|
OxyCODONE W/ACETAMINOPHEN 5-325MG TAB
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 68084035501
|
| Hospital Charge Code |
3300685
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Humana ChoiceCare |
$1.56
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.60
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
OXYGEN HOURS
|
Facility
|
IP
|
$45.00
|
|
| Hospital Charge Code |
4000702
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$31.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
OXYGEN HOURS
|
Facility
|
OP
|
$45.00
|
|
| Hospital Charge Code |
4000702
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.25 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$36.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Humana ChoiceCare |
$11.70
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.00
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$39.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.50
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
OXYGEN INITAL
|
Facility
|
OP
|
$90.00
|
|
| Hospital Charge Code |
4000703
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$85.50 |
| 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: 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: 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
|
|
|
OXYGEN INITAL
|
Facility
|
IP
|
$90.00
|
|
| Hospital Charge Code |
4000703
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.57 |
| Max. Negotiated Rate |
$85.50 |
| 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: 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
|
|
|
OXYGEN REFRIGERATED LIQUID
|
Facility
|
OP
|
$3,045.00
|
|
| Hospital Charge Code |
90003652
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$761.25 |
| Max. Negotiated Rate |
$2,892.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,827.00
|
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: Cigna Commercial |
$2,588.25
|
| Rate for Payer: First Health Commercial |
$2,740.50
|
| Rate for Payer: First Health Workers Compensation |
$1,175.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,740.50
|
| Rate for Payer: GEHA Commercial |
$2,436.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,740.50
|
| Rate for Payer: Humana ChoiceCare |
$791.70
|
| Rate for Payer: Multiplan All |
$2,770.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,827.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,131.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,740.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,892.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,283.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,679.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$761.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,831.85
|
| Rate for Payer: Zelis Auto |
$1,218.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,522.50
|
| Rate for Payer: Zelis Worker's Compensation |
$831.28
|
|
|
OXYGEN REFRIGERATED LIQUID
|
Facility
|
IP
|
$3,045.00
|
|
| Hospital Charge Code |
90003652
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$831.28 |
| Max. Negotiated Rate |
$2,892.75 |
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: Cigna Commercial |
$2,588.25
|
| Rate for Payer: First Health Commercial |
$2,740.50
|
| Rate for Payer: First Health Workers Compensation |
$1,175.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,740.50
|
| Rate for Payer: GEHA Commercial |
$2,131.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,740.50
|
| Rate for Payer: Multiplan All |
$2,770.95
|
| Rate for Payer: OMNI Networks Commercial |
$2,131.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,740.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,892.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,283.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,831.85
|
| Rate for Payer: Zelis Auto |
$1,218.00
|
| Rate for Payer: Zelis Worker's Compensation |
$831.28
|
|
|
OXYGEN UPTAKE/EXPIRED GAS/SIMPLE
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
CPT 94680
|
| Hospital Charge Code |
4094680
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$164.35 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$147.05
|
| Rate for Payer: First Health Commercial |
$155.70
|
| Rate for Payer: First Health Workers Compensation |
$66.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$155.70
|
| Rate for Payer: GEHA Commercial |
$121.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$155.70
|
| Rate for Payer: Multiplan All |
$157.43
|
| Rate for Payer: OMNI Networks Commercial |
$121.10
|
| Rate for Payer: One Health Plan PPO/POS |
$155.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$164.35
|
| Rate for Payer: Three Rivers Provider Network All |
$129.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$160.89
|
| Rate for Payer: Zelis Auto |
$69.20
|
| Rate for Payer: Zelis Worker's Compensation |
$47.23
|
|
|
OXYGEN UPTAKE/EXPIRED GAS/SIMPLE
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
CPT 94680
|
| Hospital Charge Code |
4094680
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$297.14 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$241.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$103.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$241.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$191.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$148.57
