
3303081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: First Health Commercial |
$12.60
|
| Rate for Payer: First Health Workers Compensation |
$5.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12.60
|
| Rate for Payer: GEHA Commercial |
$11.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12.60
|
| Rate for Payer: Humana ChoiceCare |
$3.64
|
| Rate for Payer: Multiplan All |
$12.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.40
|
| Rate for Payer: OMNI Networks Commercial |
$9.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.02
|
| Rate for Payer: Zelis Auto |
$5.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.82
|
|
|
MULTI-VITE + MIN 15 ML UDC
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 17856001002
|
| Hospital Charge Code |
3303081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: First Health Commercial |
$12.60
|
| Rate for Payer: First Health Workers Compensation |
$5.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12.60
|
| Rate for Payer: GEHA Commercial |
$9.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12.60
|
| Rate for Payer: Multiplan All |
$12.74
|
| Rate for Payer: OMNI Networks Commercial |
$9.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.02
|
| Rate for Payer: Zelis Auto |
$5.60
|
| Rate for Payer: Zelis Worker's Compensation |
$3.82
|
|
|
mumps abs IgG REF096552
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
CPT 86735
|
| Hospital Charge Code |
2246120
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$14.12 |
| Max. Negotiated Rate |
$215.65 |
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cigna Commercial |
$192.95
|
| Rate for Payer: First Health Commercial |
$204.30
|
| Rate for Payer: First Health Workers Compensation |
$19.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$204.30
|
| Rate for Payer: GEHA Commercial |
$158.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$204.30
|
| Rate for Payer: Multiplan All |
$206.57
|
| Rate for Payer: OMNI Networks Commercial |
$158.90
|
| Rate for Payer: One Health Plan PPO/POS |
$204.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$215.65
|
| Rate for Payer: Three Rivers Provider Network All |
$170.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$211.11
|
| Rate for Payer: Zelis Auto |
$90.80
|
| Rate for Payer: Zelis Worker's Compensation |
$14.12
|
|
|
mumps abs IgG REF096552
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
CPT 86735
|
| Hospital Charge Code |
2246120
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$11.09 |
| Max. Negotiated Rate |
$215.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$23.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$136.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$23.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$18.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$13.05
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cigna Commercial |
$192.95
|
| Rate for Payer: First Health Commercial |
$204.30
|
| Rate for Payer: First Health Workers Compensation |
$19.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$204.30
|
| Rate for Payer: GEHA Commercial |
$181.60
|
| Rate for Payer: GEHA Medicare |
$13.05
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$204.30
|
| Rate for Payer: Humana ChoiceCare |
$14.36
|
| Rate for Payer: Humana Medicare Advantage |
$13.05
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$21.92
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$18.99
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$13.05
|
| Rate for Payer: Multiplan All |
$206.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.18
|
| Rate for Payer: OMNI Networks Commercial |
$158.90
|
| Rate for Payer: One Health Plan PPO/POS |
$204.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$21.92
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$18.99
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$13.05
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$215.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$26.10
|
| Rate for Payer: Three Rivers Provider Network All |
$170.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.79
|
| Rate for Payer: United Healthcare Commercial |
$192.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$18.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.05
|
| Rate for Payer: United Payors & United Providers UP&UP |
$211.11
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$13.05
|
| Rate for Payer: Zelis Auto |
$90.80
|
| Rate for Payer: Zelis Medicare |
$11.09
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.66
|
| Rate for Payer: Zelis Worker's Compensation |
$14.12
|
|
|
mumps abs IgM REF160499
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
CPT 86735
|
| Hospital Charge Code |
2246121
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$14.12 |
| Max. Negotiated Rate |
$215.65 |
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cigna Commercial |
$192.95
|
| Rate for Payer: First Health Commercial |
$204.30
|
| Rate for Payer: First Health Workers Compensation |
$19.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$204.30
|
| Rate for Payer: GEHA Commercial |
$158.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$204.30
|
| Rate for Payer: Multiplan All |
$206.57
|
| Rate for Payer: OMNI Networks Commercial |
$158.90
|
| Rate for Payer: One Health Plan PPO/POS |
$204.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$215.65
|
| Rate for Payer: Three Rivers Provider Network All |
$170.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$211.11
|
| Rate for Payer: Zelis Auto |
$90.80
|
| Rate for Payer: Zelis Worker's Compensation |
$14.12
|
|
