|
BUNION SPLINT
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
CPT L3100
|
| Hospital Charge Code |
8230079
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$22.36 |
| Max. Negotiated Rate |
$81.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$78.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$51.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$78.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$62.22
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$73.10
|
| Rate for Payer: First Health Commercial |
$77.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$77.40
|
| Rate for Payer: GEHA Commercial |
$68.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$77.40
|
| Rate for Payer: Humana ChoiceCare |
$22.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$63.49
|
| Rate for Payer: Multiplan All |
$78.26
|
| Rate for Payer: New Mexico Health Connections Medicare |
$51.60
|
| Rate for Payer: OMNI Networks Commercial |
$60.20
|
| Rate for Payer: One Health Plan PPO/POS |
$77.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$73.30
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$63.49
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$81.70
|
| Rate for Payer: Three Rivers Provider Network All |
$64.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$75.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$63.49
|
| Rate for Payer: United Payors & United Providers UP&UP |
$79.98
|
| Rate for Payer: Zelis Auto |
$34.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$43.00
|
|
|
BUNION SPLINT
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
CPT L3100
|
| Hospital Charge Code |
8800021
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$22.36 |
| Max. Negotiated Rate |
$81.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$78.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$51.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$78.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$62.22
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$73.10
|
| Rate for Payer: First Health Commercial |
$77.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$77.40
|
| Rate for Payer: GEHA Commercial |
$68.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$77.40
|
| Rate for Payer: Humana ChoiceCare |
$22.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$63.49
|
| Rate for Payer: Multiplan All |
$78.26
|
| Rate for Payer: New Mexico Health Connections Medicare |
$51.60
|
| Rate for Payer: OMNI Networks Commercial |
$60.20
|
| Rate for Payer: One Health Plan PPO/POS |
$77.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$73.30
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$63.49
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$81.70
|
| Rate for Payer: Three Rivers Provider Network All |
$64.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$75.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$63.49
|
| Rate for Payer: United Payors & United Providers UP&UP |
$79.98
|
| Rate for Payer: Zelis Auto |
$34.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$43.00
|
|
|
BUNION SPLINT
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
CPT L3100
|
| Hospital Charge Code |
8800021
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$34.40 |
| Max. Negotiated Rate |
$81.70 |
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$73.10
|
| Rate for Payer: First Health Commercial |
$77.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$77.40
|
| Rate for Payer: GEHA Commercial |
$60.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$77.40
|
| Rate for Payer: Multiplan All |
$78.26
|
| Rate for Payer: OMNI Networks Commercial |
$60.20
|
| Rate for Payer: One Health Plan PPO/POS |
$77.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$81.70
|
| Rate for Payer: Three Rivers Provider Network All |
$64.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$79.98
|
| Rate for Payer: Zelis Auto |
$34.40
|
|
|
BUN (Vitros)
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
CPT 84520
|
| Hospital Charge Code |
2232192
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.36 |
| Max. Negotiated Rate |
$103.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$7.11
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$65.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$7.11
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$5.63
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3.95
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cigna Commercial |
$92.65
|
| Rate for Payer: First Health Commercial |
$98.10
|
| Rate for Payer: First Health Workers Compensation |
$7.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$98.10
|
| Rate for Payer: GEHA Commercial |
$87.20
|
| Rate for Payer: GEHA Medicare |
$3.95
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$98.10
|
| Rate for Payer: Humana ChoiceCare |
$4.34
|
| Rate for Payer: Humana Medicare Advantage |
$3.95
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$6.64
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$5.75
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3.95
|
| Rate for Payer: Multiplan All |
$99.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.71
|
| Rate for Payer: OMNI Networks Commercial |
$76.30
|
| Rate for Payer: One Health Plan PPO/POS |
$98.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$6.64
