|
SODIUM CHLORIDE INJ 0.9%
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 63807010001
|
| Hospital Charge Code |
3300842
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
SODIUM CHLORIDE INJ 0.9%
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 63807010001
|
| Hospital Charge Code |
3300842
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$6.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Humana ChoiceCare |
$2.08
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.80
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
SODIUM CHLORIDE TAB 1GM
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00223176001
|
| Hospital Charge Code |
3300852
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
SODIUM CHLORIDE TAB 1GM
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00223176001
|
| Hospital Charge Code |
3300852
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
SODIUM CIT / CITRIC ACID 1.5G/1G (15 mL)
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
NDC 00121059500
|
| Hospital Charge Code |
3302826
|
|
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
|
|
|
SODIUM CIT / CITRIC ACID 1.5G/1G (15 mL)
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
NDC 00121059500
|
| Hospital Charge Code |
3302826
|
|
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
|
|
|
SODIUM HYALURONATE 25MG/2.5ML
|
Facility
|
IP
|
$508.00
|
|
|
Service Code
|
CPT J7321
|
| Hospital Charge Code |
3300854
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$138.68 |
| Max. Negotiated Rate |
$482.60 |
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cigna Commercial |
$431.80
|
| Rate for Payer: First Health Commercial |
$457.20
|
| Rate for Payer: First Health Workers Compensation |
$196.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$457.20
|
| Rate for Payer: GEHA Commercial |
$355.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$457.20
|
| Rate for Payer: Multiplan All |
$462.28
|
| Rate for Payer: OMNI Networks Commercial |
$355.60
|
| Rate for Payer: One Health Plan PPO/POS |
$457.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$482.60
|
| Rate for Payer: Three Rivers Provider Network All |
$381.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$472.44
|
| Rate for Payer: Zelis Auto |
$203.20
|
| Rate for Payer: Zelis Worker's Compensation |
$138.68
|
|
|
SODIUM HYALURONATE 25MG/2.5ML
|
Facility
|
OP
|
$508.00
|
|
|
Service Code
|
CPT J7321
|
| Hospital Charge Code |
3300854
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.67 |
| Max. Negotiated Rate |
$482.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$133.81
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$304.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$133.81
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$106.01
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cigna Commercial |
$431.80
|
| Rate for Payer: First Health Commercial |
$457.20
|
| Rate for Payer: First Health Workers Compensation |
$196.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$457.20
|
| Rate for Payer: GEHA Commercial |
$78.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$457.20
|
| Rate for Payer: Humana ChoiceCare |
$132.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$108.17
|
| Rate for Payer: Multiplan All |
$462.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$304.80
|
| Rate for Payer: OMNI Networks Commercial |
$355.60
|
| Rate for Payer: One Health Plan PPO/POS |
$457.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$124.89
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$108.17
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$482.60
|
| Rate for Payer: Three Rivers Provider Network All |
$381.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$447.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$108.17
|
| Rate for Payer: United Payors & United Providers UP&UP |
$472.44
|
| Rate for Payer: Zelis Auto |
$203.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$254.00
|
| Rate for Payer: Zelis Worker's Compensation |
$138.68
|
|
|
SODIUM HYALURONATE INJ 20MG/2ML
|
Facility
|
IP
|
$355.00
|
|
|
Service Code
|
CPT J7323
|
| Hospital Charge Code |
3300853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.92 |
| Max. Negotiated Rate |
$337.25 |
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Cigna Commercial |
$301.75
|
| Rate for Payer: First Health Commercial |
$319.50
|
| Rate for Payer: First Health Workers Compensation |
$137.07
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$319.50
|
| Rate for Payer: GEHA Commercial |
$248.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$319.50
|
| Rate for Payer: Multiplan All |
$323.05
|
| Rate for Payer: OMNI Networks Commercial |
$248.50
|
| Rate for Payer: One Health Plan PPO/POS |
$319.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$337.25
|
| Rate for Payer: Three Rivers Provider Network All |
$266.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$330.15
|
| Rate for Payer: Zelis Auto |
$142.00
|
| Rate for Payer: Zelis Worker's Compensation |
$96.92
|
|
|
SODIUM HYALURONATE INJ 20MG/2ML
|
Facility
|
OP
|
$355.00
|
|
|
Service Code
|
CPT J7323
|
| Hospital Charge Code |
3300853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$95.58 |
| Max. Negotiated Rate |
$337.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$222.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$213.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$222.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$176.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$112.45
|
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Cigna Commercial |
$301.75
|
| Rate for Payer: First Health Commercial |
$319.50
|
| Rate for Payer: First Health Workers Compensation |
