|
RMVL W/RINSJ NON-BIODEGRAD DRUG DLVR IMP
|
Facility
|
IP
|
$708.00
|
|
|
Service Code
|
CPT 11983
|
| Hospital Charge Code |
23500071
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$193.28 |
| Max. Negotiated Rate |
$672.60 |
| Rate for Payer: Cash Price |
$424.80
|
| Rate for Payer: Cigna Commercial |
$601.80
|
| Rate for Payer: First Health Commercial |
$637.20
|
| Rate for Payer: First Health Workers Compensation |
$273.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$637.20
|
| Rate for Payer: GEHA Commercial |
$495.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$637.20
|
| Rate for Payer: Multiplan All |
$644.28
|
| Rate for Payer: OMNI Networks Commercial |
$495.60
|
| Rate for Payer: One Health Plan PPO/POS |
$637.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$672.60
|
| Rate for Payer: Three Rivers Provider Network All |
$531.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$658.44
|
| Rate for Payer: Zelis Auto |
$283.20
|
| Rate for Payer: Zelis Worker's Compensation |
$193.28
|
|
|
RMVL W/RINSJ NON-BIODEGRAD DRUG DLVR IMP
|
Facility
|
OP
|
$541.00
|
|
|
Service Code
|
CPT 11983
|
| Hospital Charge Code |
6111983
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$147.69 |
| Max. Negotiated Rate |
$757.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$395.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$324.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$395.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$312.97
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$378.90
|
| Rate for Payer: Cash Price |
$324.60
|
| Rate for Payer: Cash Price |
$324.60
|
| Rate for Payer: Cigna Commercial |
$459.85
|
| Rate for Payer: First Health Commercial |
$486.90
|
| Rate for Payer: First Health Workers Compensation |
$208.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$486.90
|
| Rate for Payer: GEHA Commercial |
$432.80
|
| Rate for Payer: GEHA Medicare |
$378.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$486.90
|
| Rate for Payer: Humana ChoiceCare |
$416.79
|
| Rate for Payer: Humana Medicare Advantage |
$378.90
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$636.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$319.35
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$378.90
|
| Rate for Payer: Multiplan All |
$492.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$644.13
|
| Rate for Payer: OMNI Networks Commercial |
$378.70
|
| Rate for Payer: One Health Plan PPO/POS |
$486.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$368.73
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$319.35
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$378.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$513.95
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$757.80
|
| Rate for Payer: Three Rivers Provider Network All |
$405.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$371.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$319.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$378.90
|
| Rate for Payer: United Payors & United Providers UP&UP |
$503.13
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$378.90
|
| Rate for Payer: Zelis Auto |
$216.40
|
| Rate for Payer: Zelis Medicare |
$322.06
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$454.68
|
| Rate for Payer: Zelis Worker's Compensation |
$147.69
|
|
|
RMVL W/RINSJ NON-BIODEGRAD DRUG DLVR IMP
|
Facility
|
IP
|
$541.00
|
|
|
Service Code
|
CPT 11983
|
| Hospital Charge Code |
6111983
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$147.69 |
| Max. Negotiated Rate |
$513.95 |
| Rate for Payer: Cash Price |
$324.60
|
| Rate for Payer: Cigna Commercial |
$459.85
|
| Rate for Payer: First Health Commercial |
$486.90
|
| Rate for Payer: First Health Workers Compensation |
$208.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$486.90
|
| Rate for Payer: GEHA Commercial |
$378.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$486.90
|
| Rate for Payer: Multiplan All |
$492.31
|
| Rate for Payer: OMNI Networks Commercial |
$378.70
|
| Rate for Payer: One Health Plan PPO/POS |
$486.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$513.95
|
| Rate for Payer: Three Rivers Provider Network All |
$405.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$503.13
|
| Rate for Payer: Zelis Auto |
$216.40
|
| Rate for Payer: Zelis Worker's Compensation |
$147.69
|
|
|
rocky mountain spottd fevr IgG REF016592
|
Facility
|
IP
|
$162.00
|
|
|
Service Code
|
CPT 86757
|
| Hospital Charge Code |
22990961
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$24.80 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cigna Commercial |
$137.70
|
| Rate for Payer: First Health Commercial |
$145.80
|
| Rate for Payer: First Health Workers Compensation |
$35.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$145.80
|
| Rate for Payer: GEHA Commercial |
$113.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$145.80
|
| Rate for Payer: Multiplan All |
$147.42
|
| Rate for Payer: OMNI Networks Commercial |
$113.40
|
| Rate for Payer: One Health Plan PPO/POS |
$145.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$153.90
|
| Rate for Payer: Three Rivers Provider Network All |
$121.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$150.66
|
| Rate for Payer: Zelis Auto |
$64.80
|
| Rate for Payer: Zelis Worker's Compensation |
$24.80
|
|
|
rocky mountain spottd fevr IgG REF016592
|
Facility
|
OP
|
$162.00
|
|
|
Service Code
|
CPT 86757
|
| Hospital Charge Code |
22990961
