|
BUPRENORPHINE SL 2 MG TAB
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 00904715404
|
| Hospital Charge Code |
3303258
|
|
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 SL 2 MG TAB
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 00904715404
|
| Hospital Charge Code |
3303258
|
|
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
|
|
|
BuPROPion HCL 75 MG TAB
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 60505015801
|
| Hospital Charge Code |
3300125
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$8.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Humana ChoiceCare |
$2.86
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.60
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
BuPROPion HCL 75 MG TAB
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 60505015801
|
| Hospital Charge Code |
3300125
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$7.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
BuPROPion SR 100 MG TAB
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 43547028810
|
| Hospital Charge Code |
3300126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$14.25 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$12.75
|
| Rate for Payer: First Health Commercial |
$13.50
|
| Rate for Payer: First Health Workers Compensation |
$5.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$13.50
|
| Rate for Payer: GEHA Commercial |
$10.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$13.50
|
| Rate for Payer: Multiplan All |
$13.65
|
| Rate for Payer: OMNI Networks Commercial |
$10.50
|
| Rate for Payer: One Health Plan PPO/POS |
$13.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$14.25
|
| Rate for Payer: Three Rivers Provider Network All |
$11.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.95
|
| Rate for Payer: Zelis Auto |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.09
|
|
|
BuPROPion SR 100 MG TAB
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 43547028810
|
| Hospital Charge Code |
3300126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.75 |
| Max. Negotiated Rate |
$14.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$12.75
|
| Rate for Payer: First Health Commercial |
$13.50
|
| Rate for Payer: First Health Workers Compensation |
$5.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$13.50
|
| Rate for Payer: GEHA Commercial |
$12.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$13.50
|
| Rate for Payer: Humana ChoiceCare |
$3.90
|
| Rate for Payer: Multiplan All |
$13.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.00
|
| Rate for Payer: OMNI Networks Commercial |
$10.50
|
| Rate for Payer: One Health Plan PPO/POS |
$13.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$14.25
|
| Rate for Payer: Three Rivers Provider Network All |
$11.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.95
|
| Rate for Payer: Zelis Auto |
$6.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.50
|
| Rate for Payer: Zelis Worker's Compensation |
$4.09
|
|
|
BuPROPion SR 150 MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00173013555
|
| Hospital Charge Code |
3300127
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
BuPROPion SR 150 MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00173013555
|
| Hospital Charge Code |
3300127
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
BuPROPion XL 150MG TAB
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
NDC 50268014013
|
| Hospital Charge Code |
3300128
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.25 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22.20
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$29.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Humana ChoiceCare |
$9.62
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.20
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$32.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$18.50
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
BuPROPion XL 150MG TAB
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
NDC 50268014013
|
| Hospital Charge Code |
3300128
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$25.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
burcella ab, IgG REF164608
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 86622
|
| Hospital Charge Code |
2200617
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.59 |
| Max. Negotiated Rate |
$106.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$16.08
|
| 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 |
$16.08
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$12.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$8.93
|
| 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: First Health Workers Compensation |
$14.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$100.80
|
| Rate for Payer: GEHA Commercial |
$89.60
|
| Rate for Payer: GEHA Medicare |
$8.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$100.80
|
| Rate for Payer: Humana ChoiceCare |
$9.82
|
| Rate for Payer: Humana Medicare Advantage |
$8.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$15.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$13.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$8.93
|
| Rate for Payer: Multiplan All |
$101.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$15.18
|
| 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 |
$15.01
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$13.00
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$8.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$106.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$17.86
|
| Rate for Payer: Three Rivers Provider Network All |
$84.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8.75
|
| Rate for Payer: United Healthcare Commercial |
$95.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$104.16
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$8.93
|
| Rate for Payer: Zelis Auto |
$44.80
|
| Rate for Payer: Zelis Medicare |
$7.59
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.72
|