|
mumps abs IgM REF160499
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
CPT 86735
|
| Hospital Charge Code |
2246121
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$11.09 |
| Max. Negotiated Rate |
$215.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$23.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$136.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$23.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$18.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$13.05
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cigna Commercial |
$192.95
|
| Rate for Payer: First Health Commercial |
$204.30
|
| Rate for Payer: First Health Workers Compensation |
$19.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$204.30
|
| Rate for Payer: GEHA Commercial |
$181.60
|
| Rate for Payer: GEHA Medicare |
$13.05
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$204.30
|
| Rate for Payer: Humana ChoiceCare |
$14.36
|
| Rate for Payer: Humana Medicare Advantage |
$13.05
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$21.92
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$18.99
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$13.05
|
| Rate for Payer: Multiplan All |
$206.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.18
|
| Rate for Payer: OMNI Networks Commercial |
$158.90
|
| Rate for Payer: One Health Plan PPO/POS |
$204.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$21.92
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$18.99
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$13.05
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$215.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$26.10
|
| Rate for Payer: Three Rivers Provider Network All |
$170.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.79
|
| Rate for Payer: United Healthcare Commercial |
$192.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$18.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.05
|
| Rate for Payer: United Payors & United Providers UP&UP |
$211.11
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$13.05
|
| Rate for Payer: Zelis Auto |
$90.80
|
| Rate for Payer: Zelis Medicare |
$11.09
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.66
|
| Rate for Payer: Zelis Worker's Compensation |
$14.12
|
|
|
mumps culture viral REF186150
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
CPT 87254
|
| Hospital Charge Code |
2246122
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$17.18 |
| Max. Negotiated Rate |
$215.65 |
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cigna Commercial |
$192.95
|
| Rate for Payer: First Health Commercial |
$204.30
|
| Rate for Payer: First Health Workers Compensation |
$24.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$204.30
|
| Rate for Payer: GEHA Commercial |
$158.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$204.30
|
| Rate for Payer: Multiplan All |
$206.57
|
| Rate for Payer: OMNI Networks Commercial |
$158.90
|
| Rate for Payer: One Health Plan PPO/POS |
$204.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$215.65
|
| Rate for Payer: Three Rivers Provider Network All |
$170.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$211.11
|
| Rate for Payer: Zelis Auto |
$90.80
|
| Rate for Payer: Zelis Worker's Compensation |
$17.18
|
|
|
mumps culture viral REF186150
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
CPT 87254
|
| Hospital Charge Code |
2246122
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$16.63 |
| Max. Negotiated Rate |
$215.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$35.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$136.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$35.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$27.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$19.56
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cigna Commercial |
$192.95
|
| Rate for Payer: First Health Commercial |
$204.30
|
| Rate for Payer: First Health Workers Compensation |
$24.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$204.30
|
| Rate for Payer: GEHA Commercial |
$181.60
|
| Rate for Payer: GEHA Medicare |
$19.56
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$204.30
|
| Rate for Payer: Humana ChoiceCare |
$21.52
|
| Rate for Payer: Humana Medicare Advantage |
$19.56
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$32.86
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$28.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$19.56
|
| Rate for Payer: Multiplan All |
$206.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$33.25
|
| Rate for Payer: OMNI Networks Commercial |
$158.90
|
| Rate for Payer: One Health Plan PPO/POS |
$204.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$32.86
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$28.46
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$19.56
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$215.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$39.12
|
| Rate for Payer: Three Rivers Provider Network All |
$170.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$19.17
|
| Rate for Payer: United Healthcare Commercial |
$192.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$28.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.56
|
| Rate for Payer: United Payors & United Providers UP&UP |
$211.11
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$19.56
|
| Rate for Payer: Zelis Auto |
$90.80
|
| Rate for Payer: Zelis Medicare |
$16.63
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$23.47
|
| Rate for Payer: Zelis Worker's Compensation |
$17.18
|
|
|
MUPIROCIN OINT 2% 1 GM U.D.
