|
TOCILIZUMAB 162 MG/0.9 ML SUBQ SYR
|
Facility
|
OP
|
$4,038.00
|
|
|
Service Code
|
CPT J3262
|
| Hospital Charge Code |
3303078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.48 |
| Max. Negotiated Rate |
$3,836.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$5.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,422.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$5.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$4.48
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.71
|
| Rate for Payer: Cash Price |
$2,422.80
|
| Rate for Payer: Cash Price |
$2,422.80
|
| Rate for Payer: Cigna Commercial |
$3,432.30
|
| Rate for Payer: First Health Commercial |
$3,634.20
|
| Rate for Payer: First Health Workers Compensation |
$1,559.07
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,634.20
|
| Rate for Payer: GEHA Commercial |
$6.28
|
| Rate for Payer: GEHA Medicare |
$5.71
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,634.20
|
| Rate for Payer: Humana ChoiceCare |
$6.28
|
| Rate for Payer: Humana Medicare Advantage |
$5.71
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$9.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$4.57
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.71
|
| Rate for Payer: Multiplan All |
$3,674.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.71
|
| Rate for Payer: OMNI Networks Commercial |
$2,826.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,634.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$5.28
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$4.57
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.71
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,836.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11.42
|
| Rate for Payer: Three Rivers Provider Network All |
$3,028.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.71
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,755.34
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.71
|
| Rate for Payer: Zelis Auto |
$1,615.20
|
| Rate for Payer: Zelis Medicare |
$4.85
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.85
|
| Rate for Payer: Zelis Worker's Compensation |
$1,102.37
|
|
|
TOCILIZUMAB 162 MG/0.9 ML SUBQ SYR
|
Facility
|
IP
|
$4,038.00
|
|
|
Service Code
|
CPT J3262
|
| Hospital Charge Code |
3303078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,102.37 |
| Max. Negotiated Rate |
$3,836.10 |
| Rate for Payer: Cash Price |
$2,422.80
|
| Rate for Payer: Cigna Commercial |
$3,432.30
|
| Rate for Payer: First Health Commercial |
$3,634.20
|
| Rate for Payer: First Health Workers Compensation |
$1,559.07
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,634.20
|
| Rate for Payer: GEHA Commercial |
$2,826.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,634.20
|
| Rate for Payer: Multiplan All |
$3,674.58
|
| Rate for Payer: OMNI Networks Commercial |
$2,826.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,634.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,836.10
|
| Rate for Payer: Three Rivers Provider Network All |
$3,028.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,755.34
|
| Rate for Payer: Zelis Auto |
$1,615.20
|
| Rate for Payer: Zelis Worker's Compensation |
$1,102.37
|
|
|
TOCILIZUMAB 200 MG/10 ML INJ
|
Facility
|
OP
|
$4,184.00
|
|
|
Service Code
|
CPT J3262
|
| Hospital Charge Code |
3303106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.48 |
| Max. Negotiated Rate |
$3,974.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$5.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,510.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$5.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$4.48
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.71
|
| Rate for Payer: Cash Price |
$2,510.40
|
| Rate for Payer: Cash Price |
$2,510.40
|
| Rate for Payer: Cigna Commercial |
$3,556.40
|
| Rate for Payer: First Health Commercial |
$3,765.60
|
| Rate for Payer: First Health Workers Compensation |
$1,615.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,765.60
|
| Rate for Payer: GEHA Commercial |
$6.28
|
| Rate for Payer: GEHA Medicare |
$5.71
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,765.60
|
| Rate for Payer: Humana ChoiceCare |
$6.28
|
| Rate for Payer: Humana Medicare Advantage |
$5.71
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$9.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$4.57
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.71
|
| Rate for Payer: Multiplan All |
$3,807.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.71
|
| Rate for Payer: OMNI Networks Commercial |
$2,928.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,765.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$5.28
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$4.57
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.71
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,974.80
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11.42
|
| Rate for Payer: Three Rivers Provider Network All |
$3,138.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.71
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,891.12