$137.07
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$319.50
|
| Rate for Payer: GEHA Commercial |
$123.69
|
| Rate for Payer: GEHA Medicare |
$112.45
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$319.50
|
| Rate for Payer: Humana ChoiceCare |
$123.69
|
| Rate for Payer: Humana Medicare Advantage |
$112.45
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$188.92
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$180.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$112.45
|
| Rate for Payer: Multiplan All |
$323.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$191.16
|
| Rate for Payer: OMNI Networks Commercial |
$248.50
|
| Rate for Payer: One Health Plan PPO/POS |
$319.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$207.91
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$180.07
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$112.45
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$337.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$224.90
|
| Rate for Payer: Three Rivers Provider Network All |
$266.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$110.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$180.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$112.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$330.15
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$112.45
|
| Rate for Payer: Zelis Auto |
$142.00
|
| Rate for Payer: Zelis Medicare |
$95.58
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$134.94
|
| Rate for Payer: Zelis Worker's Compensation |
$96.92
|
|
|
SODIUM NITRITE INJ 30MG/ML
|
Facility
|
IP
|
$357.00
|
|
|
Service Code
|
NDC 60267031110
|
| Hospital Charge Code |
3300855
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.46 |
| Max. Negotiated Rate |
$339.15 |
| Rate for Payer: Cash Price |
$214.20
|
| Rate for Payer: Cigna Commercial |
$303.45
|
| Rate for Payer: First Health Commercial |
$321.30
|
| Rate for Payer: First Health Workers Compensation |
$137.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$321.30
|
| Rate for Payer: GEHA Commercial |
$249.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$321.30
|
| Rate for Payer: Multiplan All |
$324.87
|
| Rate for Payer: OMNI Networks Commercial |
$249.90
|
| Rate for Payer: One Health Plan PPO/POS |
$321.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$339.15
|
| Rate for Payer: Three Rivers Provider Network All |
$267.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$332.01
|
| Rate for Payer: Zelis Auto |
$142.80
|
| Rate for Payer: Zelis Worker's Compensation |
$97.46
|
|
|
SODIUM NITRITE INJ 30MG/ML
|
Facility
|
OP
|
$357.00
|
|
|
Service Code
|
NDC 60267031110
|
| Hospital Charge Code |
3300855
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.25 |
| Max. Negotiated Rate |
$339.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$214.20
|
| Rate for Payer: Cash Price |
$214.20
|
| Rate for Payer: Cigna Commercial |
$303.45
|
| Rate for Payer: First Health Commercial |
$321.30
|
| Rate for Payer: First Health Workers Compensation |
$137.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$321.30
|
| Rate for Payer: GEHA Commercial |
$285.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$321.30
|
| Rate for Payer: Humana ChoiceCare |
$92.82
|
| Rate for Payer: Multiplan All |
$324.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$214.20
|
| Rate for Payer: OMNI Networks Commercial |
$249.90
|
| Rate for Payer: One Health Plan PPO/POS |
$321.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$339.15
|
| Rate for Payer: Three Rivers Provider Network All |
$267.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$314.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$89.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$332.01
|
| Rate for Payer: Zelis Auto |
$142.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$178.50
|
| Rate for Payer: Zelis Worker's Compensation |
$97.46
|
|
|
SODIUM PHOS ENEMA ADULTS 230 ML
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 00132020110
|
| Hospital Charge Code |
3303041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$17.10 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$15.30
|
| Rate for Payer: First Health Commercial |
$16.20
|
| Rate for Payer: First Health Workers Compensation |
$6.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$16.20
|
| Rate for Payer: GEHA Commercial |
$12.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$16.20
|
| Rate for Payer: Multiplan All |
$16.38
|
| Rate for Payer: OMNI Networks Commercial |
$12.60
|
| Rate for Payer: One Health Plan PPO/POS |
$16.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$17.10
|
| Rate for Payer: Three Rivers Provider Network All |
$13.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$16.74
|
| Rate for Payer: Zelis Auto |
$7.20
|
| Rate for Payer: Zelis Worker's Compensation |
$4.91
|
|
|
SODIUM PHOS ENEMA ADULTS 230 ML
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 00132020110
|
| Hospital Charge Code |
3303041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$17.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$15.30
|
| Rate for Payer: First Health Commercial |
$16.20
|
| Rate for Payer: First Health Workers Compensation |
$6.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$16.20
|
| Rate for Payer: GEHA Commercial |
$14.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$16.20
|
| Rate for Payer: Humana ChoiceCare |
$4.68
|
| Rate for Payer: Multiplan All |
$16.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10.80
|
| Rate for Payer: OMNI Networks Commercial |
$12.60
|
| Rate for Payer: One Health Plan PPO/POS |
$16.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$17.10
|
| Rate for Payer: Three Rivers Provider Network All |
