|
NUBHVL XM PHY/QHP EA ADDL HR
|
Facility
|
IP
|
$241.00
|
|
|
Service Code
|
CPT 96121
|
| Hospital Charge Code |
4397910
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$65.79 |
| Max. Negotiated Rate |
$228.95 |
| Rate for Payer: Cash Price |
$144.60
|
| Rate for Payer: Cigna Commercial |
$204.85
|
| Rate for Payer: First Health Commercial |
$216.90
|
| Rate for Payer: First Health Workers Compensation |
$93.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$216.90
|
| Rate for Payer: GEHA Commercial |
$168.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$216.90
|
| Rate for Payer: Multiplan All |
$219.31
|
| Rate for Payer: OMNI Networks Commercial |
$168.70
|
| Rate for Payer: One Health Plan PPO/POS |
$216.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$228.95
|
| Rate for Payer: Three Rivers Provider Network All |
$180.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$224.13
|
| Rate for Payer: Zelis Auto |
$96.40
|
| Rate for Payer: Zelis Worker's Compensation |
$65.79
|
|
|
NUEDEXTA 20MG/10MG CAPSULE
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
NDC 64597030160
|
| Hospital Charge Code |
3305007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.50 |
| Max. Negotiated Rate |
$112.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$70.80
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$100.30
|
| Rate for Payer: First Health Commercial |
$106.20
|
| Rate for Payer: First Health Workers Compensation |
$45.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$106.20
|
| Rate for Payer: GEHA Commercial |
$94.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$106.20
|
| Rate for Payer: Humana ChoiceCare |
$30.68
|
| Rate for Payer: Multiplan All |
$107.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$70.80
|
| Rate for Payer: OMNI Networks Commercial |
$82.60
|
| Rate for Payer: One Health Plan PPO/POS |
$106.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$112.10
|
| Rate for Payer: Three Rivers Provider Network All |
$88.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$103.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$29.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$109.74
|
| Rate for Payer: Zelis Auto |
$47.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$59.00
|
| Rate for Payer: Zelis Worker's Compensation |
$32.21
|
|
|
NUEDEXTA 20MG/10MG CAPSULE
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
NDC 64597030160
|
| Hospital Charge Code |
3305007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.21 |
| Max. Negotiated Rate |
$112.10 |
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$100.30
|
| Rate for Payer: First Health Commercial |
$106.20
|
| Rate for Payer: First Health Workers Compensation |
$45.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$106.20
|
| Rate for Payer: GEHA Commercial |
$82.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$106.20
|
| Rate for Payer: Multiplan All |
$107.38
|
| Rate for Payer: OMNI Networks Commercial |
$82.60
|
| Rate for Payer: One Health Plan PPO/POS |
$106.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$112.10
|
| Rate for Payer: Three Rivers Provider Network All |
$88.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$109.74
|
| Rate for Payer: Zelis Auto |
$47.20
|
| Rate for Payer: Zelis Worker's Compensation |
$32.21
|
|
|
NULYTELY
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
NDC 43386005019
|
| Hospital Charge Code |
3300696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.00 |
| Max. Negotiated Rate |
$155.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$98.40
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cigna Commercial |
$139.40
|
| Rate for Payer: First Health Commercial |
$147.60
|
| Rate for Payer: First Health Workers Compensation |
$63.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$147.60
|
| Rate for Payer: GEHA Commercial |
$131.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$147.60
|
| Rate for Payer: Humana ChoiceCare |
$42.64
|
| Rate for Payer: Multiplan All |
$149.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$98.40
|
| Rate for Payer: OMNI Networks Commercial |
$114.80
|
| Rate for Payer: One Health Plan PPO/POS |
$147.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$155.80
|
| Rate for Payer: Three Rivers Provider Network All |
$123.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$144.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$41.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$152.52
|
| Rate for Payer: Zelis Auto |
$65.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$82.00
|
| Rate for Payer: Zelis Worker's Compensation |
$44.77
|
|
|
NULYTELY
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
NDC 43386005019
|
| Hospital Charge Code |
3300696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.77 |
