|
TOBACCO USE CESSATION INTENSIVE >10 MINU
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
CPT 99407
|
| Hospital Charge Code |
9199514
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$23.48 |
| Max. Negotiated Rate |
$81.70 |
| 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: First Health Workers Compensation |
$33.20
|
| 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
|
| Rate for Payer: Zelis Worker's Compensation |
$23.48
|
|
|
TOBACCO USE CESSATION INTENSIVE >10 MINU
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
CPT 99407
|
| Hospital Charge Code |
9199514
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$23.48 |
| Max. Negotiated Rate |
$81.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$31.70
|
| 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 |
$31.70
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$25.11
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$28.29
|
| 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: First Health Workers Compensation |
$33.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$77.40
|
| Rate for Payer: GEHA Commercial |
$68.80
|
| Rate for Payer: GEHA Medicare |
$28.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$77.40
|
| Rate for Payer: Humana ChoiceCare |
$31.12
|
| Rate for Payer: Humana Medicare Advantage |
$28.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$47.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$25.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$28.29
|
| Rate for Payer: Multiplan All |
$78.26
|
| Rate for Payer: New Mexico Health Connections Medicare |
$48.09
|
| 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 |
$29.58
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$25.62
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$28.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$81.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$56.58
|
| Rate for Payer: Three Rivers Provider Network All |
$64.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$27.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$25.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$79.98
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$28.29
|
| Rate for Payer: Zelis Auto |
$34.40
|
| Rate for Payer: Zelis Medicare |
$24.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.95
|
| Rate for Payer: Zelis Worker's Compensation |
$23.48
|
|
|
TOBACCO USE CESSATION INTERMEDIATE 3-10
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT 99406
|
| Hospital Charge Code |
9199513
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$12.56 |
| Max. Negotiated Rate |
$56.58 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$31.70
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$31.70
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$25.11
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$28.29
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$36.80
|
| Rate for Payer: GEHA Medicare |
$28.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Humana ChoiceCare |
$31.12
|
| Rate for Payer: Humana Medicare Advantage |
$28.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$47.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$25.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$28.29
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$48.09
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$29.58
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$25.62
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$28.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$56.58
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$27.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$25.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$28.29
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Medicare |
$24.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.95
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
TOBACCO USE CESSATION INTERMEDIATE 3-10
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT 99406
|
| Hospital Charge Code |
20300035
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$12.56 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$32.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
TOBACCO USE CESSATION INTERMEDIATE 3-10
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT 99406
|
| Hospital Charge Code |
21600204
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$12.56 |
| Max. Negotiated Rate |
$56.58 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$31.70
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$31.70
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$25.11
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$28.29
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$36.80
|
| Rate for Payer: GEHA Medicare |
$28.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Humana ChoiceCare |
$31.12
|
| Rate for Payer: Humana Medicare Advantage |
$28.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$47.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$25.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$28.29
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$48.09
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$29.58
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$25.62
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$28.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$56.58
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$27.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$25.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$28.29
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Medicare |
$24.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.95
