|
CAPSAICIN CREAM 0.025% 60 GM TUBE
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
NDC 00536252525
|
| Hospital Charge Code |
3302839
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.37 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$32.30
|
| Rate for Payer: First Health Commercial |
$34.20
|
| Rate for Payer: First Health Workers Compensation |
$14.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$34.20
|
| Rate for Payer: GEHA Commercial |
$26.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$34.20
|
| Rate for Payer: Multiplan All |
$34.58
|
| Rate for Payer: OMNI Networks Commercial |
$26.60
|
| Rate for Payer: One Health Plan PPO/POS |
$34.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$36.10
|
| Rate for Payer: Three Rivers Provider Network All |
$28.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$35.34
|
| Rate for Payer: Zelis Auto |
$15.20
|
| Rate for Payer: Zelis Worker's Compensation |
$10.37
|
|
|
CAPSAICIN CREAM 0.025% 60 GM TUBE
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
NDC 00536252525
|
| Hospital Charge Code |
3302839
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$32.30
|
| Rate for Payer: First Health Commercial |
$34.20
|
| Rate for Payer: First Health Workers Compensation |
$14.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$34.20
|
| Rate for Payer: GEHA Commercial |
$30.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$34.20
|
| Rate for Payer: Humana ChoiceCare |
$9.88
|
| Rate for Payer: Multiplan All |
$34.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.80
|
| Rate for Payer: OMNI Networks Commercial |
$26.60
|
| Rate for Payer: One Health Plan PPO/POS |
$34.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$36.10
|
| Rate for Payer: Three Rivers Provider Network All |
$28.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$33.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$35.34
|
| Rate for Payer: Zelis Auto |
$15.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$19.00
|
| Rate for Payer: Zelis Worker's Compensation |
$10.37
|
|
|
CAP SLOTTED ECLIPSE TRUNION 45MM
|
Facility
|
IP
|
$14,250.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003468
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,700.00 |
| Max. Negotiated Rate |
$13,537.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$11,400.00
|
| Rate for Payer: Cash Price |
$8,550.00
|
| Rate for Payer: Cash Price |
$8,550.00
|
| Rate for Payer: Cigna Commercial |
$12,112.50
|
| Rate for Payer: First Health Commercial |
$12,825.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12,825.00
|
| Rate for Payer: GEHA Commercial |
$9,975.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12,825.00
|
| Rate for Payer: Multiplan All |
$12,967.50
|
| Rate for Payer: OMNI Networks Commercial |
$9,975.00
|
| Rate for Payer: One Health Plan PPO/POS |
$12,825.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13,537.50
|
| Rate for Payer: Three Rivers Provider Network All |
$10,687.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13,252.50
|
| Rate for Payer: Zelis Auto |
$5,700.00
|
|
|
CAP SLOTTED ECLIPSE TRUNION 45MM
|
Facility
|
OP
|
$14,250.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003468
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,562.50 |
| Max. Negotiated Rate |
$13,537.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8,550.00
|
| Rate for Payer: Cash Price |
$8,550.00
|
| Rate for Payer: Cash Price |
$8,550.00
|
| Rate for Payer: Cigna Commercial |
$12,112.50
|
| Rate for Payer: First Health Commercial |
$12,825.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12,825.00
|
| Rate for Payer: GEHA Commercial |
$11,400.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12,825.00
|
| Rate for Payer: Humana ChoiceCare |
$3,705.00
|
| Rate for Payer: Multiplan All |
$12,967.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8,550.00
|
| Rate for Payer: OMNI Networks Commercial |
$9,975.00
|
| Rate for Payer: One Health Plan PPO/POS |
$12,825.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13,537.50
|
| Rate for Payer: Three Rivers Provider Network All |
$10,687.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12,540.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,562.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13,252.50
|
| Rate for Payer: Zelis Auto |
$5,700.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7,125.00
|
|
|
CAP SLOTTED ECLIPSE TRUNION 47MM
|
Facility
|
IP
|
$14,250.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003485
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,700.00 |
| Max. Negotiated Rate |
$13,537.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$11,400.00
|
| Rate for Payer: Cash Price |
$8,550.00
|
| Rate for Payer: Cash Price |
$8,550.00
|
| Rate for Payer: Cigna Commercial |
$12,112.50
|
| Rate for Payer: First Health Commercial |