| Max. Negotiated Rate |
$155.80 |
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cigna Commercial |
$139.40
|
| Rate for Payer: First Health Commercial |
$147.60
|
| Rate for Payer: First Health Workers Compensation |
$63.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$147.60
|
| Rate for Payer: GEHA Commercial |
$114.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$147.60
|
| Rate for Payer: Multiplan All |
$149.24
|
| Rate for Payer: OMNI Networks Commercial |
$114.80
|
| Rate for Payer: One Health Plan PPO/POS |
$147.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$155.80
|
| Rate for Payer: Three Rivers Provider Network All |
$123.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$152.52
|
| Rate for Payer: Zelis Auto |
$65.60
|
| Rate for Payer: Zelis Worker's Compensation |
$44.77
|
|
|
NU-SHIELD 1.6 CM DISC
|
Facility
|
OP
|
$1,411.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
7009051
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$352.75 |
| Max. Negotiated Rate |
$3,062.82 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$846.60
|
| Rate for Payer: Cash Price |
$846.60
|
| Rate for Payer: Cash Price |
$846.60
|
| Rate for Payer: Cigna Commercial |
$1,199.35
|
| Rate for Payer: First Health Commercial |
$1,269.90
|
| Rate for Payer: First Health Workers Compensation |
$544.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,269.90
|
| Rate for Payer: GEHA Commercial |
$3,062.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,269.90
|
| Rate for Payer: Humana ChoiceCare |
$366.86
|
| Rate for Payer: Multiplan All |
$1,284.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$846.60
|
| Rate for Payer: OMNI Networks Commercial |
$987.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,269.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,340.45
|
| Rate for Payer: Three Rivers Provider Network All |
$1,058.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,241.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$352.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,312.23
|
| Rate for Payer: Zelis Auto |
$564.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$705.50
|
| Rate for Payer: Zelis Worker's Compensation |
$385.20
|
|
|
NU-SHIELD 1.6 CM DISC
|
Facility
|
IP
|
$1,411.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
7009051
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$385.20 |
| Max. Negotiated Rate |
$1,340.45 |
| Rate for Payer: Cash Price |
$846.60
|
| Rate for Payer: Cigna Commercial |
$1,199.35
|
| Rate for Payer: First Health Commercial |
$1,269.90
|
| Rate for Payer: First Health Workers Compensation |
$544.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,269.90
|
| Rate for Payer: GEHA Commercial |
$987.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,269.90
|
| Rate for Payer: Multiplan All |
$1,284.01
|
| Rate for Payer: OMNI Networks Commercial |
$987.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,269.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,340.45
|
| Rate for Payer: Three Rivers Provider Network All |
$1,058.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,312.23
|
| Rate for Payer: Zelis Auto |
$564.40
|
| Rate for Payer: Zelis Worker's Compensation |
$385.20
|
|
|
NUSHIELD 1.6 DISC
|
Facility
|
OP
|
$452.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
1999328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$113.00 |
| Max. Negotiated Rate |
$3,062.82 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$271.20
|
| Rate for Payer: Cash Price |
$271.20
|
| Rate for Payer: Cash Price |
$271.20
|
| Rate for Payer: Cigna Commercial |
$384.20
|
| Rate for Payer: First Health Commercial |
$406.80
|
| Rate for Payer: First Health Workers Compensation |
$174.52
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$406.80
|
| Rate for Payer: GEHA Commercial |
$3,062.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$406.80
|
| Rate for Payer: Humana ChoiceCare |
$117.52
|
| Rate for Payer: Multiplan All |
$411.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$271.20
|
| Rate for Payer: OMNI Networks Commercial |
$316.40
|
| Rate for Payer: One Health Plan PPO/POS |
$406.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$429.40
|
| Rate for Payer: Three Rivers Provider Network All |
$339.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$397.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$113.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$420.36
|
| Rate for Payer: Zelis Auto |
$180.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$226.00
|
| Rate for Payer: Zelis Worker's Compensation |
$123.40
|
|
|
NUSHIELD 1.6 DISC
|
Facility
|
IP
|
$452.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
1999328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$123.40 |
| Max. Negotiated Rate |
$429.40 |
