|
NUSHIELD 6X6
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
1999332
|
|
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 6X6
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
1999332
|
|
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
|
|
|
NYSTATIN CREAM 100,000U/GM
|
Facility
|
IP
|
$64.00
|
|
|
Service Code
|
NDC 45802005911
|
| Hospital Charge Code |
3300657
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.47 |
| Max. Negotiated Rate |
$60.80 |
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$54.40
|
| Rate for Payer: First Health Commercial |
$57.60
|
| Rate for Payer: First Health Workers Compensation |
$24.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$57.60
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$57.60
|
| Rate for Payer: Multiplan All |
$58.24
|
| Rate for Payer: OMNI Networks Commercial |
$44.80
|
| Rate for Payer: One Health Plan PPO/POS |
$57.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$60.80
|
| Rate for Payer: Three Rivers Provider Network All |
$48.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$59.52
|
| Rate for Payer: Zelis Auto |
$25.60
|
| Rate for Payer: Zelis Worker's Compensation |
$17.47
|
|
|
NYSTATIN CREAM 100,000U/GM
|
Facility
|
OP
|
$64.00
|
|
|
Service Code
|
NDC 45802005911
|
| Hospital Charge Code |
3300657
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.00 |
| Max. Negotiated Rate |
$60.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$54.40
|
| Rate for Payer: First Health Commercial |
$57.60
|
| Rate for Payer: First Health Workers Compensation |
$24.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$57.60
|
| Rate for Payer: GEHA Commercial |
$51.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$57.60
|
| Rate for Payer: Humana ChoiceCare |
$16.64
|
| Rate for Payer: Multiplan All |
$58.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$38.40
|
| Rate for Payer: OMNI Networks Commercial |
$44.80
|
| Rate for Payer: One Health Plan PPO/POS |
$57.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$60.80
|
| Rate for Payer: Three Rivers Provider Network All |
$48.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$56.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$59.52
|
| Rate for Payer: Zelis Auto |
$25.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$32.00
|
| Rate for Payer: Zelis Worker's Compensation |
$17.47
|
|
|
NYSTATIN SUSP 100,000 UNIT/ML
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 00121086805
|
| Hospital Charge Code |
3300658
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$7.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
NYSTATIN SUSP 100,000 UNIT/ML
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 00121086805
|
| Hospital Charge Code |
3300658
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$8.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Humana ChoiceCare |
$2.86
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.60
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
NYSTATIN TOPICAL POWDER
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
NDC 00832046515
|
| Hospital Charge Code |
3300659
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.25 |
| Max. Negotiated Rate |
$31.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$28.05
|
| Rate for Payer: First Health Commercial |
$29.70
|
| Rate for Payer: First Health Workers Compensation |
$12.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$29.70
|
| Rate for Payer: GEHA Commercial |
$26.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$29.70
|
| Rate for Payer: Humana ChoiceCare |
$8.58
|
| Rate for Payer: Multiplan All |
$30.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$19.80
|
| Rate for Payer: OMNI Networks Commercial |
$23.10
|
| Rate for Payer: One Health Plan PPO/POS |
$29.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$31.35
|
| Rate for Payer: Three Rivers Provider Network All |
$24.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$29.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$30.69
|
| Rate for Payer: Zelis Auto |
$13.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$16.50
|
| Rate for Payer: Zelis Worker's Compensation |
$9.01
|
|
|
NYSTATIN TOPICAL POWDER
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
NDC 00832046515
|
| Hospital Charge Code |
3300659
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.01 |
| Max. Negotiated Rate |
$31.35 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$28.05
|
| Rate for Payer: First Health Commercial |
$29.70
|
| Rate for Payer: First Health Workers Compensation |
$12.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$29.70
|
| Rate for Payer: GEHA Commercial |
$23.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$29.70
|
| Rate for Payer: Multiplan All |
$30.03
|
| Rate for Payer: OMNI Networks Commercial |
$23.10
|
| Rate for Payer: One Health Plan PPO/POS |
$29.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$31.35
|
| Rate for Payer: Three Rivers Provider Network All |
$24.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$30.69
|
| Rate for Payer: Zelis Auto |
$13.20
|
| Rate for Payer: Zelis Worker's Compensation |
$9.01
|
|
|
NYSTATIN-TRIAMCINOLONE CREAM
|
Facility
|
IP
|
$417.00
|
|
|
Service Code
|
NDC 51672126301
|
| Hospital Charge Code |
3300660
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$113.84 |
| Max. Negotiated Rate |
$396.15 |
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cigna Commercial |
$354.45
|
| Rate for Payer: First Health Commercial |
$375.30
|
| Rate for Payer: First Health Workers Compensation |
$161.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$375.30
|
| Rate for Payer: GEHA Commercial |