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$147.05
|
| Rate for Payer: First Health Commercial |
$155.70
|
| Rate for Payer: First Health Workers Compensation |
$66.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$155.70
|
| Rate for Payer: GEHA Commercial |
$138.40
|
| Rate for Payer: GEHA Medicare |
$148.57
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$155.70
|
| Rate for Payer: Humana ChoiceCare |
$163.43
|
| Rate for Payer: Humana Medicare Advantage |
$148.57
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$249.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$195.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$148.57
|
| Rate for Payer: Multiplan All |
$157.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$252.57
|
| Rate for Payer: OMNI Networks Commercial |
$121.10
|
| Rate for Payer: One Health Plan PPO/POS |
$155.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$225.71
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$195.48
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$148.57
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$164.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$297.14
|
| Rate for Payer: Three Rivers Provider Network All |
$129.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$145.60
|
| Rate for Payer: United Healthcare Commercial |
$147.05
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$148.57
|
| Rate for Payer: United Payors & United Providers UP&UP |
$160.89
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$148.57
|
| Rate for Payer: Zelis Auto |
$69.20
|
| Rate for Payer: Zelis Medicare |
$126.28
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$178.28
|
| Rate for Payer: Zelis Worker's Compensation |
$47.23
|
|
|
OXYHEMOGLOBIN ARTERIAL
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT 82810
|
| Hospital Charge Code |
4210018
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$8.30 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$14.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$82.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$14.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$11.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$9.77
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$116.45
|
| Rate for Payer: First Health Commercial |
$123.30
|
| Rate for Payer: First Health Workers Compensation |
$19.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$123.30
|
| Rate for Payer: GEHA Commercial |
$109.60
|
| Rate for Payer: GEHA Medicare |
$9.77
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$123.30
|
| Rate for Payer: Humana ChoiceCare |
$10.75
|
| Rate for Payer: Humana Medicare Advantage |
$9.77
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$16.41
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$11.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$9.77
|
| Rate for Payer: Multiplan All |
$124.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$16.61
|
| Rate for Payer: OMNI Networks Commercial |
$95.90
|
| Rate for Payer: One Health Plan PPO/POS |
$123.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$13.68
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$11.85
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$9.77
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$130.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$19.54
|
| Rate for Payer: Three Rivers Provider Network All |
$102.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.57
|
| Rate for Payer: United Healthcare Commercial |
$116.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.77
|
| Rate for Payer: United Payors & United Providers UP&UP |
$127.41
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$9.77
|
| Rate for Payer: Zelis Auto |
$54.80
|
| Rate for Payer: Zelis Medicare |
$8.30
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$11.72
|
| Rate for Payer: Zelis Worker's Compensation |
$13.51
|
|
|
OXYHEMOGLOBIN ARTERIAL
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT 82810
|
| Hospital Charge Code |
4210018
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$13.51 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$116.45
|
| Rate for Payer: First Health Commercial |
$123.30
|
| Rate for Payer: First Health Workers Compensation |
$19.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$123.30
|
| Rate for Payer: GEHA Commercial |
$95.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$123.30
|
| Rate for Payer: Multiplan All |
$124.67
|
| Rate for Payer: OMNI Networks Commercial |
$95.90
|
| Rate for Payer: One Health Plan PPO/POS |
$123.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$130.15
|
| Rate for Payer: Three Rivers Provider Network All |
$102.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$127.41
|
| Rate for Payer: Zelis Auto |
$54.80
|
| Rate for Payer: Zelis Worker's Compensation |
$13.51
|
|
|
OXYMETAZOLINE 0.05% NASAL SPRAY
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
NDC 00904742730
|
| Hospital Charge Code |
3300686
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$14.45
|
| Rate for Payer: First Health Commercial |