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
NDC 50268056815
|
| Hospital Charge Code |
3302859
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.19 |
| Max. Negotiated Rate |
$28.50 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$25.50
|
| Rate for Payer: First Health Commercial |
$27.00
|
| Rate for Payer: First Health Workers Compensation |
$11.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.00
|
| Rate for Payer: GEHA Commercial |
$21.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.00
|
| Rate for Payer: Multiplan All |
$27.30
|
| Rate for Payer: OMNI Networks Commercial |
$21.00
|
| Rate for Payer: One Health Plan PPO/POS |
$27.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$28.50
|
| Rate for Payer: Three Rivers Provider Network All |
$22.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$27.90
|
| Rate for Payer: Zelis Auto |
$12.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.19
|
|
|
MUPIROCIN OINT 2% 1 GM U.D.
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
NDC 50268056815
|
| Hospital Charge Code |
3302859
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$28.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$25.50
|
| Rate for Payer: First Health Commercial |
$27.00
|
| Rate for Payer: First Health Workers Compensation |
$11.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.00
|
| Rate for Payer: GEHA Commercial |
$24.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.00
|
| Rate for Payer: Humana ChoiceCare |
$7.80
|
| Rate for Payer: Multiplan All |
$27.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$18.00
|
| Rate for Payer: OMNI Networks Commercial |
$21.00
|
| Rate for Payer: One Health Plan PPO/POS |
$27.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$28.50
|
| Rate for Payer: Three Rivers Provider Network All |
$22.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$26.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$27.90
|
| Rate for Payer: Zelis Auto |
$12.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.19
|
|
|
MUPIROCIN OINT 2% 22 GM TUBE
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300627
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$57.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$51.00
|
| Rate for Payer: First Health Commercial |
$54.00
|
| Rate for Payer: First Health Workers Compensation |
$23.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$54.00
|
| Rate for Payer: GEHA Commercial |
$48.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$54.00
|
| Rate for Payer: Humana ChoiceCare |
$15.60
|
| Rate for Payer: Multiplan All |
$54.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$36.00
|
| Rate for Payer: OMNI Networks Commercial |
$42.00
|
| Rate for Payer: One Health Plan PPO/POS |
$54.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$57.00
|
| Rate for Payer: Three Rivers Provider Network All |
$45.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$52.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$15.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$55.80
|
| Rate for Payer: Zelis Auto |
$24.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$30.00
|
| Rate for Payer: Zelis Worker's Compensation |
$16.38
|
|
|
MUPIROCIN OINT 2% 22 GM TUBE
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300627
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.38 |
| Max. Negotiated Rate |
$57.00 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$51.00
|
| Rate for Payer: First Health Commercial |
$54.00
|
| Rate for Payer: First Health Workers Compensation |
$23.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$54.00
|
| Rate for Payer: GEHA Commercial |
$42.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$54.00
|
| Rate for Payer: Multiplan All |
$54.60
|
| Rate for Payer: OMNI Networks Commercial |
$42.00
|
| Rate for Payer: One Health Plan PPO/POS |
$54.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$57.00
|
| Rate for Payer: Three Rivers Provider Network All |
$45.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$55.80
|
| Rate for Payer: Zelis Auto |
$24.00
|
| Rate for Payer: Zelis Worker's Compensation |
$16.38
|
|
|
MUSCLE BIOPSY
|
Facility
|
IP
|
$299.00
|
|
|
Service Code
|
CPT 20200
|
| Hospital Charge Code |
6120200
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$81.63 |
| Max. Negotiated Rate |
$284.05 |
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Cigna Commercial |
$254.15
|
| Rate for Payer: First Health Commercial |
$269.10
|
| Rate for Payer: First Health Workers Compensation |
$115.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$269.10
|
| Rate for Payer: GEHA Commercial |
$209.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$269.10
|
| Rate for Payer: Multiplan All |
$272.09
|
| Rate for Payer: OMNI Networks Commercial |
$209.30
|
| Rate for Payer: One Health Plan PPO/POS |
$269.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$284.05
|
| Rate for Payer: Three Rivers Provider Network All |
$224.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$278.07
|
| Rate for Payer: Zelis Auto |
$119.60
|
| Rate for Payer: Zelis Worker's Compensation |
$81.63
|
|
|
MUSCLE BIOPSY
|
Facility
|
OP
|
$299.00
|
|
|
Service Code
|
CPT 20200
|
| Hospital Charge Code |
6120200
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$81.63 |
| Max. Negotiated Rate |
$3,076.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$179.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,401.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,538.48
