|
TERBUTALINE SULFATE INJ 1MG/ML
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
CPT J3105
|
| Hospital Charge Code |
3300877
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$32.30
|
| Rate for Payer: First Health Commercial |
$34.20
|
| Rate for Payer: First Health Workers Compensation |
$14.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$34.20
|
| Rate for Payer: GEHA Commercial |
$8.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$34.20
|
| Rate for Payer: Humana ChoiceCare |
$9.88
|
| Rate for Payer: Multiplan All |
$34.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.80
|
| Rate for Payer: OMNI Networks Commercial |
$26.60
|
| Rate for Payer: One Health Plan PPO/POS |
$34.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$36.10
|
| Rate for Payer: Three Rivers Provider Network All |
$28.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$33.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$35.34
|
| Rate for Payer: Zelis Auto |
$15.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$19.00
|
| Rate for Payer: Zelis Worker's Compensation |
$10.37
|
|
|
Test COVID & INFLU A&B AG 16 MIN AGH
|
Facility
|
IP
|
$329.00
|
|
|
Service Code
|
CPT 87426
|
| Hospital Charge Code |
2202033
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$312.55 |
| Rate for Payer: Cash Price |
$197.40
|
| Rate for Payer: Cash Price |
$197.40
|
| Rate for Payer: Cigna Commercial |
$279.65
|
| Rate for Payer: First Health Commercial |
$296.10
|
| Rate for Payer: First Health Workers Compensation |
$54.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$296.10
|
| Rate for Payer: GEHA Commercial |
$230.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$296.10
|
| Rate for Payer: Multiplan All |
$299.39
|
| Rate for Payer: OMNI Networks Commercial |
$230.30
|
| Rate for Payer: One Health Plan PPO/POS |
$296.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$312.55
|
| Rate for Payer: Three Rivers Provider Network All |
$246.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$305.97
|
| Rate for Payer: Zelis Auto |
$131.60
|
| Rate for Payer: Zelis Worker's Compensation |
$38.22
|
|
|
Test COVID & INFLU A&B AG 16 MIN AGH
|
Facility
|
OP
|
$329.00
|
|
|
Service Code
|
CPT 87426
|
| Hospital Charge Code |
2202033
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$30.03 |
| Max. Negotiated Rate |
$312.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$52.99
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$197.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$52.99
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$41.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$35.33
|
| Rate for Payer: Cash Price |
$197.40
|
| Rate for Payer: Cash Price |
$197.40
|
| Rate for Payer: Cigna Commercial |
$279.65
|
| Rate for Payer: First Health Commercial |
$296.10
|
| Rate for Payer: First Health Workers Compensation |
$54.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$296.10
|
| Rate for Payer: GEHA Commercial |
$263.20
|
| Rate for Payer: GEHA Medicare |
$35.33
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$296.10
|
| Rate for Payer: Humana ChoiceCare |
$38.86
|
| Rate for Payer: Humana Medicare Advantage |
$35.33
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$59.35
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$42.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$35.33
|
| Rate for Payer: Multiplan All |
$299.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$60.06
|
| Rate for Payer: OMNI Networks Commercial |
$230.30
|
| Rate for Payer: One Health Plan PPO/POS |
$296.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$49.46
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$42.84
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$35.33
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$312.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$70.66
|
| Rate for Payer: Three Rivers Provider Network All |
$246.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$34.62
|
| Rate for Payer: United Healthcare Commercial |
$279.65
|
| Rate for Payer: United Healthcare Managed Medicaid |
$42.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.33
|
| Rate for Payer: United Payors & United Providers UP&UP |
$305.97
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$35.33
|
| Rate for Payer: Zelis Auto |
$131.60
|
| Rate for Payer: Zelis Medicare |
$30.03
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$42.40
|
| Rate for Payer: Zelis Worker's Compensation |
$38.22
|
|
|
TESTERONE CYPINATE, 1 MG
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
CPT J1071
|
| Hospital Charge Code |
8501071
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.65 |
| Max. Negotiated Rate |
$57.95 |
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Cigna Commercial |
$51.85
|
| Rate for Payer: First Health Commercial |
$54.90
|
| Rate for Payer: First Health Workers Compensation |
$23.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$54.90
|
| Rate for Payer: GEHA Commercial |
$42.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$54.90
|
| Rate for Payer: Multiplan All |
$55.51
|
| Rate for Payer: OMNI Networks Commercial |
$42.70
|
| Rate for Payer: One Health Plan PPO/POS |
$54.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$57.95
|
| Rate for Payer: Three Rivers Provider Network All |
$45.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$56.73