$15.30
|
| Rate for Payer: First Health Workers Compensation |
$6.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15.30
|
| Rate for Payer: GEHA Commercial |
$11.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15.30
|
| Rate for Payer: Multiplan All |
$15.47
|
| Rate for Payer: OMNI Networks Commercial |
$11.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16.15
|
| Rate for Payer: Three Rivers Provider Network All |
$12.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15.81
|
| Rate for Payer: Zelis Auto |
$6.80
|
| Rate for Payer: Zelis Worker's Compensation |
$4.64
|
|
|
OXYMETAZOLINE 0.05% NASAL SPRAY
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
NDC 00904742730
|
| Hospital Charge Code |
3300686
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$14.45
|
| Rate for Payer: First Health Commercial |
$15.30
|
| Rate for Payer: First Health Workers Compensation |
$6.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15.30
|
| Rate for Payer: GEHA Commercial |
$13.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15.30
|
| Rate for Payer: Humana ChoiceCare |
$4.42
|
| Rate for Payer: Multiplan All |
$15.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10.20
|
| Rate for Payer: OMNI Networks Commercial |
$11.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16.15
|
| Rate for Payer: Three Rivers Provider Network All |
$12.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15.81
|
| Rate for Payer: Zelis Auto |
$6.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.50
|
| Rate for Payer: Zelis Worker's Compensation |
$4.64
|
|
|
OXYTOCIN INJ 10 UNIT/ML
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
CPT J2590
|
| Hospital Charge Code |
3300687
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.55 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$11.05
|
| Rate for Payer: First Health Commercial |
$11.70
|
| Rate for Payer: First Health Workers Compensation |
$5.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11.70
|
| Rate for Payer: GEHA Commercial |
$9.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11.70
|
| Rate for Payer: Multiplan All |
$11.83
|
| Rate for Payer: OMNI Networks Commercial |
$9.10
|
| Rate for Payer: One Health Plan PPO/POS |
$11.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12.35
|
| Rate for Payer: Three Rivers Provider Network All |
$9.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12.09
|
| Rate for Payer: Zelis Auto |
$5.20
|
| Rate for Payer: Zelis Worker's Compensation |
$3.55
|
|
|
OXYTOCIN INJ 10 UNIT/ML
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
CPT J2590
|
| Hospital Charge Code |
3300687
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$11.05
|
| Rate for Payer: First Health Commercial |
$11.70
|
| Rate for Payer: First Health Workers Compensation |
$5.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11.70
|
| Rate for Payer: GEHA Commercial |
$10.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11.70
|
| Rate for Payer: Humana ChoiceCare |
$3.38
|
| Rate for Payer: Multiplan All |
$11.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.80
|
| Rate for Payer: OMNI Networks Commercial |
$9.10
|
| Rate for Payer: One Health Plan PPO/POS |
$11.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12.35
|
| Rate for Payer: Three Rivers Provider Network All |
$9.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12.09
|
| Rate for Payer: Zelis Auto |
$5.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.55
|
|
|
PACU I 15"
|
Facility
|
OP
|
$305.00
|
|
| Hospital Charge Code |
6600001
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$76.25 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$259.25
|
| Rate for Payer: First Health Commercial |
$274.50
|
| Rate for Payer: First Health Workers Compensation |
$117.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$274.50
|
| Rate for Payer: GEHA Commercial |
$244.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$274.50
|
| Rate for Payer: Humana ChoiceCare |
$79.30
|
| Rate for Payer: Multiplan All |
$277.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$183.00
|
| Rate for Payer: OMNI Networks Commercial |
$213.50
|
| Rate for Payer: One Health Plan PPO/POS |
$274.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$289.75
|
| Rate for Payer: Three Rivers Provider Network All |
$228.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$268.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$76.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$283.65
|
| Rate for Payer: Zelis Auto |
$122.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$152.50
|
| Rate for Payer: Zelis Worker's Compensation |
$83.27
|
|
|
PACU I 15"
|
Facility
|
IP
|
$305.00
|
|
| Hospital Charge Code |
6600001
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$83.27 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$259.25
|
| Rate for Payer: First Health Commercial |
$274.50
|
| Rate for Payer: First Health Workers Compensation |
$117.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$274.50
|
| Rate for Payer: GEHA Commercial |
$213.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$274.50
|
| Rate for Payer: Multiplan All |
$277.55
|
| Rate for Payer: OMNI Networks Commercial |