| Rate for Payer: Zelis Worker's Compensation |
$10.14
|
|
|
burcella ab, IgG REF164608
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 86622
|
| Hospital Charge Code |
2200617
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.14 |
| 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: First Health Workers Compensation |
$14.34
|
| 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
|
| Rate for Payer: Zelis Worker's Compensation |
$10.14
|
|
|
busPIRone 15MG TAB
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 51079096020
|
| Hospital Charge Code |
3301538
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Humana ChoiceCare |
$1.82
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.20
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
busPIRone 15MG TAB
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 51079096020
|
| Hospital Charge Code |
3301538
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$4.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
busPIRone HCL TAB 5MG
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 51079098520
|
| Hospital Charge Code |
3300129
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$8.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Humana ChoiceCare |
$2.86
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.60
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
busPIRone HCL TAB 5MG
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 51079098520
|
| Hospital Charge Code |
3300129
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$7.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
BUTALBITAL/APAP/CAFFEINE 50-300-40 MG
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 11534018701
|
| Hospital Charge Code |
3302914
|
|
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
|
|
|
BUTALBITAL/APAP/CAFFEINE 50-300-40 MG
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 11534018701
|
| Hospital Charge Code |
3302914
|
|
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
|
|
|
BUTAMBEN-TETRACAIN-BENZOCAINE SPRAY
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
NDC 10223020103
|
| Hospital Charge Code |
3300130
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$72.07 |
| Max. Negotiated Rate |
$250.80 |
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cigna Commercial |
$224.40
|
| Rate for Payer: First Health Commercial |
$237.60
|
| Rate for Payer: First Health Workers Compensation |
$101.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$237.60
|
| Rate for Payer: GEHA Commercial |
$184.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$237.60
|
| Rate for Payer: Multiplan All |
$240.24
|
| Rate for Payer: OMNI Networks Commercial |
$184.80
|
| Rate for Payer: One Health Plan PPO/POS |
$237.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$250.80
|
| Rate for Payer: Three Rivers Provider Network All |
$198.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$245.52
|
| Rate for Payer: Zelis Auto |
$105.60
|
| Rate for Payer: Zelis Worker's Compensation |
$72.07
|
|
|
BUTAMBEN-TETRACAIN-BENZOCAINE SPRAY
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
NDC 10223020103
|
| Hospital Charge Code |
3300130
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$66.00 |
| Max. Negotiated Rate |
$250.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$158.40
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cigna Commercial |
$224.40
|
| Rate for Payer: First Health Commercial |
$237.60
|
| Rate for Payer: First Health Workers Compensation |
$101.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$237.60
|
| Rate for Payer: GEHA Commercial |
$211.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$237.60
|
| Rate for Payer: Humana ChoiceCare |
$68.64
|
| Rate for Payer: Multiplan All |
$240.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$158.40
|
| Rate for Payer: OMNI Networks Commercial |
$184.80
|
| Rate for Payer: One Health Plan PPO/POS |
$237.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$250.80
|
| Rate for Payer: Three Rivers Provider Network All |
$198.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$232.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$66.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$245.52
|
| Rate for Payer: Zelis Auto |
$105.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$132.00
|
| Rate for Payer: Zelis Worker's Compensation |
$72.07
|
|
|
BUTTOCK FASCIOTOMY
|
Facility
|
OP
|
$1,853.00
|
|
|
Service Code
|
CPT 27027
|
| Hospital Charge Code |
6127027
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$505.87 |
| Max. Negotiated Rate |
$13,566.52 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,225.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,111.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,225.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,763.37
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6,783.26
|
| Rate for Payer: Cash Price |
$1,111.80
|
| Rate for Payer: Cash Price |
$1,111.80
|
| Rate for Payer: Cigna Commercial |
$1,575.05
|
| Rate for Payer: First Health Commercial |
$1,667.70
|
| Rate for Payer: First Health Workers Compensation |
$715.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,667.70
|
| Rate for Payer: GEHA Commercial |
$1,482.40
|
| Rate for Payer: GEHA Medicare |
$6,783.26
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,667.70
|
| Rate for Payer: Humana ChoiceCare |
$7,461.59
|
| Rate for Payer: Humana Medicare Advantage |
$6,783.26
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$11,395.88
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,799.28
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6,783.26
|
| Rate for Payer: Multiplan All |
$1,686.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11,531.54
|
| Rate for Payer: OMNI Networks Commercial |
$1,297.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,667.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,077.52
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,799.28
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6,783.26