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.71
|
| Rate for Payer: Zelis Auto |
$1,673.60
|
| Rate for Payer: Zelis Medicare |
$4.85
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.85
|
| Rate for Payer: Zelis Worker's Compensation |
$1,142.23
|
|
|
TOCILIZUMAB 200 MG/10 ML INJ
|
Facility
|
IP
|
$4,184.00
|
|
|
Service Code
|
CPT J3262
|
| Hospital Charge Code |
3303106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,142.23 |
| Max. Negotiated Rate |
$3,974.80 |
| Rate for Payer: Cash Price |
$2,510.40
|
| Rate for Payer: Cigna Commercial |
$3,556.40
|
| Rate for Payer: First Health Commercial |
$3,765.60
|
| Rate for Payer: First Health Workers Compensation |
$1,615.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,765.60
|
| Rate for Payer: GEHA Commercial |
$2,928.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,765.60
|
| Rate for Payer: Multiplan All |
$3,807.44
|
| Rate for Payer: OMNI Networks Commercial |
$2,928.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,765.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,974.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3,138.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,891.12
|
| Rate for Payer: Zelis Auto |
$1,673.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1,142.23
|
|
|
TOCILIZUMAB 400 MG/20 ML INJ
|
Facility
|
IP
|
$9,514.00
|
|
|
Service Code
|
CPT J3262
|
| Hospital Charge Code |
3302981
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,597.32 |
| Max. Negotiated Rate |
$9,038.30 |
| Rate for Payer: Cash Price |
$5,708.40
|
| Rate for Payer: Cigna Commercial |
$8,086.90
|
| Rate for Payer: First Health Commercial |
$8,562.60
|
| Rate for Payer: First Health Workers Compensation |
$3,673.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,562.60
|
| Rate for Payer: GEHA Commercial |
$6,659.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,562.60
|
| Rate for Payer: Multiplan All |
$8,657.74
|
| Rate for Payer: OMNI Networks Commercial |
$6,659.80
|
| Rate for Payer: One Health Plan PPO/POS |
$8,562.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,038.30
|
| Rate for Payer: Three Rivers Provider Network All |
$7,135.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,848.02
|
| Rate for Payer: Zelis Auto |
$3,805.60
|
| Rate for Payer: Zelis Worker's Compensation |
$2,597.32
|
|
|
TOCILIZUMAB 400 MG/20 ML INJ
|
Facility
|
OP
|
$9,514.00
|
|
|
Service Code
|
CPT J3262
|
| Hospital Charge Code |
3302981
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.48 |
| Max. Negotiated Rate |
$9,038.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$5.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,708.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$5.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$4.48
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.71
|
| Rate for Payer: Cash Price |
$5,708.40
|
| Rate for Payer: Cash Price |
$5,708.40
|
| Rate for Payer: Cigna Commercial |
$8,086.90
|
| Rate for Payer: First Health Commercial |
$8,562.60
|
| Rate for Payer: First Health Workers Compensation |
$3,673.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,562.60
|
| Rate for Payer: GEHA Commercial |
$6.28
|
| Rate for Payer: GEHA Medicare |
$5.71
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,562.60
|
| Rate for Payer: Humana ChoiceCare |
$6.28
|
| Rate for Payer: Humana Medicare Advantage |
$5.71
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$9.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$4.57
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.71
|
| Rate for Payer: Multiplan All |
$8,657.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.71
|
| Rate for Payer: OMNI Networks Commercial |
$6,659.80
|
| Rate for Payer: One Health Plan PPO/POS |
$8,562.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$5.28
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$4.57
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.71
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,038.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11.42
|
| Rate for Payer: Three Rivers Provider Network All |
$7,135.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.71
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,848.02
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.71
|
| Rate for Payer: Zelis Auto |
$3,805.60
|
| Rate for Payer: Zelis Medicare |
$4.85
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.85
|
| Rate for Payer: Zelis Worker's Compensation |
$2,597.32
|
|
|
TOCILIZUMAB 80 MG/4 ML INJ VIAL
|
Facility
|
IP
|
$2,120.00
|
|
|
Service Code
|
CPT J3262
|
| Hospital Charge Code |
3303115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$578.76 |
| Max. Negotiated Rate |
$2,014.00 |
| Rate for Payer: Cash Price |
$1,272.00
|
| Rate for Payer: Cigna Commercial |
$1,802.00
|
| Rate for Payer: First Health Commercial |
$1,908.00
|
| Rate for Payer: First Health Workers Compensation |
$818.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,908.00
|
| Rate for Payer: GEHA Commercial |
$1,484.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,908.00