|
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Cigna Commercial |
$254.15
|
| Rate for Payer: First Health Commercial |
$269.10
|
| Rate for Payer: First Health Workers Compensation |
$115.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$269.10
|
| Rate for Payer: GEHA Commercial |
$239.20
|
| Rate for Payer: GEHA Medicare |
$1,538.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$269.10
|
| Rate for Payer: Humana ChoiceCare |
$1,692.33
|
| Rate for Payer: Humana Medicare Advantage |
$1,538.48
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,584.65
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,430.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,538.48
|
| Rate for Payer: Multiplan All |
$272.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,615.42
|
| Rate for Payer: OMNI Networks Commercial |
$209.30
|
| Rate for Payer: One Health Plan PPO/POS |
$269.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,651.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,430.07
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,538.48
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$284.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,076.96
|
| Rate for Payer: Three Rivers Provider Network All |
$224.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,507.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,430.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,538.48
|
| Rate for Payer: United Payors & United Providers UP&UP |
$278.07
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,538.48
|
| Rate for Payer: Zelis Auto |
$119.60
|
| Rate for Payer: Zelis Medicare |
$1,307.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,846.18
|
| Rate for Payer: Zelis Worker's Compensation |
$81.63
|
|
|
MUSCLE-SKIN GRAFT ARM
|
Facility
|
OP
|
$2,345.00
|
|
|
Service Code
|
CPT 15736
|
| Hospital Charge Code |
6115736
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$640.18 |
| Max. Negotiated Rate |
$3,473.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,419.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,407.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,419.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,916.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,736.93
|
| Rate for Payer: Cash Price |
$1,407.00
|
| Rate for Payer: Cash Price |
$1,407.00
|
| Rate for Payer: Cigna Commercial |
$1,993.25
|
| Rate for Payer: First Health Commercial |
$2,110.50
|
| Rate for Payer: First Health Workers Compensation |
$905.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,110.50
|
| Rate for Payer: GEHA Commercial |
$1,876.00
|
| Rate for Payer: GEHA Medicare |
$1,736.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,110.50
|
| Rate for Payer: Humana ChoiceCare |
$1,910.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,736.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,918.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,955.93
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,736.93
|
| Rate for Payer: Multiplan All |
$2,133.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,952.78
|
| Rate for Payer: OMNI Networks Commercial |
$1,641.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,110.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,258.40
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,955.93
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,736.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,227.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,473.86
|
| Rate for Payer: Three Rivers Provider Network All |
$1,758.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,702.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,955.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,736.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,180.85
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,736.93
|
| Rate for Payer: Zelis Auto |
$938.00
|
| Rate for Payer: Zelis Medicare |
$1,476.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,084.32
|
| Rate for Payer: Zelis Worker's Compensation |
$640.18
|
|
|
MUSCLE-SKIN GRAFT ARM
|
Facility
|
IP
|
$2,345.00
|
|
|
Service Code
|
CPT 15736
|
| Hospital Charge Code |
6115736
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$640.18 |
| Max. Negotiated Rate |
$2,227.75 |
| Rate for Payer: Cash Price |
$1,407.00
|
| Rate for Payer: Cigna Commercial |
$1,993.25
|
| Rate for Payer: First Health Commercial |
$2,110.50
|
| Rate for Payer: First Health Workers Compensation |
$905.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,110.50
|
| Rate for Payer: GEHA Commercial |
$1,641.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,110.50
|
| Rate for Payer: Multiplan All |
$2,133.95
|
| Rate for Payer: OMNI Networks Commercial |
$1,641.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,110.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,227.75
|
| Rate for Payer: Three Rivers Provider Network All |
$1,758.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,180.85
|
| Rate for Payer: Zelis Auto |
$938.00
|
| Rate for Payer: Zelis Worker's Compensation |
$640.18
|
|
|
MUSCLE-SKIN GRAFT HEAD/NECK
|
Facility
|
IP
|
$2,279.00
|
|
|
Service Code
|
CPT 15733
|
| Hospital Charge Code |
6115732
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$622.17 |
| Max. Negotiated Rate |
$2,165.05 |
| Rate for Payer: Cash Price |