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$5.75
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3.95
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$103.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$7.90
|
| Rate for Payer: Three Rivers Provider Network All |
$81.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.87
|
| Rate for Payer: United Healthcare Commercial |
$92.65
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.95
|
| Rate for Payer: United Payors & United Providers UP&UP |
$101.37
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3.95
|
| Rate for Payer: Zelis Auto |
$43.60
|
| Rate for Payer: Zelis Medicare |
$3.36
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.74
|
| Rate for Payer: Zelis Worker's Compensation |
$5.57
|
|
|
BUN (Vitros)
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
CPT 84520
|
| Hospital Charge Code |
2232192
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.57 |
| Max. Negotiated Rate |
$103.55 |
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cigna Commercial |
$92.65
|
| Rate for Payer: First Health Commercial |
$98.10
|
| Rate for Payer: First Health Workers Compensation |
$7.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$98.10
|
| Rate for Payer: GEHA Commercial |
$76.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$98.10
|
| Rate for Payer: Multiplan All |
$99.19
|
| Rate for Payer: OMNI Networks Commercial |
$76.30
|
| Rate for Payer: One Health Plan PPO/POS |
$98.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$103.55
|
| Rate for Payer: Three Rivers Provider Network All |
$81.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$101.37
|
| Rate for Payer: Zelis Auto |
$43.60
|
| Rate for Payer: Zelis Worker's Compensation |
$5.57
|
|
|
BUPIVACAINE 0.25% 30ML INJ
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
CPT J0665
|
| Hospital Charge Code |
3300118
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| 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: 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 |
$0.01
|
| 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
|
|
|
BUPIVACAINE 0.25% 30ML INJ
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
CPT J0665
|
| Hospital Charge Code |
3300118
|
|
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
|
|
|
BUPIVACAINE 0.25%/EPI 1:200,000 10ML
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
NDC 00409904201
|
| Hospital Charge Code |
3305028
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$34.00
|
| Rate for Payer: First Health Commercial |
$36.00
|
| Rate for Payer: First Health Workers Compensation |
$15.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.00
|
| Rate for Payer: GEHA Commercial |
$32.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.00
|
| Rate for Payer: Humana ChoiceCare |
$10.40
|
| Rate for Payer: Multiplan All |
$36.40
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.00
|
| Rate for Payer: OMNI Networks Commercial |
$28.00
|
| Rate for Payer: One Health Plan PPO/POS |
$36.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.00
|
| Rate for Payer: Three Rivers Provider Network All |
$30.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$35.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$37.20
|
| Rate for Payer: Zelis Auto |
$16.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.00
|
| Rate for Payer: Zelis Worker's Compensation |
$10.92
|
|
|
BUPIVACAINE 0.25%/EPI 1:200,000 10ML
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
NDC 00409904201
|
| Hospital Charge Code |
3305028
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.92 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$34.00
|
| Rate for Payer: First Health Commercial |
$36.00
|
| Rate for Payer: First Health Workers Compensation |
$15.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.00
|
| Rate for Payer: GEHA Commercial |
$28.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.00
|
| Rate for Payer: Multiplan All |
$36.40
|
| Rate for Payer: OMNI Networks Commercial |
$28.00
|
| Rate for Payer: One Health Plan PPO/POS |
$36.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.00
|
| Rate for Payer: Three Rivers Provider Network All |
$30.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$37.20
|
| Rate for Payer: Zelis Auto |
$16.00
|
| Rate for Payer: Zelis Worker's Compensation |
$10.92
|
|
|
BUPIVACAINE 0.25% W/EPI INJ 30ML
|
Facility
|
OP
|
$132.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$125.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$79.20
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cigna Commercial |
$112.20
|
| Rate for Payer: First Health Commercial |
$118.80
|
| Rate for Payer: First Health Workers Compensation |
$50.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$118.80
|
| Rate for Payer: GEHA Commercial |
$105.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$118.80
|
| Rate for Payer: Humana ChoiceCare |
$34.32
|
| Rate for Payer: Multiplan All |
$120.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$79.20
|
| Rate for Payer: OMNI Networks Commercial |
$92.40
|
| Rate for Payer: One Health Plan PPO/POS |
$118.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$125.40
|
| Rate for Payer: Three Rivers Provider Network All |
$99.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$116.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$33.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$122.76