$12,825.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12,825.00
|
| Rate for Payer: GEHA Commercial |
$9,975.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12,825.00
|
| Rate for Payer: Multiplan All |
$12,967.50
|
| Rate for Payer: OMNI Networks Commercial |
$9,975.00
|
| Rate for Payer: One Health Plan PPO/POS |
$12,825.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13,537.50
|
| Rate for Payer: Three Rivers Provider Network All |
$10,687.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13,252.50
|
| Rate for Payer: Zelis Auto |
$5,700.00
|
|
|
CAP SLOTTED ECLIPSE TRUNION 47MM
|
Facility
|
OP
|
$14,250.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003485
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,562.50 |
| Max. Negotiated Rate |
$13,537.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8,550.00
|
| Rate for Payer: Cash Price |
$8,550.00
|
| Rate for Payer: Cash Price |
$8,550.00
|
| Rate for Payer: Cigna Commercial |
$12,112.50
|
| Rate for Payer: First Health Commercial |
$12,825.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12,825.00
|
| Rate for Payer: GEHA Commercial |
$11,400.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12,825.00
|
| Rate for Payer: Humana ChoiceCare |
$3,705.00
|
| Rate for Payer: Multiplan All |
$12,967.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8,550.00
|
| Rate for Payer: OMNI Networks Commercial |
$9,975.00
|
| Rate for Payer: One Health Plan PPO/POS |
$12,825.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13,537.50
|
| Rate for Payer: Three Rivers Provider Network All |
$10,687.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12,540.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,562.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13,252.50
|
| Rate for Payer: Zelis Auto |
$5,700.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7,125.00
|
|
|
CAP SLOTTED ECLIPSE TRUNION 49MM
|
Facility
|
OP
|
$13,500.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003479
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,375.00 |
| Max. Negotiated Rate |
$12,825.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8,100.00
|
| Rate for Payer: Cash Price |
$8,100.00
|
| Rate for Payer: Cash Price |
$8,100.00
|
| Rate for Payer: Cigna Commercial |
$11,475.00
|
| Rate for Payer: First Health Commercial |
$12,150.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12,150.00
|
| Rate for Payer: GEHA Commercial |
$10,800.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12,150.00
|
| Rate for Payer: Humana ChoiceCare |
$3,510.00
|
| Rate for Payer: Multiplan All |
$12,285.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8,100.00
|
| Rate for Payer: OMNI Networks Commercial |
$9,450.00
|
| Rate for Payer: One Health Plan PPO/POS |
$12,150.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12,825.00
|
| Rate for Payer: Three Rivers Provider Network All |
$10,125.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11,880.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,375.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12,555.00
|
| Rate for Payer: Zelis Auto |
$5,400.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,750.00
|
|
|
CAP SLOTTED ECLIPSE TRUNION 49MM
|
Facility
|
IP
|
$13,500.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003479
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,400.00 |
| Max. Negotiated Rate |
$12,825.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10,800.00
|
| Rate for Payer: Cash Price |
$8,100.00
|
| Rate for Payer: Cash Price |
$8,100.00
|
| Rate for Payer: Cigna Commercial |
$11,475.00
|
| Rate for Payer: First Health Commercial |
$12,150.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12,150.00
|
| Rate for Payer: GEHA Commercial |
$9,450.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12,150.00
|
| Rate for Payer: Multiplan All |
$12,285.00
|
| Rate for Payer: OMNI Networks Commercial |
$9,450.00
|
| Rate for Payer: One Health Plan PPO/POS |
$12,150.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12,825.00
|
| Rate for Payer: Three Rivers Provider Network All |
$10,125.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12,555.00
|
| Rate for Payer: Zelis Auto |
$5,400.00
|
|
|
CAPSULE PILL SMART
|
Facility
|
OP
|
$2,413.00
|
|
| Hospital Charge Code |
90010722
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$603.25 |
| Max. Negotiated Rate |
$2,292.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,447.80
|
| Rate for Payer: Cash Price |
$1,447.80
|
| Rate for Payer: Cigna Commercial |
$2,051.05
|
| Rate for Payer: First Health Commercial |
$2,171.70
|
| Rate for Payer: First Health Workers Compensation |
$931.66
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,171.70
|
| Rate for Payer: GEHA Commercial |
$1,930.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,171.70
|
| Rate for Payer: Humana ChoiceCare |