|
| Rate for Payer: Zelis Auto |
$24.40
|
| Rate for Payer: Zelis Worker's Compensation |
$16.65
|
|
|
TESTERONE CYPINATE, 1 MG
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
CPT J1071
|
| Hospital Charge Code |
8501071
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$57.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$36.60
|
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Cigna Commercial |
$51.85
|
| Rate for Payer: First Health Commercial |
$54.90
|
| Rate for Payer: First Health Workers Compensation |
$23.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$54.90
|
| Rate for Payer: GEHA Commercial |
$0.03
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$54.90
|
| Rate for Payer: Humana ChoiceCare |
$15.86
|
| Rate for Payer: Multiplan All |
$55.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$36.60
|
| Rate for Payer: OMNI Networks Commercial |
$42.70
|
| Rate for Payer: One Health Plan PPO/POS |
$54.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$57.95
|
| Rate for Payer: Three Rivers Provider Network All |
$45.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$53.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$15.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$56.73
|
| Rate for Payer: Zelis Auto |
$24.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$30.50
|
| Rate for Payer: Zelis Worker's Compensation |
$16.65
|
|
|
TEST FOR BLOOD FLOW IN GRAFT
|
Facility
|
OP
|
$346.00
|
|
|
Service Code
|
CPT 15860
|
| Hospital Charge Code |
6115860
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$94.46 |
| Max. Negotiated Rate |
$757.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$197.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$207.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$197.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$156.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$378.90
|
| Rate for Payer: Cash Price |
$207.60
|
| Rate for Payer: Cash Price |
$207.60
|
| Rate for Payer: Cigna Commercial |
$294.10
|
| Rate for Payer: First Health Commercial |
$311.40
|
| Rate for Payer: First Health Workers Compensation |
$133.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$311.40
|
| Rate for Payer: GEHA Commercial |
$276.80
|
| Rate for Payer: GEHA Medicare |
$378.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$311.40
|
| 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 |
$159.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$378.90
|
| Rate for Payer: Multiplan All |
$314.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$644.13
|
| Rate for Payer: OMNI Networks Commercial |
$242.20
|
| Rate for Payer: One Health Plan PPO/POS |
$311.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$184.37
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$159.67
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$378.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$328.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$757.80
|
| Rate for Payer: Three Rivers Provider Network All |
$259.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$371.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$159.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$378.90
|
| Rate for Payer: United Payors & United Providers UP&UP |
$321.78
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$378.90
|
| Rate for Payer: Zelis Auto |
$138.40
|
| Rate for Payer: Zelis Medicare |
$322.06
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$454.68
|
| Rate for Payer: Zelis Worker's Compensation |
$94.46
|
|
|
TEST FOR BLOOD FLOW IN GRAFT
|
Facility
|
IP
|
$346.00
|
|
|
Service Code
|
CPT 15860
|
| Hospital Charge Code |
6115860
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$94.46 |
| Max. Negotiated Rate |
$328.70 |
| Rate for Payer: Cash Price |
$207.60
|
| Rate for Payer: Cigna Commercial |
$294.10
|
| Rate for Payer: First Health Commercial |
$311.40
|
| Rate for Payer: First Health Workers Compensation |
$133.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$311.40
|
| Rate for Payer: GEHA Commercial |
$242.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$311.40
|
| Rate for Payer: Multiplan All |
$314.86
|
| Rate for Payer: OMNI Networks Commercial |
$242.20
|
| Rate for Payer: One Health Plan PPO/POS |
$311.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$328.70
|
| Rate for Payer: Three Rivers Provider Network All |
$259.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$321.78
|
| Rate for Payer: Zelis Auto |
$138.40
|
| Rate for Payer: Zelis Worker's Compensation |
$94.46
|
|
|
testosterone, total REF004226
|
Facility
|
IP
|
$230.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
2200783
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$32.42 |
| Max. Negotiated Rate |
$218.50 |
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cigna Commercial |
$195.50
|
| Rate for Payer: First Health Commercial |
$207.00
|
| Rate for Payer: First Health Workers Compensation |
$45.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$207.00
|
| Rate for Payer: GEHA Commercial |
$161.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$207.00
|
| Rate for Payer: Multiplan All |
$209.30
|
| Rate for Payer: OMNI Networks Commercial |
$161.00
|
| Rate for Payer: One Health Plan PPO/POS |
$207.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$218.50
|
| Rate for Payer: Three Rivers Provider Network All |