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,760.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$13,566.52
|
| Rate for Payer: Three Rivers Provider Network All |
$1,389.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,647.59
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,799.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,783.26
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,723.29
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6,783.26
|
| Rate for Payer: Zelis Auto |
$741.20
|
| Rate for Payer: Zelis Medicare |
$5,765.77
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8,139.91
|
| Rate for Payer: Zelis Worker's Compensation |
$505.87
|
|
|
BUTTOCK FASCIOTOMY
|
Facility
|
IP
|
$1,853.00
|
|
|
Service Code
|
CPT 27027
|
| Hospital Charge Code |
6127027
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$505.87 |
| Max. Negotiated Rate |
$1,760.35 |
| Rate for Payer: Cash Price |
$1,111.80
|
| Rate for Payer: Cigna Commercial |
$1,575.05
|
| Rate for Payer: First Health Commercial |
$1,667.70
|
| Rate for Payer: First Health Workers Compensation |
$715.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,667.70
|
| Rate for Payer: GEHA Commercial |
$1,297.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,667.70
|
| Rate for Payer: Multiplan All |
$1,686.23
|
| Rate for Payer: OMNI Networks Commercial |
$1,297.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,667.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,760.35
|
| Rate for Payer: Three Rivers Provider Network All |
$1,389.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,723.29
|
| Rate for Payer: Zelis Auto |
$741.20
|
| Rate for Payer: Zelis Worker's Compensation |
$505.87
|
|
|
BUTTOCK FASCIOTOMY W/DBRDMT
|
Facility
|
IP
|
$2,093.00
|
|
|
Service Code
|
CPT 27057
|
| Hospital Charge Code |
6127057
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$571.39 |
| Max. Negotiated Rate |
$1,988.35 |
| Rate for Payer: Cash Price |
$1,255.80
|
| Rate for Payer: Cigna Commercial |
$1,779.05
|
| Rate for Payer: First Health Commercial |
$1,883.70
|
| Rate for Payer: First Health Workers Compensation |
$808.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,883.70
|
| Rate for Payer: GEHA Commercial |
$1,465.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,883.70
|
| Rate for Payer: Multiplan All |
$1,904.63
|
| Rate for Payer: OMNI Networks Commercial |
$1,465.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,883.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,988.35
|
| Rate for Payer: Three Rivers Provider Network All |
$1,569.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,946.49
|
| Rate for Payer: Zelis Auto |
$837.20
|
| Rate for Payer: Zelis Worker's Compensation |
$571.39
|
|
|
BUTTOCK FASCIOTOMY W/DBRDMT
|
Facility
|
OP
|
$2,093.00
|
|
|
Service Code
|
CPT 27057
|
| Hospital Charge Code |
6127057
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$571.39 |
| Max. Negotiated Rate |
$3,039.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,225.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,255.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,225.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,763.37
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,519.65
|
| Rate for Payer: Cash Price |
$1,255.80
|
| Rate for Payer: Cash Price |
$1,255.80
|
| Rate for Payer: Cigna Commercial |
$1,779.05
|
| Rate for Payer: First Health Commercial |
$1,883.70
|
| Rate for Payer: First Health Workers Compensation |
$808.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,883.70
|
| Rate for Payer: GEHA Commercial |
$1,674.40
|
| Rate for Payer: GEHA Medicare |
$1,519.65
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,883.70
|
| Rate for Payer: Humana ChoiceCare |
$1,671.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,519.65
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,553.01
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,799.28
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,519.65
|
| Rate for Payer: Multiplan All |
$1,904.63
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,583.41
|
| Rate for Payer: OMNI Networks Commercial |
$1,465.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,883.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,077.52
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,799.28
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,519.65
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,988.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,039.30
|
| Rate for Payer: Three Rivers Provider Network All |
$1,569.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,489.26
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,799.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,519.65
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,946.49
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,519.65
|
| Rate for Payer: Zelis Auto |
$837.20
|
| Rate for Payer: Zelis Medicare |
$1,291.70
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,823.58
|
| Rate for Payer: Zelis Worker's Compensation |
$571.39
|
|
|
BUTTON ENDO FIXATN 20MM
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
90008512
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$330.88 |
| Max. Negotiated Rate |
$1,151.40 |
| Rate for Payer: Cash Price |
$727.20
|
| Rate for Payer: Cigna Commercial |
$1,030.20
|
| Rate for Payer: First Health Commercial |
$1,090.80
|
| Rate for Payer: First Health Workers Compensation |
$467.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,090.80
|
| Rate for Payer: GEHA Commercial |
$848.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,090.80
|
| Rate for Payer: Multiplan All |
$1,102.92
|
| Rate for Payer: OMNI Networks Commercial |
$848.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,090.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,151.40
|
| Rate for Payer: Three Rivers Provider Network All |
$909.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,127.16
|
| Rate for Payer: Zelis Auto |
$484.80
|
| Rate for Payer: Zelis Worker's Compensation |
$330.88
|
|