$627.38
|
| Rate for Payer: Multiplan All |
$2,195.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,447.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,689.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,171.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,292.35
|
| Rate for Payer: Three Rivers Provider Network All |
$1,809.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,123.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$603.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,244.09
|
| Rate for Payer: Zelis Auto |
$965.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,206.50
|
| Rate for Payer: Zelis Worker's Compensation |
$658.75
|
|
|
CAPSULE PILL SMART
|
Facility
|
OP
|
$812.00
|
|
| Hospital Charge Code |
90010575
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$203.00 |
| Max. Negotiated Rate |
$771.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$487.20
|
| Rate for Payer: Cash Price |
$487.20
|
| Rate for Payer: Cigna Commercial |
$690.20
|
| Rate for Payer: First Health Commercial |
$730.80
|
| Rate for Payer: First Health Workers Compensation |
$313.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$730.80
|
| Rate for Payer: GEHA Commercial |
$649.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$730.80
|
| Rate for Payer: Humana ChoiceCare |
$211.12
|
| Rate for Payer: Multiplan All |
$738.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$487.20
|
| Rate for Payer: OMNI Networks Commercial |
$568.40
|
| Rate for Payer: One Health Plan PPO/POS |
$730.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$771.40
|
| Rate for Payer: Three Rivers Provider Network All |
$609.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$714.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$203.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$755.16
|
| Rate for Payer: Zelis Auto |
$324.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$406.00
|
| Rate for Payer: Zelis Worker's Compensation |
$221.68
|
|
|
CAPSULE PILL SMART
|
Facility
|
IP
|
$812.00
|
|
| Hospital Charge Code |
90010575
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$221.68 |
| Max. Negotiated Rate |
$771.40 |
| Rate for Payer: Cash Price |
$487.20
|
| Rate for Payer: Cigna Commercial |
$690.20
|
| Rate for Payer: First Health Commercial |
$730.80
|
| Rate for Payer: First Health Workers Compensation |
$313.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$730.80
|
| Rate for Payer: GEHA Commercial |
$568.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$730.80
|
| Rate for Payer: Multiplan All |
$738.92
|
| Rate for Payer: OMNI Networks Commercial |
$568.40
|
| Rate for Payer: One Health Plan PPO/POS |
$730.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$771.40
|
| Rate for Payer: Three Rivers Provider Network All |
$609.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$755.16
|
| Rate for Payer: Zelis Auto |
$324.80
|
| Rate for Payer: Zelis Worker's Compensation |
$221.68
|
|
|
CAPSULE PILL SMART
|
Facility
|
IP
|
$2,413.00
|
|
| Hospital Charge Code |
90010722
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$658.75 |
| Max. Negotiated Rate |
$2,292.35 |
| Rate for Payer: Cash Price |
$1,447.80
|
| Rate for Payer: Cigna Commercial |
$2,051.05
|
| Rate for Payer: First Health Commercial |
$2,171.70
|
| Rate for Payer: First Health Workers Compensation |
$931.66
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,171.70
|
| Rate for Payer: GEHA Commercial |
$1,689.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,171.70
|
| Rate for Payer: Multiplan All |
$2,195.83
|
| Rate for Payer: OMNI Networks Commercial |
$1,689.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,171.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,292.35
|
| Rate for Payer: Three Rivers Provider Network All |
$1,809.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,244.09
|
| Rate for Payer: Zelis Auto |
$965.20
|
| Rate for Payer: Zelis Worker's Compensation |
$658.75
|
|
|
CAPSULOTOMY IPHAL JOINT EACH JOINT SPX
|
Facility
|
OP
|
$3,856.00
|
|
|
Service Code
|
CPT 28272
|
| Hospital Charge Code |
9628272
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,052.69 |
| Max. Negotiated Rate |
$3,663.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,208.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,313.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,208.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,749.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,519.65
|
| Rate for Payer: Cash Price |
$2,313.60
|
| Rate for Payer: Cash Price |
$2,313.60
|
| Rate for Payer: Cigna Commercial |
$3,277.60
|
| Rate for Payer: First Health Commercial |
$3,470.40
|
| Rate for Payer: First Health Workers Compensation |
$1,488.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,470.40
|
| Rate for Payer: GEHA Commercial |
$3,084.80