| Rate for Payer: Cash Price |
$271.20
|
| Rate for Payer: Cigna Commercial |
$384.20
|
| Rate for Payer: First Health Commercial |
$406.80
|
| Rate for Payer: First Health Workers Compensation |
$174.52
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$406.80
|
| Rate for Payer: GEHA Commercial |
$316.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$406.80
|
| Rate for Payer: Multiplan All |
$411.32
|
| Rate for Payer: OMNI Networks Commercial |
$316.40
|
| Rate for Payer: One Health Plan PPO/POS |
$406.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$429.40
|
| Rate for Payer: Three Rivers Provider Network All |
$339.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$420.36
|
| Rate for Payer: Zelis Auto |
$180.80
|
| Rate for Payer: Zelis Worker's Compensation |
$123.40
|
|
|
NUSHIELD 1 SQUARE CM
|
Facility
|
OP
|
$824.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
1904160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$206.00 |
| Max. Negotiated Rate |
$3,062.82 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$494.40
|
| Rate for Payer: Cash Price |
$494.40
|
| Rate for Payer: Cash Price |
$494.40
|
| Rate for Payer: Cigna Commercial |
$700.40
|
| Rate for Payer: First Health Commercial |
$741.60
|
| Rate for Payer: First Health Workers Compensation |
$318.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$741.60
|
| Rate for Payer: GEHA Commercial |
$3,062.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$741.60
|
| Rate for Payer: Humana ChoiceCare |
$214.24
|
| Rate for Payer: Multiplan All |
$749.84
|
| Rate for Payer: New Mexico Health Connections Medicare |
$494.40
|
| Rate for Payer: OMNI Networks Commercial |
$576.80
|
| Rate for Payer: One Health Plan PPO/POS |
$741.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$782.80
|
| Rate for Payer: Three Rivers Provider Network All |
$618.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$725.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$206.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$766.32
|
| Rate for Payer: Zelis Auto |
$329.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$412.00
|
| Rate for Payer: Zelis Worker's Compensation |
$224.95
|
|
|
NUSHIELD 1 SQUARE CM
|
Facility
|
IP
|
$824.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
1904160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$224.95 |
| Max. Negotiated Rate |
$782.80 |
| Rate for Payer: Cash Price |
$494.40
|
| Rate for Payer: Cigna Commercial |
$700.40
|
| Rate for Payer: First Health Commercial |
$741.60
|
| Rate for Payer: First Health Workers Compensation |
$318.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$741.60
|
| Rate for Payer: GEHA Commercial |
$576.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$741.60
|
| Rate for Payer: Multiplan All |
$749.84
|
| Rate for Payer: OMNI Networks Commercial |
$576.80
|
| Rate for Payer: One Health Plan PPO/POS |
$741.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$782.80
|
| Rate for Payer: Three Rivers Provider Network All |
$618.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$766.32
|
| Rate for Payer: Zelis Auto |
$329.60
|
| Rate for Payer: Zelis Worker's Compensation |
$224.95
|
|
|
NU-SHIELD 2X3CM
|
Facility
|
IP
|
$787.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
7009041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$214.85 |
| Max. Negotiated Rate |
$747.65 |
| Rate for Payer: Cash Price |
$472.20
|
| Rate for Payer: Cigna Commercial |
$668.95
|
| Rate for Payer: First Health Commercial |
$708.30
|
| Rate for Payer: First Health Workers Compensation |
$303.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$708.30
|
| Rate for Payer: GEHA Commercial |
$550.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$708.30
|
| Rate for Payer: Multiplan All |
$716.17
|
| Rate for Payer: OMNI Networks Commercial |
$550.90
|
| Rate for Payer: One Health Plan PPO/POS |
$708.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$747.65
|
| Rate for Payer: Three Rivers Provider Network All |
$590.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$731.91
|
| Rate for Payer: Zelis Auto |
$314.80
|
| Rate for Payer: Zelis Worker's Compensation |
$214.85
|
|
|
NU-SHIELD 2X3CM
|
Facility
|
OP
|
$787.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
7009041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$196.75 |
| Max. Negotiated Rate |
$3,062.82 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$472.20
|
| Rate for Payer: Cash Price |
$472.20
|
| Rate for Payer: Cash Price |
$472.20
|
| Rate for Payer: Cigna Commercial |
$668.95
|
| Rate for Payer: First Health Commercial |
$708.30
|
| Rate for Payer: First Health Workers Compensation |
$303.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$708.30
|
| Rate for Payer: GEHA Commercial |