$213.50
|
| Rate for Payer: One Health Plan PPO/POS |
$274.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$289.75
|
| Rate for Payer: Three Rivers Provider Network All |
$228.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$283.65
|
| Rate for Payer: Zelis Auto |
$122.00
|
| Rate for Payer: Zelis Worker's Compensation |
$83.27
|
|
|
PACU I 1ST HOUR
|
Facility
|
IP
|
$1,117.00
|
|
| Hospital Charge Code |
6600004
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$304.94 |
| Max. Negotiated Rate |
$1,061.15 |
| Rate for Payer: Cash Price |
$670.20
|
| Rate for Payer: Cigna Commercial |
$949.45
|
| Rate for Payer: First Health Commercial |
$1,005.30
|
| Rate for Payer: First Health Workers Compensation |
$431.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,005.30
|
| Rate for Payer: GEHA Commercial |
$781.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,005.30
|
| Rate for Payer: Multiplan All |
$1,016.47
|
| Rate for Payer: OMNI Networks Commercial |
$781.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,005.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,061.15
|
| Rate for Payer: Three Rivers Provider Network All |
$837.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,038.81
|
| Rate for Payer: Zelis Auto |
$446.80
|
| Rate for Payer: Zelis Worker's Compensation |
$304.94
|
|
|
PACU I 1ST HOUR
|
Facility
|
OP
|
$1,117.00
|
|
| Hospital Charge Code |
6600004
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$279.25 |
| Max. Negotiated Rate |
$1,061.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$670.20
|
| Rate for Payer: Cash Price |
$670.20
|
| Rate for Payer: Cigna Commercial |
$949.45
|
| Rate for Payer: First Health Commercial |
$1,005.30
|
| Rate for Payer: First Health Workers Compensation |
$431.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,005.30
|
| Rate for Payer: GEHA Commercial |
$893.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,005.30
|
| Rate for Payer: Humana ChoiceCare |
$290.42
|
| Rate for Payer: Multiplan All |
$1,016.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$670.20
|
| Rate for Payer: OMNI Networks Commercial |
$781.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,005.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,061.15
|
| Rate for Payer: Three Rivers Provider Network All |
$837.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$982.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$279.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,038.81
|
| Rate for Payer: Zelis Auto |
$446.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$558.50
|
| Rate for Payer: Zelis Worker's Compensation |
$304.94
|
|
|
PACU II 15"
|
Facility
|
IP
|
$406.00
|
|
| Hospital Charge Code |
6600003
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$110.84 |
| Max. Negotiated Rate |
$385.70 |
| Rate for Payer: Cash Price |
$243.60
|
| Rate for Payer: Cigna Commercial |
$345.10
|
| Rate for Payer: First Health Commercial |
$365.40
|
| Rate for Payer: First Health Workers Compensation |
$156.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$365.40
|
| Rate for Payer: GEHA Commercial |
$284.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$365.40
|
| Rate for Payer: Multiplan All |
$369.46
|
| Rate for Payer: OMNI Networks Commercial |
$284.20
|
| Rate for Payer: One Health Plan PPO/POS |
$365.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$385.70
|
| Rate for Payer: Three Rivers Provider Network All |
$304.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$377.58
|
| Rate for Payer: Zelis Auto |
$162.40
|
| Rate for Payer: Zelis Worker's Compensation |
$110.84
|
|
|
PACU II 15"
|
Facility
|
OP
|
$406.00
|
|
| Hospital Charge Code |
6600003
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$101.50 |
| Max. Negotiated Rate |
$385.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$243.60
|
| Rate for Payer: Cash Price |
$243.60
|
| Rate for Payer: Cigna Commercial |
$345.10
|
| Rate for Payer: First Health Commercial |
$365.40
|
| Rate for Payer: First Health Workers Compensation |
$156.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$365.40
|
| Rate for Payer: GEHA Commercial |
$324.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$365.40
|
| Rate for Payer: Humana ChoiceCare |
$105.56
|
| Rate for Payer: Multiplan All |
$369.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$243.60
|
| Rate for Payer: OMNI Networks Commercial |
$284.20
|
| Rate for Payer: One Health Plan PPO/POS |
$365.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$385.70
|
| Rate for Payer: Three Rivers Provider Network All |
$304.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$357.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$101.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$377.58
|
| Rate for Payer: Zelis Auto |
$162.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$203.00
|
| Rate for Payer: Zelis Worker's Compensation |
$110.84
|
|
|
PACU II 1ST HOUR
|
Facility
|
OP
|
$1,218.00
|
|
| Hospital Charge Code |
6600005
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$304.50 |
| Max. Negotiated Rate |
$1,157.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$730.80
|
| Rate for Payer: Cash Price |
$730.80
|
| Rate for Payer: Cigna Commercial |