$172.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$213.90
|
| Rate for Payer: Zelis Auto |
$92.00
|
| Rate for Payer: Zelis Worker's Compensation |
$32.42
|
|
|
testosterone, total REF004226
|
Facility
|
OP
|
$230.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
2200783
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.94 |
| Max. Negotiated Rate |
$218.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$46.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$138.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$46.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$36.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$25.81
|
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cigna Commercial |
$195.50
|
| Rate for Payer: First Health Commercial |
$207.00
|
| Rate for Payer: First Health Workers Compensation |
$45.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$207.00
|
| Rate for Payer: GEHA Commercial |
$184.00
|
| Rate for Payer: GEHA Medicare |
$25.81
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$207.00
|
| Rate for Payer: Humana ChoiceCare |
$28.39
|
| Rate for Payer: Humana Medicare Advantage |
$25.81
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$43.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$37.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$25.81
|
| Rate for Payer: Multiplan All |
$209.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$43.88
|
| Rate for Payer: OMNI Networks Commercial |
$161.00
|
| Rate for Payer: One Health Plan PPO/POS |
$207.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$43.36
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$37.55
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$25.81
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$218.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$51.62
|
| Rate for Payer: Three Rivers Provider Network All |
$172.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$25.29
|
| Rate for Payer: United Healthcare Commercial |
$195.50
|
| Rate for Payer: United Healthcare Managed Medicaid |
$37.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.81
|
| Rate for Payer: United Payors & United Providers UP&UP |
$213.90
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$25.81
|
| Rate for Payer: Zelis Auto |
$92.00
|
| Rate for Payer: Zelis Medicare |
$21.94
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$30.97
|
| Rate for Payer: Zelis Worker's Compensation |
$32.42
|
|
|
TESTOSTERONE (Vitros)
|
Facility
|
IP
|
$243.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
2232263
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$32.42 |
| Max. Negotiated Rate |
$230.85 |
| Rate for Payer: Cash Price |
$145.80
|
| Rate for Payer: Cash Price |
$145.80
|
| Rate for Payer: Cigna Commercial |
$206.55
|
| Rate for Payer: First Health Commercial |
$218.70
|
| Rate for Payer: First Health Workers Compensation |
$45.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$218.70
|
| Rate for Payer: GEHA Commercial |
$170.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$218.70
|
| Rate for Payer: Multiplan All |
$221.13
|
| Rate for Payer: OMNI Networks Commercial |
$170.10
|
| Rate for Payer: One Health Plan PPO/POS |
$218.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$230.85
|
| Rate for Payer: Three Rivers Provider Network All |
$182.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$225.99
|
| Rate for Payer: Zelis Auto |
$97.20
|
| Rate for Payer: Zelis Worker's Compensation |
$32.42
|
|
|
TESTOSTERONE (Vitros)
|
Facility
|
OP
|
$243.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
2232263
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.94 |
| Max. Negotiated Rate |
$230.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$46.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$145.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$46.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$36.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$25.81
|
| Rate for Payer: Cash Price |
$145.80
|
| Rate for Payer: Cash Price |
$145.80
|
| Rate for Payer: Cigna Commercial |
$206.55
|
| Rate for Payer: First Health Commercial |
$218.70
|
| Rate for Payer: First Health Workers Compensation |
$45.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$218.70
|
| Rate for Payer: GEHA Commercial |
$194.40
|
| Rate for Payer: GEHA Medicare |
$25.81
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$218.70
|
| Rate for Payer: Humana ChoiceCare |
$28.39
|
| Rate for Payer: Humana Medicare Advantage |
$25.81
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$43.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$37.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$25.81
|
| Rate for Payer: Multiplan All |
$221.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$43.88
|
| Rate for Payer: OMNI Networks Commercial |
$170.10
|
| Rate for Payer: One Health Plan PPO/POS |
$218.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$43.36
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$37.55
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$25.81
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$230.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$51.62
|
| Rate for Payer: Three Rivers Provider Network All |
$182.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$25.29
|
| Rate for Payer: United Healthcare Commercial |