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$16.45 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$34.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$97.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$34.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$27.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$19.35
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cigna Commercial |
$137.70
|
| Rate for Payer: First Health Commercial |
$145.80
|
| Rate for Payer: First Health Workers Compensation |
$35.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$145.80
|
| Rate for Payer: GEHA Commercial |
$129.60
|
| Rate for Payer: GEHA Medicare |
$19.35
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$145.80
|
| Rate for Payer: Humana ChoiceCare |
$21.29
|
| Rate for Payer: Humana Medicare Advantage |
$19.35
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$32.51
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$28.15
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$19.35
|
| Rate for Payer: Multiplan All |
$147.42
|
| Rate for Payer: New Mexico Health Connections Medicare |
$32.90
|
| Rate for Payer: OMNI Networks Commercial |
$113.40
|
| Rate for Payer: One Health Plan PPO/POS |
$145.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$32.51
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$28.15
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$19.35
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$153.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$38.70
|
| Rate for Payer: Three Rivers Provider Network All |
$121.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.96
|
| Rate for Payer: United Healthcare Commercial |
$137.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$28.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.35
|
| Rate for Payer: United Payors & United Providers UP&UP |
$150.66
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$19.35
|
| Rate for Payer: Zelis Auto |
$64.80
|
| Rate for Payer: Zelis Medicare |
$16.45
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$23.22
|
| Rate for Payer: Zelis Worker's Compensation |
$24.80
|
|
|
rocky mountain spottd fevr IgM REF016667
|
Facility
|
IP
|
$162.00
|
|
|
Service Code
|
CPT 86757
|
| Hospital Charge Code |
22990962
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$24.80 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cigna Commercial |
$137.70
|
| Rate for Payer: First Health Commercial |
$145.80
|
| Rate for Payer: First Health Workers Compensation |
$35.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$145.80
|
| Rate for Payer: GEHA Commercial |
$113.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$145.80
|
| Rate for Payer: Multiplan All |
$147.42
|
| Rate for Payer: OMNI Networks Commercial |
$113.40
|
| Rate for Payer: One Health Plan PPO/POS |
$145.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$153.90
|
| Rate for Payer: Three Rivers Provider Network All |
$121.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$150.66
|
| Rate for Payer: Zelis Auto |
$64.80
|
| Rate for Payer: Zelis Worker's Compensation |
$24.80
|
|
|
rocky mountain spottd fevr IgM REF016667
|
Facility
|
OP
|
$162.00
|
|
|
Service Code
|
CPT 86757
|
| Hospital Charge Code |
22990962
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$16.45 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$34.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$97.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$34.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$27.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$19.35
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cash Price |
$97.20
|
| Rate for Payer: Cigna Commercial |
$137.70
|
| Rate for Payer: First Health Commercial |
$145.80
|
| Rate for Payer: First Health Workers Compensation |
$35.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$145.80
|
| Rate for Payer: GEHA Commercial |
$129.60
|
| Rate for Payer: GEHA Medicare |
$19.35
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$145.80
|
| Rate for Payer: Humana ChoiceCare |
$21.29
|
| Rate for Payer: Humana Medicare Advantage |
$19.35
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$32.51
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$28.15
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$19.35
|
| Rate for Payer: Multiplan All |
$147.42
|
| Rate for Payer: New Mexico Health Connections Medicare |
$32.90
|
| Rate for Payer: OMNI Networks Commercial |
$113.40
|
| Rate for Payer: One Health Plan PPO/POS |
$145.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$32.51
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$28.15
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$19.35
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$153.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$38.70
|
| Rate for Payer: Three Rivers Provider Network All |
$121.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.96
|
| Rate for Payer: United Healthcare Commercial |
$137.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$28.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.35
|
| Rate for Payer: United Payors & United Providers UP&UP |
$150.66
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$19.35
|
| Rate for Payer: Zelis Auto |
$64.80
|
| Rate for Payer: Zelis Medicare |
$16.45
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$23.22
|
| Rate for Payer: Zelis Worker's Compensation |
$24.80
|
|
|
ROCURONIUM BROMIDE 100 MG/10 ML