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
TOBACCO USE CESSATION INTERMEDIATE 3-10
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT 99406
|
| Hospital Charge Code |
9199513
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$12.56 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$32.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
TOBACCO USE CESSATION INTERMEDIATE 3-10
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
CPT 99406
|
| Hospital Charge Code |
1900035
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$23.75 |
| Max. Negotiated Rate |
$82.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$31.70
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$52.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$31.70
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$25.11
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$28.29
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$73.95
|
| Rate for Payer: First Health Commercial |
$78.30
|
| Rate for Payer: First Health Workers Compensation |
$33.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$78.30
|
| Rate for Payer: GEHA Commercial |
$69.60
|
| Rate for Payer: GEHA Medicare |
$28.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$78.30
|
| Rate for Payer: Humana ChoiceCare |
$31.12
|
| Rate for Payer: Humana Medicare Advantage |
$28.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$47.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$25.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$28.29
|
| Rate for Payer: Multiplan All |
$79.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$48.09
|
| Rate for Payer: OMNI Networks Commercial |
$60.90
|
| Rate for Payer: One Health Plan PPO/POS |
$78.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$29.58
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$25.62
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$28.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$82.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$56.58
|
| Rate for Payer: Three Rivers Provider Network All |
$65.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$27.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$25.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$80.91
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$28.29
|
| Rate for Payer: Zelis Auto |
$34.80
|
| Rate for Payer: Zelis Medicare |
$24.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.95
|
| Rate for Payer: Zelis Worker's Compensation |
$23.75
|
|
|
TOBACCO USE CESSATION INTERMEDIATE 3-10
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT 99406
|
| Hospital Charge Code |
21600204
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$12.56 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$32.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
TOBACCO USE CESSATION INTERMEDIATE 3-10
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT 99406
|
| Hospital Charge Code |
20300035
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$12.56 |
| Max. Negotiated Rate |
$56.58 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$31.70
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$31.70
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$25.11
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$28.29
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$36.80
|
| Rate for Payer: GEHA Medicare |
$28.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Humana ChoiceCare |
$31.12
|
| Rate for Payer: Humana Medicare Advantage |
$28.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$47.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$25.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$28.29
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$48.09
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$29.58
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$25.62
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$28.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$56.58
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$27.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$25.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$28.29
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Medicare |
$24.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.95
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
TOBACCO USE CESSATION INTERMEDIATE 3-10
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
CPT 99406
|
| Hospital Charge Code |
1900035
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$23.75 |
| Max. Negotiated Rate |
$82.65 |
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$73.95
|
| Rate for Payer: First Health Commercial |
$78.30
|
| Rate for Payer: First Health Workers Compensation |
$33.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$78.30
|
| Rate for Payer: GEHA Commercial |
$60.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$78.30
|
| Rate for Payer: Multiplan All |
$79.17
|
| Rate for Payer: OMNI Networks Commercial |
$60.90
|
| Rate for Payer: One Health Plan PPO/POS |
$78.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$82.65
|
| Rate for Payer: Three Rivers Provider Network All |
$65.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$80.91
|
| Rate for Payer: Zelis Auto |
$34.80
|
| Rate for Payer: Zelis Worker's Compensation |
$23.75
|
|
|
TOBRAMYCIN-DEXAMETH OPTH SUSP
|
Facility
|
OP
|
$474.00
|
|
|
Service Code
|
NDC 24208029505
|
| Hospital Charge Code |
3300900
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$118.50 |
| Max. Negotiated Rate |
$450.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$284.40
|
| Rate for Payer: Cash Price |