|
| Rate for Payer: Zelis Auto |
$52.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$66.00
|
| Rate for Payer: Zelis Worker's Compensation |
$36.04
|
|
|
BUPIVACAINE 0.25% W/EPI INJ 30ML
|
Facility
|
IP
|
$132.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.04 |
| Max. Negotiated Rate |
$125.40 |
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cigna Commercial |
$112.20
|
| Rate for Payer: First Health Commercial |
$118.80
|
| Rate for Payer: First Health Workers Compensation |
$50.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$118.80
|
| Rate for Payer: GEHA Commercial |
$92.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$118.80
|
| Rate for Payer: Multiplan All |
$120.12
|
| Rate for Payer: OMNI Networks Commercial |
$92.40
|
| Rate for Payer: One Health Plan PPO/POS |
$118.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$125.40
|
| Rate for Payer: Three Rivers Provider Network All |
$99.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$122.76
|
| Rate for Payer: Zelis Auto |
$52.80
|
| Rate for Payer: Zelis Worker's Compensation |
$36.04
|
|
|
BUPIVACAINE 0.25% W/EPI INJ 50ML
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
NDC 63323046157
|
| Hospital Charge Code |
3302682
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$22.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$20.40
|
| Rate for Payer: First Health Commercial |
$21.60
|
| Rate for Payer: First Health Workers Compensation |
$9.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$21.60
|
| Rate for Payer: GEHA Commercial |
$19.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$21.60
|
| Rate for Payer: Humana ChoiceCare |
$6.24
|
| Rate for Payer: Multiplan All |
$21.84
|
| Rate for Payer: New Mexico Health Connections Medicare |
$14.40
|
| Rate for Payer: OMNI Networks Commercial |
$16.80
|
| Rate for Payer: One Health Plan PPO/POS |
$21.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$22.80
|
| Rate for Payer: Three Rivers Provider Network All |
$18.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$21.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$22.32
|
| Rate for Payer: Zelis Auto |
$9.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6.55
|
|
|
BUPIVACAINE 0.25% W/EPI INJ 50ML
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
NDC 63323046157
|
| Hospital Charge Code |
3302682
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.55 |
| Max. Negotiated Rate |
$22.80 |
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$20.40
|
| Rate for Payer: First Health Commercial |
$21.60
|
| Rate for Payer: First Health Workers Compensation |
$9.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$21.60
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$21.60
|
| Rate for Payer: Multiplan All |
$21.84
|
| Rate for Payer: OMNI Networks Commercial |
$16.80
|
| Rate for Payer: One Health Plan PPO/POS |
$21.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$22.80
|
| Rate for Payer: Three Rivers Provider Network All |
$18.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$22.32
|
| Rate for Payer: Zelis Auto |
$9.60
|
| Rate for Payer: Zelis Worker's Compensation |
$6.55
|
|
|
BUPIVACAINE 0.5% 10 ML INJ SDV
|
Facility
|
IP
|
$9.80
|
|
|
Service Code
|
NDC 55150016910
|
| Hospital Charge Code |
3303175
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$9.31 |
| Rate for Payer: Cash Price |
$5.88
|
| Rate for Payer: Cigna Commercial |
$8.33
|
| Rate for Payer: First Health Commercial |
$8.82
|
| Rate for Payer: First Health Workers Compensation |
$3.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.82
|
| Rate for Payer: GEHA Commercial |
$6.86
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.82
|
| Rate for Payer: Multiplan All |
$8.92
|
| Rate for Payer: OMNI Networks Commercial |
$6.86
|
| Rate for Payer: One Health Plan PPO/POS |
$8.82
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.31
|
| Rate for Payer: Three Rivers Provider Network All |
$7.35
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.11
|
| Rate for Payer: Zelis Auto |
$3.92
|
| Rate for Payer: Zelis Worker's Compensation |
$2.68
|
|
|
BUPIVACAINE 0.5% 10 ML INJ SDV
|
Facility
|
OP
|
$9.80
|
|
|
Service Code
|
NDC 55150016910
|
| Hospital Charge Code |
3303175
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$9.31 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5.88
|
| Rate for Payer: Cash Price |
$5.88
|
| Rate for Payer: Cigna Commercial |
$8.33
|
| Rate for Payer: First Health Commercial |
$8.82
|
| Rate for Payer: First Health Workers Compensation |
$3.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.82
|
| Rate for Payer: GEHA Commercial |
$7.84
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.82
|
| Rate for Payer: Humana ChoiceCare |
$2.55
|
| Rate for Payer: Multiplan All |
$8.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5.88
|
| Rate for Payer: OMNI Networks Commercial |
$6.86
|
| Rate for Payer: One Health Plan PPO/POS |
$8.82
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.31
|
| Rate for Payer: Three Rivers Provider Network All |
$7.35
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8.62
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.11
|
| Rate for Payer: Zelis Auto |
$3.92
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.90
|
| Rate for Payer: Zelis Worker's Compensation |