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3305024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.75 |
| Max. Negotiated Rate |
$52.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$46.75
|
| Rate for Payer: First Health Commercial |
$49.50
|
| Rate for Payer: First Health Workers Compensation |
$21.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$49.50
|
| Rate for Payer: GEHA Commercial |
$44.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$49.50
|
| Rate for Payer: Humana ChoiceCare |
$14.30
|
| Rate for Payer: Multiplan All |
$50.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$33.00
|
| Rate for Payer: OMNI Networks Commercial |
$38.50
|
| Rate for Payer: One Health Plan PPO/POS |
$49.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$52.25
|
| Rate for Payer: Three Rivers Provider Network All |
$41.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$48.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$51.15
|
| Rate for Payer: Zelis Auto |
$22.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$27.50
|
| Rate for Payer: Zelis Worker's Compensation |
$15.02
|
|
|
ROCURONIUM BROMIDE 100 MG/10 ML
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3305024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.02 |
| Max. Negotiated Rate |
$52.25 |
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$46.75
|
| Rate for Payer: First Health Commercial |
$49.50
|
| Rate for Payer: First Health Workers Compensation |
$21.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$49.50
|
| Rate for Payer: GEHA Commercial |
$38.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$49.50
|
| Rate for Payer: Multiplan All |
$50.05
|
| Rate for Payer: OMNI Networks Commercial |
$38.50
|
| Rate for Payer: One Health Plan PPO/POS |
$49.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$52.25
|
| Rate for Payer: Three Rivers Provider Network All |
$41.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$51.15
|
| Rate for Payer: Zelis Auto |
$22.00
|
| Rate for Payer: Zelis Worker's Compensation |
$15.02
|
|
|
ROCURONIUM BROMIDE 50MG/5ML - 5ML
|
Facility
|
IP
|
$52.00
|
|
|
Service Code
|
NDC 63323042605
|
| Hospital Charge Code |
3300804
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.20 |
| Max. Negotiated Rate |
$49.40 |
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$44.20
|
| Rate for Payer: First Health Commercial |
$46.80
|
| Rate for Payer: First Health Workers Compensation |
$20.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$46.80
|
| Rate for Payer: GEHA Commercial |
$36.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$46.80
|
| Rate for Payer: Multiplan All |
$47.32
|
| Rate for Payer: OMNI Networks Commercial |
$36.40
|
| Rate for Payer: One Health Plan PPO/POS |
$46.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$49.40
|
| Rate for Payer: Three Rivers Provider Network All |
$39.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$48.36
|
| Rate for Payer: Zelis Auto |
$20.80
|
| Rate for Payer: Zelis Worker's Compensation |
$14.20
|
|
|
ROCURONIUM BROMIDE 50MG/5ML - 5ML
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
NDC 63323042605
|
| Hospital Charge Code |
3300804
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$49.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$44.20
|
| Rate for Payer: First Health Commercial |
$46.80
|
| Rate for Payer: First Health Workers Compensation |
$20.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$46.80
|
| Rate for Payer: GEHA Commercial |
$41.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$46.80
|
| Rate for Payer: Humana ChoiceCare |
$13.52
|
| Rate for Payer: Multiplan All |
$47.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.20
|
| Rate for Payer: OMNI Networks Commercial |
$36.40
|
| Rate for Payer: One Health Plan PPO/POS |
$46.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$49.40
|
| Rate for Payer: Three Rivers Provider Network All |
$39.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$45.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$48.36
|
| Rate for Payer: Zelis Auto |
$20.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$26.00
|
| Rate for Payer: Zelis Worker's Compensation |
$14.20
|
|
|
ROD 11 X 150 EXTERNAL FIXTATOR
|
Facility
|
OP
|
$1,731.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006437
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$432.75 |
| Max. Negotiated Rate |
$1,644.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,038.60
|
| Rate for Payer: Cash Price |
$1,038.60
|
| Rate for Payer: Cash Price |
$1,038.60
|
| Rate for Payer: Cigna Commercial |
$1,471.35
|
| Rate for Payer: First Health Commercial |
$1,557.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,557.90
|
| Rate for Payer: GEHA Commercial |
$1,384.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,557.90
|
| Rate for Payer: Humana ChoiceCare |
$450.06
|
| Rate for Payer: Multiplan All |
$1,575.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,038.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,211.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,557.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,644.45
|
| Rate for Payer: Three Rivers Provider Network All |
$1,298.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,523.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$432.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,609.83
|
| Rate for Payer: Zelis Auto |
$692.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$865.50
|
|
|
ROD 11 X 150 EXTERNAL FIXTATOR
|
Facility
|