$291.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$375.30
|
| Rate for Payer: Multiplan All |
$379.47
|
| Rate for Payer: OMNI Networks Commercial |
$291.90
|
| Rate for Payer: One Health Plan PPO/POS |
$375.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$396.15
|
| Rate for Payer: Three Rivers Provider Network All |
$312.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$387.81
|
| Rate for Payer: Zelis Auto |
$166.80
|
| Rate for Payer: Zelis Worker's Compensation |
$113.84
|
|
|
NYSTATIN-TRIAMCINOLONE CREAM
|
Facility
|
OP
|
$417.00
|
|
|
Service Code
|
NDC 51672126301
|
| Hospital Charge Code |
3300660
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$104.25 |
| Max. Negotiated Rate |
$396.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$250.20
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cigna Commercial |
$354.45
|
| Rate for Payer: First Health Commercial |
$375.30
|
| Rate for Payer: First Health Workers Compensation |
$161.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$375.30
|
| Rate for Payer: GEHA Commercial |
$333.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$375.30
|
| Rate for Payer: Humana ChoiceCare |
$108.42
|
| Rate for Payer: Multiplan All |
$379.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$250.20
|
| Rate for Payer: OMNI Networks Commercial |
$291.90
|
| Rate for Payer: One Health Plan PPO/POS |
$375.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$396.15
|
| Rate for Payer: Three Rivers Provider Network All |
$312.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$366.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$104.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$387.81
|
| Rate for Payer: Zelis Auto |
$166.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$208.50
|
| Rate for Payer: Zelis Worker's Compensation |
$113.84
|
|
|
oak, white IgE REF602480
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299148
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.22
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: GEHA Medicare |
$5.22
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.22
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.76
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.59
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.22
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10.44
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.12
|
| Rate for Payer: United Healthcare Commercial |
$47.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.22
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Medicare |
$4.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.26
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
oak, white IgE REF602480
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299148
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
OASIS BURN MATRIX PER SQ CM
|
Facility
|
OP
|
$260.58
|
|
|
Service Code
|
CPT Q4103
|
| Hospital Charge Code |
1904104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.88 |
| Max. Negotiated Rate |
$247.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$8.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$156.35
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$8.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$6.88
|
| Rate for Payer: Cash Price |
$156.35
|
| Rate for Payer: Cash Price |
$156.35
|
| Rate for Payer: Cigna Commercial |
$221.49
|
| Rate for Payer: First Health Commercial |
$234.52
|
| Rate for Payer: First Health Workers Compensation |
$100.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$234.52
|
| Rate for Payer: GEHA Commercial |
$13.74
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$234.52
|
| Rate for Payer: Humana ChoiceCare |
$67.75
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.02
|
| Rate for Payer: Multiplan All |
$237.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$156.35
|
| Rate for Payer: OMNI Networks Commercial |
$182.41
|
| Rate for Payer: One Health Plan PPO/POS |
$234.52
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.11
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.02
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$247.55
|
| Rate for Payer: Three Rivers Provider Network All |
$195.44
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$229.31
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.02
|
| Rate for Payer: United Payors & United Providers UP&UP |
$242.34
|
| Rate for Payer: Zelis Auto |
$104.23
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$130.29
|
| Rate for Payer: Zelis Worker's Compensation |
$71.14
|
|
|
OASIS BURN MATRIX PER SQ CM
|
Facility
|
IP
|
$260.58
|
|
|
Service Code
|
CPT Q4103
|
| Hospital Charge Code |
1904104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.14 |
| Max. Negotiated Rate |
$247.55 |
| Rate for Payer: Cash Price |
$156.35
|
| Rate for Payer: Cigna Commercial |
$221.49
|
| Rate for Payer: First Health Commercial |
$234.52
|
| Rate for Payer: First Health Workers Compensation |
$100.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$234.52
|
| Rate for Payer: GEHA Commercial |
$182.41
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$234.52
|
| Rate for Payer: Multiplan All |
$237.13
|
| Rate for Payer: OMNI Networks Commercial |
$182.41
|
| Rate for Payer: One Health Plan PPO/POS |
$234.52
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$247.55
|
| Rate for Payer: Three Rivers Provider Network All |
$195.44
|
| Rate for Payer: United Payors & United Providers UP&UP |
$242.34
|
| Rate for Payer: Zelis Auto |
$104.23
|
| Rate for Payer: Zelis Worker's Compensation |
$71.14
|
|
|
OASIS GRAFT 3X3.5
|
Facility
|
IP
|
$2,250.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7005212