|
| Rate for Payer: Multiplan All |
$1,929.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,484.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,908.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,014.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,590.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,971.60
|
| Rate for Payer: Zelis Auto |
$848.00
|
| Rate for Payer: Zelis Worker's Compensation |
$578.76
|
|
|
TOCILIZUMAB 80 MG/4 ML INJ VIAL
|
Facility
|
OP
|
$2,120.00
|
|
|
Service Code
|
CPT J3262
|
| Hospital Charge Code |
3303115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.48 |
| Max. Negotiated Rate |
$2,014.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$5.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,272.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$5.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$4.48
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.71
|
| Rate for Payer: Cash Price |
$1,272.00
|
| Rate for Payer: Cash Price |
$1,272.00
|
| Rate for Payer: Cigna Commercial |
$1,802.00
|
| Rate for Payer: First Health Commercial |
$1,908.00
|
| Rate for Payer: First Health Workers Compensation |
$818.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,908.00
|
| Rate for Payer: GEHA Commercial |
$6.28
|
| Rate for Payer: GEHA Medicare |
$5.71
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,908.00
|
| Rate for Payer: Humana ChoiceCare |
$6.28
|
| Rate for Payer: Humana Medicare Advantage |
$5.71
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$9.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$4.57
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.71
|
| Rate for Payer: Multiplan All |
$1,929.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.71
|
| Rate for Payer: OMNI Networks Commercial |
$1,484.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,908.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$5.28
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$4.57
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.71
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,014.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11.42
|
| Rate for Payer: Three Rivers Provider Network All |
$1,590.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.71
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,971.60
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.71
|
| Rate for Payer: Zelis Auto |
$848.00
|
| Rate for Payer: Zelis Medicare |
$4.85
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.85
|
| Rate for Payer: Zelis Worker's Compensation |
$578.76
|
|
|
TOE CREST PAD LARGE LEFT
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
90031202
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.25 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$34.20
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: First Health Commercial |
$51.30
|
| Rate for Payer: First Health Workers Compensation |
$22.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$51.30
|
| Rate for Payer: GEHA Commercial |
$45.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$51.30
|
| Rate for Payer: Humana ChoiceCare |
$14.82
|
| Rate for Payer: Multiplan All |
$51.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$34.20
|
| Rate for Payer: OMNI Networks Commercial |
$39.90
|
| Rate for Payer: One Health Plan PPO/POS |
$51.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$54.15
|
| Rate for Payer: Three Rivers Provider Network All |
$42.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$50.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.01
|
| Rate for Payer: Zelis Auto |
$22.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$28.50
|
| Rate for Payer: Zelis Worker's Compensation |
$15.56
|
|
|
TOE CREST PAD LARGE LEFT
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
90031202
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.56 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: First Health Commercial |
$51.30
|
| Rate for Payer: First Health Workers Compensation |
$22.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$51.30
|
| Rate for Payer: GEHA Commercial |
$39.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$51.30
|
| Rate for Payer: Multiplan All |
$51.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.90
|
| Rate for Payer: One Health Plan PPO/POS |
$51.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$54.15
|
| Rate for Payer: Three Rivers Provider Network All |
$42.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.01
|
| Rate for Payer: Zelis Auto |
$22.80
|
| Rate for Payer: Zelis Worker's Compensation |
$15.56
|
|
|
TOE CREST PAD LARGE RIGHT
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
90031203
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.56 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: First Health Commercial |
$51.30
|
| Rate for Payer: First Health Workers Compensation |
$22.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$51.30
|
| Rate for Payer: GEHA Commercial |
$39.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$51.30
|
| Rate for Payer: Multiplan All |