$3,062.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$708.30
|
| Rate for Payer: Humana ChoiceCare |
$204.62
|
| Rate for Payer: Multiplan All |
$716.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$472.20
|
| Rate for Payer: OMNI Networks Commercial |
$550.90
|
| Rate for Payer: One Health Plan PPO/POS |
$708.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$747.65
|
| Rate for Payer: Three Rivers Provider Network All |
$590.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$692.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$196.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$731.91
|
| Rate for Payer: Zelis Auto |
$314.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$393.50
|
| Rate for Payer: Zelis Worker's Compensation |
$214.85
|
|
|
NUSHIELD 2X3 HIGH SKIN SUBSTITUTE
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
1999232
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.25 |
| Max. Negotiated Rate |
$3,062.82 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.60
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cigna Commercial |
$102.85
|
| Rate for Payer: First Health Commercial |
$108.90
|
| Rate for Payer: First Health Workers Compensation |
$46.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.90
|
| Rate for Payer: GEHA Commercial |
$3,062.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.90
|
| Rate for Payer: Humana ChoiceCare |
$31.46
|
| Rate for Payer: Multiplan All |
$110.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$72.60
|
| Rate for Payer: OMNI Networks Commercial |
$84.70
|
| Rate for Payer: One Health Plan PPO/POS |
$108.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.95
|
| Rate for Payer: Three Rivers Provider Network All |
$90.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$106.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$30.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$112.53
|
| Rate for Payer: Zelis Auto |
$48.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$60.50
|
| Rate for Payer: Zelis Worker's Compensation |
$33.03
|
|
|
NUSHIELD 2X3 HIGH SKIN SUBSTITUTE
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
1999232
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.03 |
| Max. Negotiated Rate |
$114.95 |
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cigna Commercial |
$102.85
|
| Rate for Payer: First Health Commercial |
$108.90
|
| Rate for Payer: First Health Workers Compensation |
$46.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.90
|
| Rate for Payer: GEHA Commercial |
$84.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.90
|
| Rate for Payer: Multiplan All |
$110.11
|
| Rate for Payer: OMNI Networks Commercial |
$84.70
|
| Rate for Payer: One Health Plan PPO/POS |
$108.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.95
|
| Rate for Payer: Three Rivers Provider Network All |
$90.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$112.53
|
| Rate for Payer: Zelis Auto |
$48.40
|
| Rate for Payer: Zelis Worker's Compensation |
$33.03
|
|
|
NU-SHIELD 2X4CM
|
Facility
|
OP
|
$964.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
7006623
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$241.00 |
| Max. Negotiated Rate |
$3,062.82 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$578.40
|
| Rate for Payer: Cash Price |
$578.40
|
| Rate for Payer: Cash Price |
$578.40
|
| Rate for Payer: Cigna Commercial |
$819.40
|
| Rate for Payer: First Health Commercial |
$867.60
|
| Rate for Payer: First Health Workers Compensation |
$372.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$867.60
|
| Rate for Payer: GEHA Commercial |
$3,062.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$867.60
|
| Rate for Payer: Humana ChoiceCare |
$250.64
|
| Rate for Payer: Multiplan All |
$877.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$578.40
|
| Rate for Payer: OMNI Networks Commercial |
$674.80
|
| Rate for Payer: One Health Plan PPO/POS |
$867.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$915.80
|
| Rate for Payer: Three Rivers Provider Network All |
$723.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$848.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$241.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$896.52
|
| Rate for Payer: Zelis Auto |
$385.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$482.00
|
| Rate for Payer: Zelis Worker's Compensation |
$263.17
|
|
|
NU-SHIELD 2X4CM
|
Facility
|
IP
|
$964.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
7006623
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$263.17 |
| Max. Negotiated Rate |
$915.80 |
| Rate for Payer: Cash Price |
$578.40
|
| Rate for Payer: Cigna Commercial |
$819.40
|
| Rate for Payer: First Health Commercial |
$867.60
|
| Rate for Payer: First Health Workers Compensation |