IP
|
$1,731.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006437
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$692.40 |
| Max. Negotiated Rate |
$1,644.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,384.80
|
| Rate for Payer: Cash Price |
$1,038.60
|
| Rate for Payer: Cash Price |
$1,038.60
|
| Rate for Payer: Cigna Commercial |
$1,471.35
|
| Rate for Payer: First Health Commercial |
$1,557.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,557.90
|
| Rate for Payer: GEHA Commercial |
$1,211.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,557.90
|
| Rate for Payer: Multiplan All |
$1,575.21
|
| Rate for Payer: OMNI Networks Commercial |
$1,211.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,557.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,644.45
|
| Rate for Payer: Three Rivers Provider Network All |
$1,298.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,609.83
|
| Rate for Payer: Zelis Auto |
$692.40
|
|
|
ROD 11 X 250 EXTERNAL FIXTATOR
|
Facility
|
IP
|
$1,769.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006436
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$707.60 |
| Max. Negotiated Rate |
$1,680.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,415.20
|
| Rate for Payer: Cash Price |
$1,061.40
|
| Rate for Payer: Cash Price |
$1,061.40
|
| Rate for Payer: Cigna Commercial |
$1,503.65
|
| Rate for Payer: First Health Commercial |
$1,592.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,592.10
|
| Rate for Payer: GEHA Commercial |
$1,238.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,592.10
|
| Rate for Payer: Multiplan All |
$1,609.79
|
| Rate for Payer: OMNI Networks Commercial |
$1,238.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,592.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,680.55
|
| Rate for Payer: Three Rivers Provider Network All |
$1,326.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,645.17
|
| Rate for Payer: Zelis Auto |
$707.60
|
|
|
ROD 11 X 250 EXTERNAL FIXTATOR
|
Facility
|
OP
|
$1,769.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006436
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$442.25 |
| Max. Negotiated Rate |
$1,680.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,061.40
|
| Rate for Payer: Cash Price |
$1,061.40
|
| Rate for Payer: Cash Price |
$1,061.40
|
| Rate for Payer: Cigna Commercial |
$1,503.65
|
| Rate for Payer: First Health Commercial |
$1,592.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,592.10
|
| Rate for Payer: GEHA Commercial |
$1,415.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,592.10
|
| Rate for Payer: Humana ChoiceCare |
$459.94
|
| Rate for Payer: Multiplan All |
$1,609.79
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,061.40
|
| Rate for Payer: OMNI Networks Commercial |
$1,238.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,592.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,680.55
|
| Rate for Payer: Three Rivers Provider Network All |
$1,326.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,556.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$442.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,645.17
|
| Rate for Payer: Zelis Auto |
$707.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$884.50
|
|
|
ROD 11 X 350 EXTERNAL FIXTATOR
|
Facility
|
OP
|
$1,769.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003471
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$442.25 |
| Max. Negotiated Rate |
$1,680.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,061.40
|
| Rate for Payer: Cash Price |
$1,061.40
|
| Rate for Payer: Cash Price |
$1,061.40
|
| Rate for Payer: Cigna Commercial |
$1,503.65
|
| Rate for Payer: First Health Commercial |
$1,592.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,592.10
|
| Rate for Payer: GEHA Commercial |
$1,415.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,592.10
|
| Rate for Payer: Humana ChoiceCare |
$459.94
|
| Rate for Payer: Multiplan All |
$1,609.79
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,061.40
|
| Rate for Payer: OMNI Networks Commercial |
$1,238.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,592.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,680.55
|
| Rate for Payer: Three Rivers Provider Network All |
$1,326.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,556.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$442.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,645.17
|
| Rate for Payer: Zelis Auto |
$707.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$884.50
|
|
|
ROD 11 X 350 EXTERNAL FIXTATOR
|
Facility
|
IP
|
$1,769.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003471
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$707.60 |
| Max. Negotiated Rate |
$1,680.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,415.20
|
| Rate for Payer: Cash Price |
$1,061.40
|
| Rate for Payer: Cash Price |
$1,061.40
|
| Rate for Payer: Cigna Commercial |
$1,503.65
|
| Rate for Payer: First Health Commercial |
$1,592.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,592.10
|
| Rate for Payer: GEHA Commercial |
$1,238.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,592.10
|
| Rate for Payer: Multiplan All |
$1,609.79
|
| Rate for Payer: OMNI Networks Commercial |
$1,238.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,592.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,680.55
|
| Rate for Payer: Three Rivers Provider Network All |
$1,326.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,645.17