$2.68
|
|
|
BUPIVACAINE 0.5% 30ML INJ
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300120
|
|
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
|
|
|
BUPIVACAINE 0.5% 30ML INJ
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300120
|
|
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
|
|
|
BUPIVACAINE 0.5% W/EPI 30ML INJ
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 63323046237
|
| Hospital Charge Code |
3300121
|
|
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
|
|
|
BUPIVACAINE 0.5% W/EPI 30ML INJ
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 63323046237
|
| Hospital Charge Code |
3300121
|
|
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
|
|
|
BUPIVACAINE 0.75% - SPINAL
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 00409361301
|
| Hospital Charge Code |
3300122
|
|
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
|
|
|
BUPIVACAINE 0.75% - SPINAL
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 00409361301
|
| Hospital Charge Code |
3300122
|
|
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
|
|
|
BUPRENORPHINE/NALOXONE 2-0.5 MG FILM
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 00781721664
|
| Hospital Charge Code |
3302939
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.75 |
| Max. Negotiated Rate |
$18.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$11.40
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: First Health Commercial |
$17.10
|
| Rate for Payer: First Health Workers Compensation |
$7.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$17.10
|
| Rate for Payer: GEHA Commercial |
$15.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17.10
|
| Rate for Payer: Humana ChoiceCare |
$4.94
|
| Rate for Payer: Multiplan All |
$17.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.40
|
| Rate for Payer: OMNI Networks Commercial |
$13.30
|
| Rate for Payer: One Health Plan PPO/POS |
$17.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18.05
|
| Rate for Payer: Three Rivers Provider Network All |
$14.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17.67
|
| Rate for Payer: Zelis Auto |
$7.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$9.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.19
|
|
|
BUPRENORPHINE/NALOXONE 2-0.5 MG FILM
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 00781721664
|
| Hospital Charge Code |
3302939
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.19 |
| Max. Negotiated Rate |
$18.05 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: First Health Commercial |
$17.10
|
| Rate for Payer: First Health Workers Compensation |
$7.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$17.10
|
| Rate for Payer: GEHA Commercial |
$13.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17.10
|
| Rate for Payer: Multiplan All |
$17.29
|
| Rate for Payer: OMNI Networks Commercial |
$13.30
|
| Rate for Payer: One Health Plan PPO/POS |
$17.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18.05
|
| Rate for Payer: Three Rivers Provider Network All |
$14.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17.67
|
| Rate for Payer: Zelis Auto |
$7.60
|
| Rate for Payer: Zelis Worker's Compensation |
$5.19
|
|
|
BUPRENORPHINE/NALOXONE 4-1 MG FILM
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00781722764
|
| Hospital Charge Code |
3303062
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$33.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$29.75
|
| Rate for Payer: First Health Commercial |
$31.50
|
| Rate for Payer: First Health Workers Compensation |
$13.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$31.50
|
| Rate for Payer: GEHA Commercial |
$28.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$31.50
|
| Rate for Payer: Humana ChoiceCare |
$9.10
|
| Rate for Payer: Multiplan All |
$31.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$21.00
|
| Rate for Payer: OMNI Networks Commercial |
$24.50
|
| Rate for Payer: One Health Plan PPO/POS |
$31.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$33.25
|
| Rate for Payer: Three Rivers Provider Network All |
$26.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$30.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$32.55
|
| Rate for Payer: Zelis Auto |
$14.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.50
|
| Rate for Payer: Zelis Worker's Compensation |
$9.55
|
|
|
BUPRENORPHINE/NALOXONE 4-1 MG FILM
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00781722764
|
| Hospital Charge Code |
3303062
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.55 |
| Max. Negotiated Rate |
$33.25 |
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$29.75
|
| Rate for Payer: First Health Commercial |
$31.50
|
| Rate for Payer: First Health Workers Compensation |
$13.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$31.50
|
| Rate for Payer: GEHA Commercial |
$24.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$31.50
|
| Rate for Payer: Multiplan All |
$31.85
|
| Rate for Payer: OMNI Networks Commercial |
$24.50
|
| Rate for Payer: One Health Plan PPO/POS |
$31.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$33.25
|
| Rate for Payer: Three Rivers Provider Network All |
$26.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$32.55
|
| Rate for Payer: Zelis Auto |
$14.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.55
|
|