$206.55
|
| Rate for Payer: United Healthcare Managed Medicaid |
$37.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.81
|
| Rate for Payer: United Payors & United Providers UP&UP |
$225.99
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$25.81
|
| Rate for Payer: Zelis Auto |
$97.20
|
| Rate for Payer: Zelis Medicare |
$21.94
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$30.97
|
| Rate for Payer: Zelis Worker's Compensation |
$32.42
|
|
|
TEST TEST
|
Facility
|
OP
|
$47.00
|
|
|
Service Code
|
CPT 82948
|
| Hospital Charge Code |
7300100
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$44.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$28.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.04
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$39.95
|
| Rate for Payer: First Health Commercial |
$42.30
|
| Rate for Payer: First Health Workers Compensation |
$5.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$42.30
|
| Rate for Payer: GEHA Commercial |
$37.60
|
| Rate for Payer: GEHA Medicare |
$5.04
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$42.30
|
| Rate for Payer: Humana ChoiceCare |
$5.54
|
| Rate for Payer: Humana Medicare Advantage |
$5.04
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.34
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.04
|
| Rate for Payer: Multiplan All |
$42.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.57
|
| Rate for Payer: OMNI Networks Commercial |
$32.90
|
| Rate for Payer: One Health Plan PPO/POS |
$42.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.47
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.34
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$44.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10.08
|
| Rate for Payer: Three Rivers Provider Network All |
$35.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.94
|
| Rate for Payer: United Healthcare Commercial |
$39.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$43.71
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.04
|
| Rate for Payer: Zelis Auto |
$18.80
|
| Rate for Payer: Zelis Medicare |
$4.28
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.05
|
| Rate for Payer: Zelis Worker's Compensation |
$4.06
|
|
|
TEST TEST
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
CPT 82948
|
| Hospital Charge Code |
7300100
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$44.65 |
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$39.95
|
| Rate for Payer: First Health Commercial |
$42.30
|
| Rate for Payer: First Health Workers Compensation |
$5.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$42.30
|
| Rate for Payer: GEHA Commercial |
$32.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$42.30
|
| Rate for Payer: Multiplan All |
$42.77
|
| Rate for Payer: OMNI Networks Commercial |
$32.90
|
| Rate for Payer: One Health Plan PPO/POS |
$42.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$44.65
|
| Rate for Payer: Three Rivers Provider Network All |
$35.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$43.71
|
| Rate for Payer: Zelis Auto |
$18.80
|
| Rate for Payer: Zelis Worker's Compensation |
$4.06
|
|
|
tetanus antitoxoid IgG ab REF163691
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2299845
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$100.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$21.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.99
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$134.40
|
| Rate for Payer: GEHA Medicare |
$14.99
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Humana ChoiceCare |
$16.49
|
| Rate for Payer: Humana Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$25.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.99
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.48
|
| Rate for Payer: OMNI Networks Commercial |
$117.60
|
| Rate for Payer: One Health Plan PPO/POS |
$151.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$25.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.98
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.69
|
| Rate for Payer: United Healthcare Commercial |
$142.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.99
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Medicare |
$12.74
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.99
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
tetanus antitoxoid IgG ab REF163691
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2299845
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$117.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: OMNI Networks Commercial |
$117.60
|
| Rate for Payer: One Health Plan PPO/POS |
$151.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
tetanus/diphtheria ab profile REF163253
|
Facility
|
IP
|
$217.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2299846
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$206.15 |
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$184.45
|
| Rate for Payer: First Health Commercial |
$195.30
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$195.30
|
| Rate for Payer: GEHA Commercial |
$151.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$195.30
|
| Rate for Payer: Multiplan All |
$197.47
|
| Rate for Payer: OMNI Networks Commercial |
$151.90
|
| Rate for Payer: One Health Plan PPO/POS |
$195.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$206.15