$51.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.90
|
| Rate for Payer: One Health Plan PPO/POS |
$51.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$54.15
|
| Rate for Payer: Three Rivers Provider Network All |
$42.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.01
|
| Rate for Payer: Zelis Auto |
$22.80
|
| Rate for Payer: Zelis Worker's Compensation |
$15.56
|
|
|
TOE CREST PAD LARGE RIGHT
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
90031203
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.25 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$34.20
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: First Health Commercial |
$51.30
|
| Rate for Payer: First Health Workers Compensation |
$22.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$51.30
|
| Rate for Payer: GEHA Commercial |
$45.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$51.30
|
| Rate for Payer: Humana ChoiceCare |
$14.82
|
| Rate for Payer: Multiplan All |
$51.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$34.20
|
| Rate for Payer: OMNI Networks Commercial |
$39.90
|
| Rate for Payer: One Health Plan PPO/POS |
$51.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$54.15
|
| Rate for Payer: Three Rivers Provider Network All |
$42.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$50.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.01
|
| Rate for Payer: Zelis Auto |
$22.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$28.50
|
| Rate for Payer: Zelis Worker's Compensation |
$15.56
|
|
|
TOE CREST PAD MED LEFT
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
90031205
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.25 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$34.20
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: First Health Commercial |
$51.30
|
| Rate for Payer: First Health Workers Compensation |
$22.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$51.30
|
| Rate for Payer: GEHA Commercial |
$45.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$51.30
|
| Rate for Payer: Humana ChoiceCare |
$14.82
|
| Rate for Payer: Multiplan All |
$51.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$34.20
|
| Rate for Payer: OMNI Networks Commercial |
$39.90
|
| Rate for Payer: One Health Plan PPO/POS |
$51.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$54.15
|
| Rate for Payer: Three Rivers Provider Network All |
$42.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$50.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.01
|
| Rate for Payer: Zelis Auto |
$22.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$28.50
|
| Rate for Payer: Zelis Worker's Compensation |
$15.56
|
|
|
TOE CREST PAD MED LEFT
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
90031205
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.56 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: First Health Commercial |
$51.30
|
| Rate for Payer: First Health Workers Compensation |
$22.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$51.30
|
| Rate for Payer: GEHA Commercial |
$39.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$51.30
|
| Rate for Payer: Multiplan All |
$51.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.90
|
| Rate for Payer: One Health Plan PPO/POS |
$51.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$54.15
|
| Rate for Payer: Three Rivers Provider Network All |
$42.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.01
|
| Rate for Payer: Zelis Auto |
$22.80
|
| Rate for Payer: Zelis Worker's Compensation |
$15.56
|
|
|
TOE CREST PAD MED RIGHT
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
90031204
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.25 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$34.20
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: First Health Commercial |
$51.30
|
| Rate for Payer: First Health Workers Compensation |
$22.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$51.30
|
| Rate for Payer: GEHA Commercial |
$45.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$51.30
|
| Rate for Payer: Humana ChoiceCare |
$14.82
|
| Rate for Payer: Multiplan All |
$51.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$34.20
|
| Rate for Payer: OMNI Networks Commercial |
$39.90
|
| Rate for Payer: One Health Plan PPO/POS |
$51.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$54.15
|
| Rate for Payer: Three Rivers Provider Network All |
$42.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$50.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.01
|
| Rate for Payer: Zelis Auto |
$22.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$28.50
|
| Rate for Payer: Zelis Worker's Compensation |
$15.56
|
|
|
TOE CREST PAD MED RIGHT
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
90031204
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.56 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: First Health Commercial |
$51.30
|
| Rate for Payer: First Health Workers Compensation |
$22.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$51.30
|
| Rate for Payer: GEHA Commercial |