|
| Rate for Payer: GEHA Medicare |
$1,519.65
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,470.40
|
| 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 |
$1,785.30
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,519.65
|
| Rate for Payer: Multiplan All |
$3,508.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,583.41
|
| Rate for Payer: OMNI Networks Commercial |
$2,699.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,470.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,061.37
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,785.30
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,519.65
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,663.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,039.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,892.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,489.26
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,785.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,519.65
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,586.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,519.65
|
| Rate for Payer: Zelis Auto |
$1,542.40
|
| 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 |
$1,052.69
|
|
|
CAPSULOTOMY IPHAL JOINT EACH JOINT SPX
|
Facility
|
IP
|
$3,856.00
|
|
|
Service Code
|
CPT 28272
|
| Hospital Charge Code |
9628272
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,052.69 |
| Max. Negotiated Rate |
$3,663.20 |
| Rate for Payer: Cash Price |
$2,313.60
|
| Rate for Payer: Cigna Commercial |
$3,277.60
|
| Rate for Payer: First Health Commercial |
$3,470.40
|
| Rate for Payer: First Health Workers Compensation |
$1,488.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,470.40
|
| Rate for Payer: GEHA Commercial |
$2,699.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,470.40
|
| Rate for Payer: Multiplan All |
$3,508.96
|
| Rate for Payer: OMNI Networks Commercial |
$2,699.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,470.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,663.20
|
| Rate for Payer: Three Rivers Provider Network All |
$2,892.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,586.08
|
| Rate for Payer: Zelis Auto |
$1,542.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1,052.69
|
|
|
CARBAMAZEPINE ER 100 MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 51672412301
|
| Hospital Charge Code |
3303099
|
|
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
|
|
|
CARBAMAZEPINE ER 100 MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 51672412301
|
| Hospital Charge Code |
3303099
|
|
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
|
|
|
carbamazepine, free REF702906
|
Facility
|
IP
|
$131.00
|
|
|
Service Code
|
CPT 80157
|
| Hospital Charge Code |
2200411
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.35 |
| Max. Negotiated Rate |
$124.45 |
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$111.35
|
| Rate for Payer: First Health Commercial |
$117.90
|
| Rate for Payer: First Health Workers Compensation |
$20.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$117.90
|
| Rate for Payer: GEHA Commercial |
$91.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$117.90
|
| Rate for Payer: Multiplan All |
$119.21
|
| Rate for Payer: OMNI Networks Commercial |
$91.70
|
| Rate for Payer: One Health Plan PPO/POS |
$117.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$124.45
|
| Rate for Payer: Three Rivers Provider Network All |
$98.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$121.83
|
| Rate for Payer: Zelis Auto |
$52.40
|
| Rate for Payer: Zelis Worker's Compensation |
$14.35
|
|
|
carbamazepine, free REF702906
|
Facility
|
OP
|
$131.00
|
|
|
Service Code
|
CPT 80157
|
| Hospital Charge Code |
2200411
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.26 |
| Max. Negotiated Rate |
$124.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$23.85
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$78.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$23.85
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$18.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$13.25
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$111.35
|
| Rate for Payer: First Health Commercial |
$117.90
|
| Rate for Payer: First Health Workers Compensation |
$20.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$117.90
|
| Rate for Payer: GEHA Commercial |
$104.80
|
| Rate for Payer: GEHA Medicare |
$13.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$117.90
|
| Rate for Payer: Humana ChoiceCare |
$14.57
|
| Rate for Payer: Humana Medicare Advantage |
$13.25
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$22.26
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$19.28
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$13.25
|
| Rate for Payer: Multiplan All |
$119.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.52