$13.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$15.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$16.74
|
| Rate for Payer: Zelis Auto |
$7.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$9.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.91
|
|
|
SODIUM POLYSTYRENE 30GM/120ML
|
Facility
|
OP
|
$560.00
|
|
|
Service Code
|
NDC 46287000604
|
| Hospital Charge Code |
3302916
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$532.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$336.00
|
| Rate for Payer: Cash Price |
$336.00
|
| Rate for Payer: Cigna Commercial |
$476.00
|
| Rate for Payer: First Health Commercial |
$504.00
|
| Rate for Payer: First Health Workers Compensation |
$216.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$504.00
|
| Rate for Payer: GEHA Commercial |
$448.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$504.00
|
| Rate for Payer: Humana ChoiceCare |
$145.60
|
| Rate for Payer: Multiplan All |
$509.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$336.00
|
| Rate for Payer: OMNI Networks Commercial |
$392.00
|
| Rate for Payer: One Health Plan PPO/POS |
$504.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$532.00
|
| Rate for Payer: Three Rivers Provider Network All |
$420.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$492.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$140.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$520.80
|
| Rate for Payer: Zelis Auto |
$224.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$280.00
|
| Rate for Payer: Zelis Worker's Compensation |
$152.88
|
|
|
SODIUM POLYSTYRENE 30GM/120ML
|
Facility
|
IP
|
$560.00
|
|
|
Service Code
|
NDC 46287000604
|
| Hospital Charge Code |
3302916
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$152.88 |
| Max. Negotiated Rate |
$532.00 |
| Rate for Payer: Cash Price |
$336.00
|
| Rate for Payer: Cigna Commercial |
$476.00
|
| Rate for Payer: First Health Commercial |
$504.00
|
| Rate for Payer: First Health Workers Compensation |
$216.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$504.00
|
| Rate for Payer: GEHA Commercial |
$392.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$504.00
|
| Rate for Payer: Multiplan All |
$509.60
|
| Rate for Payer: OMNI Networks Commercial |
$392.00
|
| Rate for Payer: One Health Plan PPO/POS |
$504.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$532.00
|
| Rate for Payer: Three Rivers Provider Network All |
$420.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$520.80
|
| Rate for Payer: Zelis Auto |
$224.00
|
| Rate for Payer: Zelis Worker's Compensation |
$152.88
|
|
|
SODIUM POLYSTYRENE ORAL 15GM/60ML
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
NDC 46287000660
|
| Hospital Charge Code |
3300857
|
|
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
|
|
|
SODIUM POLYSTYRENE ORAL 15GM/60ML
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
NDC 46287000660
|
| Hospital Charge Code |
3300857
|
|
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
|
|
|
SODIUM THIOSULFATE INJ 25%
|
Facility
|
OP
|
$357.00
|
|
|
Service Code
|
NDC 60267070550
|
| Hospital Charge Code |
3300858
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.25 |
| Max. Negotiated Rate |
$339.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$214.20
|
| Rate for Payer: Cash Price |
$214.20
|
| Rate for Payer: Cigna Commercial |
$303.45
|
| Rate for Payer: First Health Commercial |
$321.30
|
| Rate for Payer: First Health Workers Compensation |
$137.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$321.30
|
| Rate for Payer: GEHA Commercial |
$285.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$321.30
|
| Rate for Payer: Humana ChoiceCare |
$92.82
|
| Rate for Payer: Multiplan All |
$324.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$214.20
|
| Rate for Payer: OMNI Networks Commercial |
$249.90
|
| Rate for Payer: One Health Plan PPO/POS |
$321.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$339.15
|
| Rate for Payer: Three Rivers Provider Network All |
$267.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$314.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$89.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$332.01
|
| Rate for Payer: Zelis Auto |
$142.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$178.50
|
| Rate for Payer: Zelis Worker's Compensation |
$97.46
|
|
|
SODIUM THIOSULFATE INJ 25%
|
Facility
|
IP
|
$357.00
|
|
|
Service Code
|
NDC 60267070550
|
| Hospital Charge Code |
3300858
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.46 |
| Max. Negotiated Rate |
$339.15 |
| Rate for Payer: Cash Price |
$214.20
|
| Rate for Payer: Cigna Commercial |
$303.45
|
| Rate for Payer: First Health Commercial |
$321.30
|
| Rate for Payer: First Health Workers Compensation |
$137.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$321.30
|
| Rate for Payer: GEHA Commercial |
$249.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$321.30
|
| Rate for Payer: Multiplan All |
$324.87
|
| Rate for Payer: OMNI Networks Commercial |
$249.90
|
| Rate for Payer: One Health Plan PPO/POS |
$321.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$339.15
|
| Rate for Payer: Three Rivers Provider Network All |
$267.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$332.01
|
| Rate for Payer: Zelis Auto |
$142.80
|
| Rate for Payer: Zelis Worker's Compensation |
$97.46
|
|
|
SODIUM (Vitros)
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
CPT 84295
|
| Hospital Charge Code |
2232195
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$69.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$43.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$6.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$4.81