$1,035.30
|
| Rate for Payer: First Health Commercial |
$1,096.20
|
| Rate for Payer: First Health Workers Compensation |
$470.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,096.20
|
| Rate for Payer: GEHA Commercial |
$974.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,096.20
|
| Rate for Payer: Humana ChoiceCare |
$316.68
|
| Rate for Payer: Multiplan All |
$1,108.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$730.80
|
| Rate for Payer: OMNI Networks Commercial |
$852.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,096.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,157.10
|
| Rate for Payer: Three Rivers Provider Network All |
$913.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,071.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$304.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,132.74
|
| Rate for Payer: Zelis Auto |
$487.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$609.00
|
| Rate for Payer: Zelis Worker's Compensation |
$332.51
|
|
|
PACU II 1ST HOUR
|
Facility
|
IP
|
$1,218.00
|
|
| Hospital Charge Code |
6600005
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$332.51 |
| Max. Negotiated Rate |
$1,157.10 |
| Rate for Payer: Cash Price |
$730.80
|
| Rate for Payer: Cigna Commercial |
$1,035.30
|
| Rate for Payer: First Health Commercial |
$1,096.20
|
| Rate for Payer: First Health Workers Compensation |
$470.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,096.20
|
| Rate for Payer: GEHA Commercial |
$852.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,096.20
|
| Rate for Payer: Multiplan All |
$1,108.38
|
| Rate for Payer: OMNI Networks Commercial |
$852.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,096.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,157.10
|
| Rate for Payer: Three Rivers Provider Network All |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,132.74
|
| Rate for Payer: Zelis Auto |
$487.20
|
| Rate for Payer: Zelis Worker's Compensation |
$332.51
|
|
|
pai 1 activity REF146787
|
Facility
|
OP
|
$249.00
|
|
|
Service Code
|
CPT 85415
|
| Hospital Charge Code |
2299553
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.61 |
| Max. Negotiated Rate |
$236.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$30.95
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$149.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$30.95
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$24.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$17.19
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$211.65
|
| Rate for Payer: First Health Commercial |
$224.10
|
| Rate for Payer: First Health Workers Compensation |
$26.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$224.10
|
| Rate for Payer: GEHA Commercial |
$199.20
|
| Rate for Payer: GEHA Medicare |
$17.19
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$224.10
|
| Rate for Payer: Humana ChoiceCare |
$18.91
|
| Rate for Payer: Humana Medicare Advantage |
$17.19
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$28.88
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$25.01
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$17.19
|
| Rate for Payer: Multiplan All |
$226.59
|
| Rate for Payer: New Mexico Health Connections Medicare |
$29.22
|
| Rate for Payer: OMNI Networks Commercial |
$174.30
|
| Rate for Payer: One Health Plan PPO/POS |
$224.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$28.88
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$25.01
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$17.19
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$236.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$34.38
|
| Rate for Payer: Three Rivers Provider Network All |
$186.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16.85
|
| Rate for Payer: United Healthcare Commercial |
$211.65
|
| Rate for Payer: United Healthcare Managed Medicaid |
$25.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.19
|
| Rate for Payer: United Payors & United Providers UP&UP |
$231.57
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$17.19
|
| Rate for Payer: Zelis Auto |
$99.60
|
| Rate for Payer: Zelis Medicare |
$14.61
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.63
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
pai 1 activity REF146787
|
Facility
|
IP
|
$249.00
|
|
|
Service Code
|
CPT 85415
|
| Hospital Charge Code |
2299553
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$236.55 |
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$211.65
|
| Rate for Payer: First Health Commercial |
$224.10
|
| Rate for Payer: First Health Workers Compensation |
$26.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$224.10
|
| Rate for Payer: GEHA Commercial |
$174.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$224.10
|
| Rate for Payer: Multiplan All |
$226.59
|
| Rate for Payer: OMNI Networks Commercial |
$174.30
|
| Rate for Payer: One Health Plan PPO/POS |
$224.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$236.55
|
| Rate for Payer: Three Rivers Provider Network All |
$186.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$231.57
|
| Rate for Payer: Zelis Auto |
$99.60
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