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$900.00 |
| Max. Negotiated Rate |
$2,137.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,800.00
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cigna Commercial |
$1,912.50
|
| Rate for Payer: First Health Commercial |
$2,025.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,025.00
|
| Rate for Payer: GEHA Commercial |
$1,575.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,025.00
|
| Rate for Payer: Multiplan All |
$2,047.50
|
| Rate for Payer: OMNI Networks Commercial |
$1,575.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,025.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,137.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,687.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,092.50
|
| Rate for Payer: Zelis Auto |
$900.00
|
|
|
OASIS GRAFT 3X3.5
|
Facility
|
OP
|
$2,250.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7005212
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$562.50 |
| Max. Negotiated Rate |
$2,137.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,350.00
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cigna Commercial |
$1,912.50
|
| Rate for Payer: First Health Commercial |
$2,025.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,025.00
|
| Rate for Payer: GEHA Commercial |
$1,800.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,025.00
|
| Rate for Payer: Humana ChoiceCare |
$585.00
|
| Rate for Payer: Multiplan All |
$2,047.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,350.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,575.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,025.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,137.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,687.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,980.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$562.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,092.50
|
| Rate for Payer: Zelis Auto |
$900.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,125.00
|
|
|
OBSERVATION ADDITIONAL HOUR
|
Facility
|
OP
|
$90.00
|
|
| Hospital Charge Code |
31110003
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$325.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna Commercial |
$76.50
|
| Rate for Payer: First Health Commercial |
$81.00
|
| Rate for Payer: First Health Workers Compensation |
$34.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.00
|
| Rate for Payer: GEHA Commercial |
$72.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.00
|
| Rate for Payer: Humana ChoiceCare |
$23.40
|
| Rate for Payer: Multiplan All |
$81.90
|
| Rate for Payer: New Mexico Health Connections Medicare |
$54.00
|
| Rate for Payer: OMNI Networks Commercial |
$63.00
|
| Rate for Payer: One Health Plan PPO/POS |
$81.00
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$325.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$85.50
|
| Rate for Payer: Three Rivers Provider Network All |
$67.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$79.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$22.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$83.70
|
| Rate for Payer: Zelis Auto |
$36.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$45.00
|
| Rate for Payer: Zelis Worker's Compensation |
$24.57
|
|
|
OBSERVATION ADDITIONAL HOUR
|
Facility
|
IP
|
$90.00
|
|
| Hospital Charge Code |
31110003
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$24.57 |
| Max. Negotiated Rate |
$325.00 |
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna Commercial |
$76.50
|
| Rate for Payer: First Health Commercial |
$81.00
|
| Rate for Payer: First Health Workers Compensation |
$34.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.00
|
| Rate for Payer: GEHA Commercial |
$63.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.00
|
| Rate for Payer: Multiplan All |
$81.90
|
| Rate for Payer: OMNI Networks Commercial |
$63.00
|
| Rate for Payer: One Health Plan PPO/POS |
$81.00
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$325.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$85.50
|
| Rate for Payer: Three Rivers Provider Network All |
$67.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$83.70
|
| Rate for Payer: Zelis Auto |
$36.00
|
| Rate for Payer: Zelis Worker's Compensation |
$24.57
|
|
|
OBSERVATION CARE DISCHARGE
|
Facility
|
IP
|
$313.00
|
|
|
Service Code
|
CPT 99217
|
| Hospital Charge Code |
9899217
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$85.45 |
| Max. Negotiated Rate |
$297.35 |
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$266.05
|
| Rate for Payer: First Health Commercial |
$281.70
|
| Rate for Payer: First Health Workers Compensation |
$120.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$281.70
|
| Rate for Payer: GEHA Commercial |
$219.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$281.70
|
| Rate for Payer: Multiplan All |
$284.83
|
| Rate for Payer: OMNI Networks Commercial |
$219.10
|
| Rate for Payer: One Health Plan PPO/POS |
$281.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$297.35
|
| Rate for Payer: Three Rivers Provider Network All |
$234.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$291.09
|
| Rate for Payer: Zelis Auto |
$125.20
|
| Rate for Payer: Zelis Worker's Compensation |
$85.45
|
|
|
OBSERVATION CARE DISCHARGE MANAGEMENT
|
Facility
|
OP
|
$313.00
|
|
|
Service Code
|
CPT 99217
|
| Hospital Charge Code |
21999402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$78.25 |
| Max. Negotiated Rate |
$297.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$187.80
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$266.05
|