$1,367.40
|
| Rate for Payer: Cigna Commercial |
$1,937.15
|
| Rate for Payer: First Health Commercial |
$2,051.10
|
| Rate for Payer: First Health Workers Compensation |
$879.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,051.10
|
| Rate for Payer: GEHA Commercial |
$1,595.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,051.10
|
| Rate for Payer: Multiplan All |
$2,073.89
|
| Rate for Payer: OMNI Networks Commercial |
$1,595.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,051.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,165.05
|
| Rate for Payer: Three Rivers Provider Network All |
$1,709.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,119.47
|
| Rate for Payer: Zelis Auto |
$911.60
|
| Rate for Payer: Zelis Worker's Compensation |
$622.17
|
|
|
MUSCLE-SKIN GRAFT HEAD/NECK
|
Facility
|
OP
|
$2,279.00
|
|
|
Service Code
|
CPT 15733
|
| Hospital Charge Code |
6115732
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$622.17 |
| Max. Negotiated Rate |
$6,952.48 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$4,065.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,367.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$4,065.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3,220.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,476.24
|
| Rate for Payer: Cash Price |
$1,367.40
|
| Rate for Payer: Cash Price |
$1,367.40
|
| Rate for Payer: Cigna Commercial |
$1,937.15
|
| Rate for Payer: First Health Commercial |
$2,051.10
|
| Rate for Payer: First Health Workers Compensation |
$879.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,051.10
|
| Rate for Payer: GEHA Commercial |
$1,823.20
|
| Rate for Payer: GEHA Medicare |
$3,476.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,051.10
|
| Rate for Payer: Humana ChoiceCare |
$3,823.86
|
| Rate for Payer: Humana Medicare Advantage |
$3,476.24
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,840.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,286.24
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,476.24
|
| Rate for Payer: Multiplan All |
$2,073.89
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,909.61
|
| Rate for Payer: OMNI Networks Commercial |
$1,595.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,051.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$3,794.42
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3,286.24
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,476.24
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,165.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,952.48
|
| Rate for Payer: Three Rivers Provider Network All |
$1,709.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,406.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,286.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,476.24
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,119.47
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,476.24
|
| Rate for Payer: Zelis Auto |
$911.60
|
| Rate for Payer: Zelis Medicare |
$2,954.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,171.49
|
| Rate for Payer: Zelis Worker's Compensation |
$622.17
|
|
|
MUSCLE-SKIN GRAFT LEG
|
Facility
|
IP
|
$2,542.00
|
|
|
Service Code
|
CPT 15738
|
| Hospital Charge Code |
6115738
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$693.97 |
| Max. Negotiated Rate |
$2,414.90 |
| Rate for Payer: Cash Price |
$1,525.20
|
| Rate for Payer: Cigna Commercial |
$2,160.70
|
| Rate for Payer: First Health Commercial |
$2,287.80
|
| Rate for Payer: First Health Workers Compensation |
$981.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,287.80
|
| Rate for Payer: GEHA Commercial |
$1,779.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,287.80
|
| Rate for Payer: Multiplan All |
$2,313.22
|
| Rate for Payer: OMNI Networks Commercial |
$1,779.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,287.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,414.90
|
| Rate for Payer: Three Rivers Provider Network All |
$1,906.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,364.06
|
| Rate for Payer: Zelis Auto |
$1,016.80
|
| Rate for Payer: Zelis Worker's Compensation |
$693.97
|
|
|
MUSCLE-SKIN GRAFT LEG
|
Facility
|
OP
|
$2,542.00
|
|
|
Service Code
|
CPT 15738
|
| Hospital Charge Code |
6115738
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$693.97 |
| Max. Negotiated Rate |
$6,952.48 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,419.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,525.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,419.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,916.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,476.24
|
| Rate for Payer: Cash Price |
$1,525.20
|
| Rate for Payer: Cash Price |
$1,525.20
|
| Rate for Payer: Cigna Commercial |
$2,160.70
|
| Rate for Payer: First Health Commercial |
$2,287.80
|
| Rate for Payer: First Health Workers Compensation |
$981.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,287.80
|
| Rate for Payer: GEHA Commercial |
$2,033.60
|
| Rate for Payer: GEHA Medicare |
$3,476.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,287.80
|
| Rate for Payer: Humana ChoiceCare |
$3,823.86
|
| Rate for Payer: Humana Medicare Advantage |
$3,476.24
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,840.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,955.93
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,476.24
|
| Rate for Payer: Multiplan All |