|
| Rate for Payer: Three Rivers Provider Network All |
$162.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$201.81
|
| Rate for Payer: Zelis Auto |
$86.80
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
tetanus/diphtheria ab profile REF163253
|
Facility
|
OP
|
$217.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2299846
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$206.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$21.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.99
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$184.45
|
| Rate for Payer: First Health Commercial |
$195.30
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$195.30
|
| Rate for Payer: GEHA Commercial |
$173.60
|
| Rate for Payer: GEHA Medicare |
$14.99
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$195.30
|
| Rate for Payer: Humana ChoiceCare |
$16.49
|
| Rate for Payer: Humana Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$25.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.99
|
| Rate for Payer: Multiplan All |
$197.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.48
|
| Rate for Payer: OMNI Networks Commercial |
$151.90
|
| Rate for Payer: One Health Plan PPO/POS |
$195.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$25.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$206.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.98
|
| Rate for Payer: Three Rivers Provider Network All |
$162.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.69
|
| Rate for Payer: United Healthcare Commercial |
$184.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$201.81
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.99
|
| Rate for Payer: Zelis Auto |
$86.80
|
| Rate for Payer: Zelis Medicare |
$12.74
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.99
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
TETANUS-DIPHTHERIA TOXOIDS
|
Facility
|
IP
|
$199.98
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
7290714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.59 |
| Max. Negotiated Rate |
$189.98 |
| Rate for Payer: Cash Price |
$119.99
|
| Rate for Payer: Cigna Commercial |
$169.98
|
| Rate for Payer: First Health Commercial |
$179.98
|
| Rate for Payer: First Health Workers Compensation |
$77.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$179.98
|
| Rate for Payer: GEHA Commercial |
$139.99
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$179.98
|
| Rate for Payer: Multiplan All |
$181.98
|
| Rate for Payer: OMNI Networks Commercial |
$139.99
|
| Rate for Payer: One Health Plan PPO/POS |
$179.98
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$189.98
|
| Rate for Payer: Three Rivers Provider Network All |
$149.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$185.98
|
| Rate for Payer: Zelis Auto |
$79.99
|
| Rate for Payer: Zelis Worker's Compensation |
$54.59
|
|
|
TETANUS-DIPHTHERIA TOXOIDS
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3300880
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.11 |
| Max. Negotiated Rate |
$189.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$169.15
|
| Rate for Payer: First Health Commercial |
$179.10
|
| Rate for Payer: First Health Workers Compensation |
$76.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$179.10
|
| Rate for Payer: GEHA Commercial |
$41.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$179.10
|
| Rate for Payer: Humana ChoiceCare |
$51.74
|
| Rate for Payer: Multiplan All |
$181.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$119.40
|
| Rate for Payer: OMNI Networks Commercial |
$139.30
|
| Rate for Payer: One Health Plan PPO/POS |
$179.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$189.05
|
| Rate for Payer: Three Rivers Provider Network All |
$149.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$175.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$49.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$185.07
|
| Rate for Payer: Zelis Auto |
$79.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$99.50
|
| Rate for Payer: Zelis Worker's Compensation |
$54.33
|
|
|
TETANUS-DIPHTHERIA TOXOIDS
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3300880
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.33 |
| Max. Negotiated Rate |
$189.05 |
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$169.15
|
| Rate for Payer: First Health Commercial |
$179.10
|
| Rate for Payer: First Health Workers Compensation |
$76.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$179.10
|
| Rate for Payer: GEHA Commercial |
$139.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$179.10
|
| Rate for Payer: Multiplan All |
$181.09
|
| Rate for Payer: OMNI Networks Commercial |
$139.30
|
| Rate for Payer: One Health Plan PPO/POS |
$179.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$189.05
|
| Rate for Payer: Three Rivers Provider Network All |
$149.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$185.07
|
| Rate for Payer: Zelis Auto |
$79.60
|
| Rate for Payer: Zelis Worker's Compensation |
$54.33
|
|
|
TETANUS-DIPHTHERIA TOXOIDS
|
Facility
|
OP
|
$199.98
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
7290714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.11 |
| Max. Negotiated Rate |
$189.98 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$119.99
|
| Rate for Payer: Cash Price |
$119.99
|