$39.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$51.30
|
| Rate for Payer: Multiplan All |
$51.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.90
|
| Rate for Payer: One Health Plan PPO/POS |
$51.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$54.15
|
| Rate for Payer: Three Rivers Provider Network All |
$42.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.01
|
| Rate for Payer: Zelis Auto |
$22.80
|
| Rate for Payer: Zelis Worker's Compensation |
$15.56
|
|
|
TOE CREST PAD SMALL LEFT
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
90031200
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.25 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$34.20
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: First Health Commercial |
$51.30
|
| Rate for Payer: First Health Workers Compensation |
$22.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$51.30
|
| Rate for Payer: GEHA Commercial |
$45.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$51.30
|
| Rate for Payer: Humana ChoiceCare |
$14.82
|
| Rate for Payer: Multiplan All |
$51.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$34.20
|
| Rate for Payer: OMNI Networks Commercial |
$39.90
|
| Rate for Payer: One Health Plan PPO/POS |
$51.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$54.15
|
| Rate for Payer: Three Rivers Provider Network All |
$42.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$50.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.01
|
| Rate for Payer: Zelis Auto |
$22.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$28.50
|
| Rate for Payer: Zelis Worker's Compensation |
$15.56
|
|
|
TOE CREST PAD SMALL LEFT
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
90031200
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.56 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: First Health Commercial |
$51.30
|
| Rate for Payer: First Health Workers Compensation |
$22.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$51.30
|
| Rate for Payer: GEHA Commercial |
$39.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$51.30
|
| Rate for Payer: Multiplan All |
$51.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.90
|
| Rate for Payer: One Health Plan PPO/POS |
$51.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$54.15
|
| Rate for Payer: Three Rivers Provider Network All |
$42.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.01
|
| Rate for Payer: Zelis Auto |
$22.80
|
| Rate for Payer: Zelis Worker's Compensation |
$15.56
|
|
|
TOE CREST PAD SMALL RIGHT
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
90031201
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.56 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: First Health Commercial |
$51.30
|
| Rate for Payer: First Health Workers Compensation |
$22.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$51.30
|
| Rate for Payer: GEHA Commercial |
$39.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$51.30
|
| Rate for Payer: Multiplan All |
$51.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.90
|
| Rate for Payer: One Health Plan PPO/POS |
$51.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$54.15
|
| Rate for Payer: Three Rivers Provider Network All |
$42.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.01
|
| Rate for Payer: Zelis Auto |
$22.80
|
| Rate for Payer: Zelis Worker's Compensation |
$15.56
|
|
|
TOE CREST PAD SMALL RIGHT
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
90031201
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.25 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$34.20
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: First Health Commercial |
$51.30
|
| Rate for Payer: First Health Workers Compensation |
$22.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$51.30
|
| Rate for Payer: GEHA Commercial |
$45.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$51.30
|
| Rate for Payer: Humana ChoiceCare |
$14.82
|
| Rate for Payer: Multiplan All |
$51.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$34.20
|
| Rate for Payer: OMNI Networks Commercial |
$39.90
|
| Rate for Payer: One Health Plan PPO/POS |
$51.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$54.15
|
| Rate for Payer: Three Rivers Provider Network All |
$42.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$50.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.01
|
| Rate for Payer: Zelis Auto |
$22.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$28.50
|
| Rate for Payer: Zelis Worker's Compensation |
$15.56
|
|
|
TOE JOINT TRANSFER
|
Facility
|
IP
|
$6,998.00
|
|
|
Service Code
|
CPT 26556
|
| Hospital Charge Code |
6126556
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,910.45 |
| Max. Negotiated Rate |
$6,648.10 |
| Rate for Payer: Cash Price |
$4,198.80
|
| Rate for Payer: Cigna Commercial |
$5,948.30
|
| Rate for Payer: First Health Commercial |
$6,298.20
|
| Rate for Payer: First Health Workers Compensation |
$2,701.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,298.20
|
| Rate for Payer: GEHA Commercial |
$4,898.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,298.20
|