| Rate for Payer: First Health Commercial |
$281.70
|
| Rate for Payer: First Health Workers Compensation |
$120.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$281.70
|
| Rate for Payer: GEHA Commercial |
$250.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$281.70
|
| Rate for Payer: Humana ChoiceCare |
$81.38
|
| Rate for Payer: Multiplan All |
$284.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$187.80
|
| Rate for Payer: OMNI Networks Commercial |
$219.10
|
| Rate for Payer: One Health Plan PPO/POS |
$281.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$297.35
|
| Rate for Payer: Three Rivers Provider Network All |
$234.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$275.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$78.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$291.09
|
| Rate for Payer: Zelis Auto |
$125.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$156.50
|
| Rate for Payer: Zelis Worker's Compensation |
$85.45
|
|
|
OBSERVATION CARE DISCHARGE MANAGEMENT
|
Facility
|
IP
|
$313.00
|
|
|
Service Code
|
CPT 99217
|
| Hospital Charge Code |
21799471
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$85.45 |
| Max. Negotiated Rate |
$297.35 |
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$266.05
|
| Rate for Payer: First Health Commercial |
$281.70
|
| Rate for Payer: First Health Workers Compensation |
$120.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$281.70
|
| Rate for Payer: GEHA Commercial |
$219.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$281.70
|
| Rate for Payer: Multiplan All |
$284.83
|
| Rate for Payer: OMNI Networks Commercial |
$219.10
|
| Rate for Payer: One Health Plan PPO/POS |
$281.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$297.35
|
| Rate for Payer: Three Rivers Provider Network All |
$234.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$291.09
|
| Rate for Payer: Zelis Auto |
$125.20
|
| Rate for Payer: Zelis Worker's Compensation |
$85.45
|
|
|
OBSERVATION CARE DISCHARGE MANAGEMENT
|
Facility
|
IP
|
$313.00
|
|
|
Service Code
|
CPT 99217
|
| Hospital Charge Code |
21999402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$85.45 |
| Max. Negotiated Rate |
$297.35 |
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$266.05
|
| Rate for Payer: First Health Commercial |
$281.70
|
| Rate for Payer: First Health Workers Compensation |
$120.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$281.70
|
| Rate for Payer: GEHA Commercial |
$219.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$281.70
|
| Rate for Payer: Multiplan All |
$284.83
|
| Rate for Payer: OMNI Networks Commercial |
$219.10
|
| Rate for Payer: One Health Plan PPO/POS |
$281.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$297.35
|
| Rate for Payer: Three Rivers Provider Network All |
$234.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$291.09
|
| Rate for Payer: Zelis Auto |
$125.20
|
| Rate for Payer: Zelis Worker's Compensation |
$85.45
|
|
|
OBSERVATION CARE DISCHARGE MANAGEMENT
|
Facility
|
OP
|
$313.00
|
|
|
Service Code
|
CPT 99217
|
| Hospital Charge Code |
21799471
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$78.25 |
| Max. Negotiated Rate |
$297.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$187.80
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$266.05
|
| Rate for Payer: First Health Commercial |
$281.70
|
| Rate for Payer: First Health Workers Compensation |
$120.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$281.70
|
| Rate for Payer: GEHA Commercial |
$250.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$281.70
|
| Rate for Payer: Humana ChoiceCare |
$81.38
|
| Rate for Payer: Multiplan All |
$284.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$187.80
|
| Rate for Payer: OMNI Networks Commercial |
$219.10
|
| Rate for Payer: One Health Plan PPO/POS |
$281.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$297.35
|
| Rate for Payer: Three Rivers Provider Network All |
$234.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$275.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$78.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$291.09
|
| Rate for Payer: Zelis Auto |
$125.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$156.50
|
| Rate for Payer: Zelis Worker's Compensation |
$85.45
|
|
|
OBSERVATION EACH ADDL HOUR
|
Facility
|
OP
|
$41.00
|
|
|
Service Code
|
CPT G0378
|
| Hospital Charge Code |
9400079
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$10.66 |
| Max. Negotiated Rate |
$325.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$42.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$24.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$42.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$33.61
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$32.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Humana ChoiceCare |
$10.66
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$34.29
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.60
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$39.59
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$325.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$36.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$34.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.50
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
OBSERVATION EACH ADDL HOUR
|
Facility
|
IP
|
$41.00
|
|
|
Service Code
|
CPT G0378
|
| Hospital Charge Code |
9400079
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$325.00 |
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$28.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$325.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