| Rate for Payer: Cash Price |
$119.99
|
| Rate for Payer: Cigna Commercial |
$169.98
|
| Rate for Payer: First Health Commercial |
$179.98
|
| Rate for Payer: First Health Workers Compensation |
$77.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$179.98
|
| Rate for Payer: GEHA Commercial |
$41.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$179.98
|
| Rate for Payer: Humana ChoiceCare |
$51.99
|
| Rate for Payer: Multiplan All |
$181.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$119.99
|
| Rate for Payer: OMNI Networks Commercial |
$139.99
|
| Rate for Payer: One Health Plan PPO/POS |
$179.98
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$189.98
|
| Rate for Payer: Three Rivers Provider Network All |
$149.99
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$175.98
|
| Rate for Payer: United Healthcare Managed Medicaid |
$49.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$185.98
|
| Rate for Payer: Zelis Auto |
$79.99
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$99.99
|
| Rate for Payer: Zelis Worker's Compensation |
$54.59
|
|
|
TETRACAINE 1% SPINAL
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
NDC 17478004532
|
| Hospital Charge Code |
3300881
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.83 |
| Max. Negotiated Rate |
$55.10 |
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$49.30
|
| Rate for Payer: First Health Commercial |
$52.20
|
| Rate for Payer: First Health Workers Compensation |
$22.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$52.20
|
| Rate for Payer: GEHA Commercial |
$40.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$52.20
|
| Rate for Payer: Multiplan All |
$52.78
|
| Rate for Payer: OMNI Networks Commercial |
$40.60
|
| Rate for Payer: One Health Plan PPO/POS |
$52.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$55.10
|
| Rate for Payer: Three Rivers Provider Network All |
$43.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.94
|
| Rate for Payer: Zelis Auto |
$23.20
|
| Rate for Payer: Zelis Worker's Compensation |
$15.83
|
|
|
TETRACAINE 1% SPINAL
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
NDC 17478004532
|
| Hospital Charge Code |
3300881
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.50 |
| Max. Negotiated Rate |
$55.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$34.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$49.30
|
| Rate for Payer: First Health Commercial |
$52.20
|
| Rate for Payer: First Health Workers Compensation |
$22.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$52.20
|
| Rate for Payer: GEHA Commercial |
$46.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$52.20
|
| Rate for Payer: Humana ChoiceCare |
$15.08
|
| Rate for Payer: Multiplan All |
$52.78
|
| Rate for Payer: New Mexico Health Connections Medicare |
$34.80
|
| Rate for Payer: OMNI Networks Commercial |
$40.60
|
| Rate for Payer: One Health Plan PPO/POS |
$52.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$55.10
|
| Rate for Payer: Three Rivers Provider Network All |
$43.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$51.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.94
|
| Rate for Payer: Zelis Auto |
$23.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$29.00
|
| Rate for Payer: Zelis Worker's Compensation |
$15.83
|
|
|
TETRACAINE HCL OPTH SOLN 0.5%
|
Facility
|
IP
|
$99.00
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
3300882
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.03 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$84.15
|
| Rate for Payer: First Health Commercial |
$89.10
|
| Rate for Payer: First Health Workers Compensation |
$38.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$89.10
|
| Rate for Payer: GEHA Commercial |
$69.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$89.10
|
| Rate for Payer: Multiplan All |
$90.09
|
| Rate for Payer: OMNI Networks Commercial |
$69.30
|
| Rate for Payer: One Health Plan PPO/POS |
$89.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$94.05
|
| Rate for Payer: Three Rivers Provider Network All |
$74.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$92.07
|
| Rate for Payer: Zelis Auto |
$39.60
|
| Rate for Payer: Zelis Worker's Compensation |
$27.03
|
|
|
TETRACAINE HCL OPTH SOLN 0.5%
|
Facility
|
OP
|
$99.00
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
3300882
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$84.15
|
| Rate for Payer: First Health Commercial |
$89.10
|
| Rate for Payer: First Health Workers Compensation |
$38.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$89.10
|
| Rate for Payer: GEHA Commercial |
$79.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$89.10
|
| Rate for Payer: Humana ChoiceCare |
$25.74
|
| Rate for Payer: Multiplan All |
$90.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$59.40
|
| Rate for Payer: OMNI Networks Commercial |
$69.30
|
| Rate for Payer: One Health Plan PPO/POS |
$89.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$94.05
|
| Rate for Payer: Three Rivers Provider Network All |
$74.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$87.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$24.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$92.07
|
| Rate for Payer: Zelis Auto |
$39.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$49.50
|
| Rate for Payer: Zelis Worker's Compensation |
$27.03
|
|