|
| Rate for Payer: Zelis Auto |
$707.60
|
|
|
ROD TO ROD DELTA COUPLING
|
Facility
|
OP
|
$2,995.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006434
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$748.75 |
| Max. Negotiated Rate |
$2,845.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,797.00
|
| Rate for Payer: Cash Price |
$1,797.00
|
| Rate for Payer: Cash Price |
$1,797.00
|
| Rate for Payer: Cigna Commercial |
$2,545.75
|
| Rate for Payer: First Health Commercial |
$2,695.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,695.50
|
| Rate for Payer: GEHA Commercial |
$2,396.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,695.50
|
| Rate for Payer: Humana ChoiceCare |
$778.70
|
| Rate for Payer: Multiplan All |
$2,725.45
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,797.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,096.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,695.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,845.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,246.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,635.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$748.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,785.35
|
| Rate for Payer: Zelis Auto |
$1,198.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,497.50
|
|
|
ROD TO ROD DELTA COUPLING
|
Facility
|
IP
|
$2,995.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006434
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,198.00 |
| Max. Negotiated Rate |
$2,845.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,396.00
|
| Rate for Payer: Cash Price |
$1,797.00
|
| Rate for Payer: Cash Price |
$1,797.00
|
| Rate for Payer: Cigna Commercial |
$2,545.75
|
| Rate for Payer: First Health Commercial |
$2,695.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,695.50
|
| Rate for Payer: GEHA Commercial |
$2,096.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,695.50
|
| Rate for Payer: Multiplan All |
$2,725.45
|
| Rate for Payer: OMNI Networks Commercial |
$2,096.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,695.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,845.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,246.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,785.35
|
| Rate for Payer: Zelis Auto |
$1,198.00
|
|
|
ROLAIDS LIQUID - NAVAJO
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
NDC 41167010081
|
| Hospital Charge Code |
3301422
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$62.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$56.10
|
| Rate for Payer: First Health Commercial |
$59.40
|
| Rate for Payer: First Health Workers Compensation |
$25.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$59.40
|
| Rate for Payer: GEHA Commercial |
$52.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$59.40
|
| Rate for Payer: Humana ChoiceCare |
$17.16
|
| Rate for Payer: Multiplan All |
$60.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$39.60
|
| Rate for Payer: OMNI Networks Commercial |
$46.20
|
| Rate for Payer: One Health Plan PPO/POS |
$59.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$62.70
|
| Rate for Payer: Three Rivers Provider Network All |
$49.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$58.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$61.38
|
| Rate for Payer: Zelis Auto |
$26.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.02
|
|
|
ROLAIDS LIQUID - NAVAJO
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
NDC 41167010081
|
| Hospital Charge Code |
3301422
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.02 |
| Max. Negotiated Rate |
$62.70 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$56.10
|
| Rate for Payer: First Health Commercial |
$59.40
|
| Rate for Payer: First Health Workers Compensation |
$25.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$59.40
|
| Rate for Payer: GEHA Commercial |
$46.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$59.40
|
| Rate for Payer: Multiplan All |
$60.06
|
| Rate for Payer: OMNI Networks Commercial |
$46.20
|
| Rate for Payer: One Health Plan PPO/POS |
$59.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$62.70
|
| Rate for Payer: Three Rivers Provider Network All |
$49.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$61.38
|
| Rate for Payer: Zelis Auto |
$26.40
|
| Rate for Payer: Zelis Worker's Compensation |
$18.02
|
|
|
ROPINIRole HCL TAB 0.25MG
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 00904637361
|
| Hospital Charge Code |
3300806
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$8.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Humana ChoiceCare |
$2.60
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.00
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
ROPINIRole HCL TAB 0.25MG
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 00904637361
|
| Hospital Charge Code |
3300806
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$7.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
ROPINIRole HYDROCHLORIDE TAB 1MG
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 00054011825
|
| Hospital Charge Code |
3300807
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Humana ChoiceCare |
$5.46
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.60
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
ROPINIRole HYDROCHLORIDE TAB 1MG
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 00054011825
|
| Hospital Charge Code |
3300807
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