$284.40
|
| Rate for Payer: Cigna Commercial |
$402.90
|
| Rate for Payer: First Health Commercial |
$426.60
|
| Rate for Payer: First Health Workers Compensation |
$183.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$426.60
|
| Rate for Payer: GEHA Commercial |
$379.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$426.60
|
| Rate for Payer: Humana ChoiceCare |
$123.24
|
| Rate for Payer: Multiplan All |
$431.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$284.40
|
| Rate for Payer: OMNI Networks Commercial |
$331.80
|
| Rate for Payer: One Health Plan PPO/POS |
$426.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$450.30
|
| Rate for Payer: Three Rivers Provider Network All |
$355.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$417.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$118.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$440.82
|
| Rate for Payer: Zelis Auto |
$189.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$237.00
|
| Rate for Payer: Zelis Worker's Compensation |
$129.40
|
|
|
TOBRAMYCIN-DEXAMETH OPTH SUSP
|
Facility
|
IP
|
$474.00
|
|
|
Service Code
|
NDC 24208029505
|
| Hospital Charge Code |
3300900
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$129.40 |
| Max. Negotiated Rate |
$450.30 |
| Rate for Payer: Cash Price |
$284.40
|
| Rate for Payer: Cigna Commercial |
$402.90
|
| Rate for Payer: First Health Commercial |
$426.60
|
| Rate for Payer: First Health Workers Compensation |
$183.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$426.60
|
| Rate for Payer: GEHA Commercial |
$331.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$426.60
|
| Rate for Payer: Multiplan All |
$431.34
|
| Rate for Payer: OMNI Networks Commercial |
$331.80
|
| Rate for Payer: One Health Plan PPO/POS |
$426.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$450.30
|
| Rate for Payer: Three Rivers Provider Network All |
$355.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$440.82
|
| Rate for Payer: Zelis Auto |
$189.60
|
| Rate for Payer: Zelis Worker's Compensation |
$129.40
|
|
|
TOBRAMYCIN INJ POWDER VIAL 1.2GM
|
Facility
|
OP
|
$480.00
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
3302813
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$288.00
|
| Rate for Payer: Cash Price |
$288.00
|
| Rate for Payer: Cash Price |
$288.00
|
| Rate for Payer: Cigna Commercial |
$408.00
|
| Rate for Payer: First Health Commercial |
$432.00
|
| Rate for Payer: First Health Workers Compensation |
$185.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$432.00
|
| Rate for Payer: GEHA Commercial |
$2.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$432.00
|
| Rate for Payer: Humana ChoiceCare |
$124.80
|
| Rate for Payer: Multiplan All |
$436.80
|
| Rate for Payer: New Mexico Health Connections Medicare |
$288.00
|
| Rate for Payer: OMNI Networks Commercial |
$336.00
|
| Rate for Payer: One Health Plan PPO/POS |
$432.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$456.00
|
| Rate for Payer: Three Rivers Provider Network All |
$360.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$422.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$120.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$446.40
|
| Rate for Payer: Zelis Auto |
$192.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$240.00
|
| Rate for Payer: Zelis Worker's Compensation |
$131.04
|
|
|
TOBRAMYCIN INJ POWDER VIAL 1.2GM
|
Facility
|
IP
|
$480.00
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
302813
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$131.04 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Cash Price |
$288.00
|
| Rate for Payer: Cigna Commercial |
$408.00
|
| Rate for Payer: First Health Commercial |
$432.00
|
| Rate for Payer: First Health Workers Compensation |
$185.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$432.00
|
| Rate for Payer: GEHA Commercial |
$336.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$432.00
|
| Rate for Payer: Multiplan All |
$436.80
|
| Rate for Payer: OMNI Networks Commercial |
$336.00
|
| Rate for Payer: One Health Plan PPO/POS |
$432.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$456.00
|
| Rate for Payer: Three Rivers Provider Network All |
$360.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$446.40
|
| Rate for Payer: Zelis Auto |
$192.00
|
| Rate for Payer: Zelis Worker's Compensation |
$131.04
|
|
|
TOBRAMYCIN INJ POWDER VIAL 1.2GM
|
Facility
|
IP
|
$480.00
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
3302813
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$131.04 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Cash Price |
$288.00
|
| Rate for Payer: Cigna Commercial |
$408.00
|
| Rate for Payer: First Health Commercial |
$432.00
|
| Rate for Payer: First Health Workers Compensation |
$185.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$432.00
|
| Rate for Payer: GEHA Commercial |
$336.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$432.00
|
| Rate for Payer: Multiplan All |
$436.80
|
| Rate for Payer: OMNI Networks Commercial |
$336.00
|
| Rate for Payer: One Health Plan PPO/POS |
$432.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$456.00
|
| Rate for Payer: Three Rivers Provider Network All |
$360.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$446.40
|
| Rate for Payer: Zelis Auto |
$192.00
|
| Rate for Payer: Zelis Worker's Compensation |
$131.04
|
|
|
TOBRAMYCIN POWDER - 5GM
|
Facility
|
IP
|
$518.00
|
|
|
Service Code
|
NDC 38779031903
|
| Hospital Charge Code |
3301185
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$141.41 |
| Max. Negotiated Rate |
$492.10 |
| Rate for Payer: Cash Price |
$310.80
|