$372.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$867.60
|
| Rate for Payer: GEHA Commercial |
$674.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$867.60
|
| Rate for Payer: Multiplan All |
$877.24
|
| Rate for Payer: OMNI Networks Commercial |
$674.80
|
| Rate for Payer: One Health Plan PPO/POS |
$867.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$915.80
|
| Rate for Payer: Three Rivers Provider Network All |
$723.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$896.52
|
| Rate for Payer: Zelis Auto |
$385.60
|
| Rate for Payer: Zelis Worker's Compensation |
$263.17
|
|
|
NUSHIELD 2X4 HIGH SKIN SUBSTITUTE
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
1999233
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.25 |
| Max. Negotiated Rate |
$3,062.82 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.60
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cigna Commercial |
$102.85
|
| Rate for Payer: First Health Commercial |
$108.90
|
| Rate for Payer: First Health Workers Compensation |
$46.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.90
|
| Rate for Payer: GEHA Commercial |
$3,062.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.90
|
| Rate for Payer: Humana ChoiceCare |
$31.46
|
| Rate for Payer: Multiplan All |
$110.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$72.60
|
| Rate for Payer: OMNI Networks Commercial |
$84.70
|
| Rate for Payer: One Health Plan PPO/POS |
$108.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.95
|
| Rate for Payer: Three Rivers Provider Network All |
$90.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$106.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$30.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$112.53
|
| Rate for Payer: Zelis Auto |
$48.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$60.50
|
| Rate for Payer: Zelis Worker's Compensation |
$33.03
|
|
|
NUSHIELD 2X4 HIGH SKIN SUBSTITUTE
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
1999233
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.03 |
| Max. Negotiated Rate |
$114.95 |
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cigna Commercial |
$102.85
|
| Rate for Payer: First Health Commercial |
$108.90
|
| Rate for Payer: First Health Workers Compensation |
$46.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.90
|
| Rate for Payer: GEHA Commercial |
$84.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.90
|
| Rate for Payer: Multiplan All |
$110.11
|
| Rate for Payer: OMNI Networks Commercial |
$84.70
|
| Rate for Payer: One Health Plan PPO/POS |
$108.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.95
|
| Rate for Payer: Three Rivers Provider Network All |
$90.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$112.53
|
| Rate for Payer: Zelis Auto |
$48.40
|
| Rate for Payer: Zelis Worker's Compensation |
$33.03
|
|
|
NUSHIELD 3X4
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
1999329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.25 |
| Max. Negotiated Rate |
$3,062.82 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.60
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cigna Commercial |
$102.85
|
| Rate for Payer: First Health Commercial |
$108.90
|
| Rate for Payer: First Health Workers Compensation |
$46.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.90
|
| Rate for Payer: GEHA Commercial |
$3,062.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.90
|
| Rate for Payer: Humana ChoiceCare |
$31.46
|
| Rate for Payer: Multiplan All |
$110.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$72.60
|
| Rate for Payer: OMNI Networks Commercial |
$84.70
|
| Rate for Payer: One Health Plan PPO/POS |
$108.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.95
|
| Rate for Payer: Three Rivers Provider Network All |
$90.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$106.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$30.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$112.53
|
| Rate for Payer: Zelis Auto |
$48.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$60.50
|
| Rate for Payer: Zelis Worker's Compensation |
$33.03
|
|
|
NUSHIELD 3X4
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
1999329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.03 |
| Max. Negotiated Rate |
$114.95 |
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cigna Commercial |
$102.85
|
| Rate for Payer: First Health Commercial |
$108.90
|
| Rate for Payer: First Health Workers Compensation |
$46.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.90
|
| Rate for Payer: GEHA Commercial |
$84.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.90
|
| Rate for Payer: Multiplan All |
$110.11
|
| Rate for Payer: OMNI Networks Commercial |
$84.70
|
| Rate for Payer: One Health Plan PPO/POS |
$108.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.95