| Rate for Payer: Multiplan All |
$6,368.18
|
| Rate for Payer: OMNI Networks Commercial |
$4,898.60
|
| Rate for Payer: One Health Plan PPO/POS |
$6,298.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,648.10
|
| Rate for Payer: Three Rivers Provider Network All |
$5,248.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,508.14
|
| Rate for Payer: Zelis Auto |
$2,799.20
|
| Rate for Payer: Zelis Worker's Compensation |
$1,910.45
|
|
|
TOE JOINT TRANSFER
|
Facility
|
OP
|
$6,998.00
|
|
|
Service Code
|
CPT 26556
|
| Hospital Charge Code |
6126556
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,749.50 |
| Max. Negotiated Rate |
$6,648.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,198.80
|
| Rate for Payer: Cash Price |
$4,198.80
|
| Rate for Payer: Cigna Commercial |
$5,948.30
|
| Rate for Payer: First Health Commercial |
$6,298.20
|
| Rate for Payer: First Health Workers Compensation |
$2,701.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,298.20
|
| Rate for Payer: GEHA Commercial |
$5,598.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,298.20
|
| Rate for Payer: Humana ChoiceCare |
$1,819.48
|
| Rate for Payer: Multiplan All |
$6,368.18
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,198.80
|
| Rate for Payer: OMNI Networks Commercial |
$4,898.60
|
| Rate for Payer: One Health Plan PPO/POS |
$6,298.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,648.10
|
| Rate for Payer: Three Rivers Provider Network All |
$5,248.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,158.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,749.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,508.14
|
| Rate for Payer: Zelis Auto |
$2,799.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,499.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,910.45
|
|
|
TOLTERODINE TARTRATE CAP SR 2MG
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
NDC 00009519001
|
| Hospital Charge Code |
3300901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$49.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$44.20
|
| Rate for Payer: First Health Commercial |
$46.80
|
| Rate for Payer: First Health Workers Compensation |
$20.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$46.80
|
| Rate for Payer: GEHA Commercial |
$41.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$46.80
|
| Rate for Payer: Humana ChoiceCare |
$13.52
|
| Rate for Payer: Multiplan All |
$47.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.20
|
| Rate for Payer: OMNI Networks Commercial |
$36.40
|
| Rate for Payer: One Health Plan PPO/POS |
$46.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$49.40
|
| Rate for Payer: Three Rivers Provider Network All |
$39.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$45.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$48.36
|
| Rate for Payer: Zelis Auto |
$20.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$26.00
|
| Rate for Payer: Zelis Worker's Compensation |
$14.20
|
|
|
TOLTERODINE TARTRATE CAP SR 2MG
|
Facility
|
IP
|
$52.00
|
|
|
Service Code
|
NDC 00009519001
|
| Hospital Charge Code |
3300901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.20 |
| Max. Negotiated Rate |
$49.40 |
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$44.20
|
| Rate for Payer: First Health Commercial |
$46.80
|
| Rate for Payer: First Health Workers Compensation |
$20.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$46.80
|
| Rate for Payer: GEHA Commercial |
$36.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$46.80
|
| Rate for Payer: Multiplan All |
$47.32
|
| Rate for Payer: OMNI Networks Commercial |
$36.40
|
| Rate for Payer: One Health Plan PPO/POS |
$46.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$49.40
|
| Rate for Payer: Three Rivers Provider Network All |
$39.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$48.36
|
| Rate for Payer: Zelis Auto |
$20.80
|
| Rate for Payer: Zelis Worker's Compensation |
$14.20
|
|
|
TOLTERODINE TARTRATE CAP SR 4MG
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
NDC 00009519101
|
| Hospital Charge Code |
3300902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$49.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$44.20
|
| Rate for Payer: First Health Commercial |
$46.80
|
| Rate for Payer: First Health Workers Compensation |
$20.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$46.80
|
| Rate for Payer: GEHA Commercial |
$41.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$46.80
|
| Rate for Payer: Humana ChoiceCare |
$13.52
|
| Rate for Payer: Multiplan All |
$47.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.20
|
| Rate for Payer: OMNI Networks Commercial |
$36.40
|
| Rate for Payer: One Health Plan PPO/POS |
$46.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$49.40
|
| Rate for Payer: Three Rivers Provider Network All |
$39.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$45.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$48.36
|
| Rate for Payer: Zelis Auto |
$20.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$26.00
|
| Rate for Payer: Zelis Worker's Compensation |
$14.20
|
|