| Rate for Payer: Cigna Commercial |
$440.30
|
| Rate for Payer: First Health Commercial |
$466.20
|
| Rate for Payer: First Health Workers Compensation |
$200.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$466.20
|
| Rate for Payer: GEHA Commercial |
$362.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$466.20
|
| Rate for Payer: Multiplan All |
$471.38
|
| Rate for Payer: OMNI Networks Commercial |
$362.60
|
| Rate for Payer: One Health Plan PPO/POS |
$466.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$492.10
|
| Rate for Payer: Three Rivers Provider Network All |
$388.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$481.74
|
| Rate for Payer: Zelis Auto |
$207.20
|
| Rate for Payer: Zelis Worker's Compensation |
$141.41
|
|
|
TOBRAMYCIN POWDER - 5GM
|
Facility
|
OP
|
$518.00
|
|
|
Service Code
|
NDC 38779031903
|
| Hospital Charge Code |
3301185
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$129.50 |
| Max. Negotiated Rate |
$492.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$310.80
|
| Rate for Payer: Cash Price |
$310.80
|
| Rate for Payer: Cigna Commercial |
$440.30
|
| Rate for Payer: First Health Commercial |
$466.20
|
| Rate for Payer: First Health Workers Compensation |
$200.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$466.20
|
| Rate for Payer: GEHA Commercial |
$414.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$466.20
|
| Rate for Payer: Humana ChoiceCare |
$134.68
|
| Rate for Payer: Multiplan All |
$471.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$310.80
|
| Rate for Payer: OMNI Networks Commercial |
$362.60
|
| Rate for Payer: One Health Plan PPO/POS |
$466.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$492.10
|
| Rate for Payer: Three Rivers Provider Network All |
$388.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$455.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$129.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$481.74
|
| Rate for Payer: Zelis Auto |
$207.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$259.00
|
| Rate for Payer: Zelis Worker's Compensation |
$141.41
|
|
|
tobramycin serum peak REF007154
|
Facility
|
OP
|
$259.00
|
|
|
Service Code
|
CPT 80200
|
| Hospital Charge Code |
2299556
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$13.71 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$29.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$155.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$29.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$23.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$16.13
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$220.15
|
| Rate for Payer: First Health Commercial |
$233.10
|
| Rate for Payer: First Health Workers Compensation |
$29.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$233.10
|
| Rate for Payer: GEHA Commercial |
$207.20
|
| Rate for Payer: GEHA Medicare |
$16.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$233.10
|
| Rate for Payer: Humana ChoiceCare |
$17.74
|
| Rate for Payer: Humana Medicare Advantage |
$16.13
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$27.10
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$23.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$16.13
|
| Rate for Payer: Multiplan All |
$235.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.42
|
| Rate for Payer: OMNI Networks Commercial |
$181.30
|
| Rate for Payer: One Health Plan PPO/POS |
$233.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$27.10
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$23.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$16.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$246.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$32.26
|
| Rate for Payer: Three Rivers Provider Network All |
$194.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$15.81
|
| Rate for Payer: United Healthcare Commercial |
$220.15
|
| Rate for Payer: United Healthcare Managed Medicaid |
$23.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.13
|
| Rate for Payer: United Payors & United Providers UP&UP |
$240.87
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$16.13
|
| Rate for Payer: Zelis Auto |
$103.60
|
| Rate for Payer: Zelis Medicare |
$13.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$19.36
|
| Rate for Payer: Zelis Worker's Compensation |
$20.91
|
|
|
tobramycin serum peak REF007154
|
Facility
|
IP
|
$259.00
|
|
|
Service Code
|
CPT 80200
|
| Hospital Charge Code |
2299556
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$20.91 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$220.15
|
| Rate for Payer: First Health Commercial |
$233.10
|
| Rate for Payer: First Health Workers Compensation |
$29.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$233.10
|
| Rate for Payer: GEHA Commercial |
$181.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$233.10
|
| Rate for Payer: Multiplan All |
$235.69
|
| Rate for Payer: OMNI Networks Commercial |
$181.30
|
| Rate for Payer: One Health Plan PPO/POS |
$233.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$246.05
|
| Rate for Payer: Three Rivers Provider Network All |
$194.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$240.87
|
| Rate for Payer: Zelis Auto |
$103.60
|
| Rate for Payer: Zelis Worker's Compensation |
$20.91
|
|
|
tobramycin serum trough REF007155
|
Facility
|
IP
|
$259.00
|
|
|
Service Code
|
CPT 80200
|
| Hospital Charge Code |
2299555
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$20.91 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$220.15
|
| Rate for Payer: First Health Commercial |
$233.10
|
| Rate for Payer: First Health Workers Compensation |