$2,313.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,909.61
|
| Rate for Payer: OMNI Networks Commercial |
$1,779.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,287.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,258.40
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,955.93
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,476.24
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,414.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,952.48
|
| Rate for Payer: Three Rivers Provider Network All |
$1,906.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,406.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,955.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,476.24
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,364.06
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,476.24
|
| Rate for Payer: Zelis Auto |
$1,016.80
|
| Rate for Payer: Zelis Medicare |
$2,954.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,171.49
|
| Rate for Payer: Zelis Worker's Compensation |
$693.97
|
|
|
MUSCLE-SKIN GRAFT TRUNK
|
Facility
|
IP
|
$2,723.00
|
|
|
Service Code
|
CPT 15734
|
| Hospital Charge Code |
6115734
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$743.38 |
| Max. Negotiated Rate |
$2,586.85 |
| Rate for Payer: Cash Price |
$1,633.80
|
| Rate for Payer: Cigna Commercial |
$2,314.55
|
| Rate for Payer: First Health Commercial |
$2,450.70
|
| Rate for Payer: First Health Workers Compensation |
$1,051.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,450.70
|
| Rate for Payer: GEHA Commercial |
$1,906.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,450.70
|
| Rate for Payer: Multiplan All |
$2,477.93
|
| Rate for Payer: OMNI Networks Commercial |
$1,906.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,450.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,586.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2,042.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,532.39
|
| Rate for Payer: Zelis Auto |
$1,089.20
|
| Rate for Payer: Zelis Worker's Compensation |
$743.38
|
|
|
MUSCLE-SKIN GRAFT TRUNK
|
Facility
|
OP
|
$2,723.00
|
|
|
Service Code
|
CPT 15734
|
| Hospital Charge Code |
6115734
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$743.38 |
| Max. Negotiated Rate |
$6,952.48 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,419.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,633.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,419.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,916.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,476.24
|
| Rate for Payer: Cash Price |
$1,633.80
|
| Rate for Payer: Cash Price |
$1,633.80
|
| Rate for Payer: Cigna Commercial |
$2,314.55
|
| Rate for Payer: First Health Commercial |
$2,450.70
|
| Rate for Payer: First Health Workers Compensation |
$1,051.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,450.70
|
| Rate for Payer: GEHA Commercial |
$2,178.40
|
| Rate for Payer: GEHA Medicare |
$3,476.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,450.70
|
| Rate for Payer: Humana ChoiceCare |
$3,823.86
|
| Rate for Payer: Humana Medicare Advantage |
$3,476.24
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,840.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,955.93
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,476.24
|
| Rate for Payer: Multiplan All |
$2,477.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,909.61
|
| Rate for Payer: OMNI Networks Commercial |
$1,906.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,450.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,258.40
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,955.93
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,476.24
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,586.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,952.48
|
| Rate for Payer: Three Rivers Provider Network All |
$2,042.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,406.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,955.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,476.24
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,532.39
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,476.24
|
| Rate for Payer: Zelis Auto |
$1,089.20
|
| Rate for Payer: Zelis Medicare |
$2,954.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,171.49
|
| Rate for Payer: Zelis Worker's Compensation |
$743.38
|
|
|
MUSCLE/TENDON TRANSFER
|
Facility
|
IP
|
$1,534.00
|
|
|
Service Code
|
CPT 24301
|
| Hospital Charge Code |
6124301
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$418.78 |
| Max. Negotiated Rate |
$1,457.30 |
| Rate for Payer: Cash Price |
$920.40
|
| Rate for Payer: Cigna Commercial |
$1,303.90
|
| Rate for Payer: First Health Commercial |
$1,380.60
|
| Rate for Payer: First Health Workers Compensation |
$592.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,380.60
|
| Rate for Payer: GEHA Commercial |
$1,073.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,380.60
|
| Rate for Payer: Multiplan All |
$1,395.94
|
| Rate for Payer: OMNI Networks Commercial |
$1,073.80
|
| Rate for Payer: One Health Plan PPO/POS |
$1,380.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,457.30
|
| Rate for Payer: Three Rivers Provider Network All |
$1,150.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,426.62
|
| Rate for Payer: Zelis Auto |
$613.60
|
| Rate for Payer: Zelis Worker's Compensation |
$418.78
|
|