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$62.05
|
| Rate for Payer: First Health Commercial |
$65.70
|
| Rate for Payer: First Health Workers Compensation |
$8.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$65.70
|
| Rate for Payer: GEHA Commercial |
$58.40
|
| Rate for Payer: GEHA Medicare |
$4.81
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$65.70
|
| Rate for Payer: Humana ChoiceCare |
$5.29
|
| Rate for Payer: Humana Medicare Advantage |
$4.81
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$4.81
|
| Rate for Payer: Multiplan All |
$66.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.18
|
| Rate for Payer: OMNI Networks Commercial |
$51.10
|
| Rate for Payer: One Health Plan PPO/POS |
$65.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.08
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.00
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$4.81
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$69.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$9.62
|
| Rate for Payer: Three Rivers Provider Network All |
$54.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.71
|
| Rate for Payer: United Healthcare Commercial |
$62.05
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.81
|
| Rate for Payer: United Payors & United Providers UP&UP |
$67.89
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$4.81
|
| Rate for Payer: Zelis Auto |
$29.20
|
| Rate for Payer: Zelis Medicare |
$4.09
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.77
|
| Rate for Payer: Zelis Worker's Compensation |
$6.08
|
|
|
SODIUM (Vitros)
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
CPT 84295
|
| Hospital Charge Code |
2232195
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$69.35 |
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$62.05
|
| Rate for Payer: First Health Commercial |
$65.70
|
| Rate for Payer: First Health Workers Compensation |
$8.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$65.70
|
| Rate for Payer: GEHA Commercial |
$51.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$65.70
|
| Rate for Payer: Multiplan All |
$66.43
|
| Rate for Payer: OMNI Networks Commercial |
$51.10
|
| Rate for Payer: One Health Plan PPO/POS |
$65.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$69.35
|
| Rate for Payer: Three Rivers Provider Network All |
$54.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$67.89
|
| Rate for Payer: Zelis Auto |
$29.20
|
| Rate for Payer: Zelis Worker's Compensation |
$6.08
|
|
|
SOFT THUMB CMC SPLINT
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT L3908
|
| Hospital Charge Code |
8230055
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$44.80 |
| Max. Negotiated Rate |
$106.40 |
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$95.20
|
| Rate for Payer: First Health Commercial |
$100.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$100.80
|
| Rate for Payer: GEHA Commercial |
$78.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$100.80
|
| Rate for Payer: Multiplan All |
$101.92
|
| Rate for Payer: OMNI Networks Commercial |
$78.40
|
| Rate for Payer: One Health Plan PPO/POS |
$100.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$106.40
|
| Rate for Payer: Three Rivers Provider Network All |
$84.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$104.16
|
| Rate for Payer: Zelis Auto |
$44.80
|
|
|
SOFT THUMB CMC SPLINT
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT L3908
|
| Hospital Charge Code |
8800010
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$44.80 |
| Max. Negotiated Rate |
$106.40 |
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$95.20
|
| Rate for Payer: First Health Commercial |
$100.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$100.80
|
| Rate for Payer: GEHA Commercial |
$78.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$100.80
|
| Rate for Payer: Multiplan All |
$101.92
|
| Rate for Payer: OMNI Networks Commercial |
$78.40
|
| Rate for Payer: One Health Plan PPO/POS |
$100.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$106.40
|
| Rate for Payer: Three Rivers Provider Network All |
$84.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$104.16
|
| Rate for Payer: Zelis Auto |
$44.80
|
|
|
SOFT THUMB CMC SPLINT
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT L3908
|
| Hospital Charge Code |
8800010
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$29.12 |
| Max. Negotiated Rate |
$145.12 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$145.12
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$67.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$145.12
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$114.97
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$95.20
|
| Rate for Payer: First Health Commercial |
$100.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$100.80
|
| Rate for Payer: GEHA Commercial |
$89.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$100.80
|
| Rate for Payer: Humana ChoiceCare |
$29.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$117.31
|
| Rate for Payer: Multiplan All |
$101.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$67.20
|
| Rate for Payer: OMNI Networks Commercial |
$78.40
|
| Rate for Payer: One Health Plan PPO/POS |
$100.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$135.45
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$117.31
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$106.40
|
| Rate for Payer: Three Rivers Provider Network All |
$84.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$117.31
|
| Rate for Payer: United Payors & United Providers UP&UP |
$104.16
|
| Rate for Payer: Zelis Auto |
$44.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$56.00
|
|