$29.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$233.10
|
| Rate for Payer: GEHA Commercial |
$181.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$233.10
|
| Rate for Payer: Multiplan All |
$235.69
|
| Rate for Payer: OMNI Networks Commercial |
$181.30
|
| Rate for Payer: One Health Plan PPO/POS |
$233.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$246.05
|
| Rate for Payer: Three Rivers Provider Network All |
$194.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$240.87
|
| Rate for Payer: Zelis Auto |
$103.60
|
| Rate for Payer: Zelis Worker's Compensation |
$20.91
|
|
|
tobramycin serum trough REF007155
|
Facility
|
OP
|
$259.00
|
|
|
Service Code
|
CPT 80200
|
| Hospital Charge Code |
2299555
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$13.71 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$29.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$155.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$29.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$23.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$16.13
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$220.15
|
| Rate for Payer: First Health Commercial |
$233.10
|
| Rate for Payer: First Health Workers Compensation |
$29.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$233.10
|
| Rate for Payer: GEHA Commercial |
$207.20
|
| Rate for Payer: GEHA Medicare |
$16.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$233.10
|
| Rate for Payer: Humana ChoiceCare |
$17.74
|
| Rate for Payer: Humana Medicare Advantage |
$16.13
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$27.10
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$23.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$16.13
|
| Rate for Payer: Multiplan All |
$235.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.42
|
| Rate for Payer: OMNI Networks Commercial |
$181.30
|
| Rate for Payer: One Health Plan PPO/POS |
$233.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$27.10
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$23.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$16.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$246.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$32.26
|
| Rate for Payer: Three Rivers Provider Network All |
$194.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$15.81
|
| Rate for Payer: United Healthcare Commercial |
$220.15
|
| Rate for Payer: United Healthcare Managed Medicaid |
$23.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.13
|
| Rate for Payer: United Payors & United Providers UP&UP |
$240.87
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$16.13
|
| Rate for Payer: Zelis Auto |
$103.60
|
| Rate for Payer: Zelis Medicare |
$13.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$19.36
|
| Rate for Payer: Zelis Worker's Compensation |
$20.91
|
|
|
TOBRAMYCIN SULFATE INJ 80MG/2ML
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
3300898
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$2.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Humana ChoiceCare |
$5.20
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.00
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
|
TOBRAMYCIN SULFATE INJ 80MG/2ML
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
3300898
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$14.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
|
TOBRAMYCIN SULFATE OPTH SOLN 0.3%
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
NDC 70069013101
|
| Hospital Charge Code |
3300899
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$89.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$56.40
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$79.90
|
| Rate for Payer: First Health Commercial |
$84.60
|
| Rate for Payer: First Health Workers Compensation |
$36.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$84.60
|
| Rate for Payer: GEHA Commercial |
$75.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$84.60
|
| Rate for Payer: Humana ChoiceCare |
$24.44
|
| Rate for Payer: Multiplan All |
$85.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$56.40
|
| Rate for Payer: OMNI Networks Commercial |
$65.80
|
| Rate for Payer: One Health Plan PPO/POS |
$84.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$89.30
|
| Rate for Payer: Three Rivers Provider Network All |
$70.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$82.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$23.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$87.42
|
| Rate for Payer: Zelis Auto |
$37.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$47.00
|
| Rate for Payer: Zelis Worker's Compensation |
$25.66
|
|
|
TOBRAMYCIN SULFATE OPTH SOLN 0.3%
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
NDC 70069013101
|
| Hospital Charge Code |
3300899
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.66 |
| Max. Negotiated Rate |
$89.30 |
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$79.90
|
| Rate for Payer: First Health Commercial |
$84.60
|
| Rate for Payer: First Health Workers Compensation |
$36.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$84.60
|
| Rate for Payer: GEHA Commercial |
$65.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$84.60
|
| Rate for Payer: Multiplan All |
$85.54
|
| Rate for Payer: OMNI Networks Commercial |
$65.80
|
| Rate for Payer: One Health Plan PPO/POS |
$84.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$89.30
|
| Rate for Payer: Three Rivers Provider Network All |
$70.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$87.42
|
| Rate for Payer: Zelis Auto |
$37.60
|
| Rate for Payer: Zelis Worker's Compensation |
$25.66
|
|