|
| Rate for Payer: Three Rivers Provider Network All |
$90.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$112.53
|
| Rate for Payer: Zelis Auto |
$48.40
|
| Rate for Payer: Zelis Worker's Compensation |
$33.03
|
|
|
NU-SHIELD 4X4CM
|
Facility
|
OP
|
$5,100.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
7009047
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,845.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,060.00
|
| Rate for Payer: Cash Price |
$3,060.00
|
| Rate for Payer: Cash Price |
$3,060.00
|
| Rate for Payer: Cigna Commercial |
$4,335.00
|
| Rate for Payer: First Health Commercial |
$4,590.00
|
| Rate for Payer: First Health Workers Compensation |
$1,969.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,590.00
|
| Rate for Payer: GEHA Commercial |
$3,062.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,590.00
|
| Rate for Payer: Humana ChoiceCare |
$1,326.00
|
| Rate for Payer: Multiplan All |
$4,641.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,060.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,570.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,590.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,845.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,825.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,488.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,275.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,743.00
|
| Rate for Payer: Zelis Auto |
$2,040.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,550.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,392.30
|
|
|
NU-SHIELD 4X4CM
|
Facility
|
IP
|
$5,100.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
7009047
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,392.30 |
| Max. Negotiated Rate |
$4,845.00 |
| Rate for Payer: Cash Price |
$3,060.00
|
| Rate for Payer: Cigna Commercial |
$4,335.00
|
| Rate for Payer: First Health Commercial |
$4,590.00
|
| Rate for Payer: First Health Workers Compensation |
$1,969.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,590.00
|
| Rate for Payer: GEHA Commercial |
$3,570.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,590.00
|
| Rate for Payer: Multiplan All |
$4,641.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,570.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,590.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,845.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,825.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,743.00
|
| Rate for Payer: Zelis Auto |
$2,040.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,392.30
|
|
|
NUSHIELD 4X6
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
1999331
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.03 |
| Max. Negotiated Rate |
$114.95 |
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cigna Commercial |
$102.85
|
| Rate for Payer: First Health Commercial |
$108.90
|
| Rate for Payer: First Health Workers Compensation |
$46.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.90
|
| Rate for Payer: GEHA Commercial |
$84.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.90
|
| Rate for Payer: Multiplan All |
$110.11
|
| Rate for Payer: OMNI Networks Commercial |
$84.70
|
| Rate for Payer: One Health Plan PPO/POS |
$108.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.95
|
| Rate for Payer: Three Rivers Provider Network All |
$90.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$112.53
|
| Rate for Payer: Zelis Auto |
$48.40
|
| Rate for Payer: Zelis Worker's Compensation |
$33.03
|
|
|
NUSHIELD 4X6
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
1999331
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.25 |
| Max. Negotiated Rate |
$3,062.82 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.60
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cigna Commercial |
$102.85
|
| Rate for Payer: First Health Commercial |
$108.90
|
| Rate for Payer: First Health Workers Compensation |
$46.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.90
|
| Rate for Payer: GEHA Commercial |
$3,062.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.90
|
| Rate for Payer: Humana ChoiceCare |
$31.46
|
| Rate for Payer: Multiplan All |
$110.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$72.60
|
| Rate for Payer: OMNI Networks Commercial |
$84.70
|
| Rate for Payer: One Health Plan PPO/POS |
$108.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.95
|
| Rate for Payer: Three Rivers Provider Network All |
$90.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$106.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$30.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$112.53
|
| Rate for Payer: Zelis Auto |
$48.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$60.50
|
| Rate for Payer: Zelis Worker's Compensation |
$33.03
|
|