|
| Rate for Payer: OMNI Networks Commercial |
$91.70
|
| Rate for Payer: One Health Plan PPO/POS |
$117.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$22.26
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$19.28
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$13.25
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$124.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$26.50
|
| Rate for Payer: Three Rivers Provider Network All |
$98.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.98
|
| Rate for Payer: United Healthcare Commercial |
$111.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$19.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$121.83
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$13.25
|
| Rate for Payer: Zelis Auto |
$52.40
|
| Rate for Payer: Zelis Medicare |
$11.26
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.90
|
| Rate for Payer: Zelis Worker's Compensation |
$14.35
|
|
|
carBAMazepine TAB 200MG
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 00904617261
|
| Hospital Charge Code |
3300143
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$6.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
carBAMazepine TAB 200MG
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 00904617261
|
| Hospital Charge Code |
3300143
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$7.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Humana ChoiceCare |
$2.34
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5.40
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.50
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
carBAMazepine TAB SR 12HR 400MG
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
NDC 00781598801
|
| Hospital Charge Code |
3300144
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.28 |
| Max. Negotiated Rate |
$21.85 |
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cigna Commercial |
$19.55
|
| Rate for Payer: First Health Commercial |
$20.70
|
| Rate for Payer: First Health Workers Compensation |
$8.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$20.70
|
| Rate for Payer: GEHA Commercial |
$16.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$20.70
|
| Rate for Payer: Multiplan All |
$20.93
|
| Rate for Payer: OMNI Networks Commercial |
$16.10
|
| Rate for Payer: One Health Plan PPO/POS |
$20.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$21.85
|
| Rate for Payer: Three Rivers Provider Network All |
$17.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$21.39
|
| Rate for Payer: Zelis Auto |
$9.20
|
| Rate for Payer: Zelis Worker's Compensation |
$6.28
|
|
|
carBAMazepine TAB SR 12HR 400MG
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
NDC 00781598801
|
| Hospital Charge Code |
3300144
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.75 |
| Max. Negotiated Rate |
$21.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$13.80
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cigna Commercial |
$19.55
|
| Rate for Payer: First Health Commercial |
$20.70
|
| Rate for Payer: First Health Workers Compensation |
$8.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$20.70
|
| Rate for Payer: GEHA Commercial |
$18.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$20.70
|
| Rate for Payer: Humana ChoiceCare |
$5.98
|
| Rate for Payer: Multiplan All |
$20.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$13.80
|
| Rate for Payer: OMNI Networks Commercial |
$16.10
|
| Rate for Payer: One Health Plan PPO/POS |
$20.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$21.85
|
| Rate for Payer: Three Rivers Provider Network All |
$17.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$20.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$21.39
|
| Rate for Payer: Zelis Auto |
$9.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$11.50
|
| Rate for Payer: Zelis Worker's Compensation |
$6.28
|
|
|
CARBAMAZEPINE (Vitros)
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
CPT 80156
|
| Hospital Charge Code |
2232218
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$45.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.57
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: First Health Workers Compensation |
$25.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$68.40
|
| Rate for Payer: GEHA Commercial |
$60.80
|
| Rate for Payer: GEHA Medicare |
$14.57
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$68.40
|
| Rate for Payer: Humana ChoiceCare |
$16.03
|
| Rate for Payer: Humana Medicare Advantage |
$14.57
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$24.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.19
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.57
|
| Rate for Payer: Multiplan All |
$69.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.77
|
| Rate for Payer: OMNI Networks Commercial |
$53.20
|
| Rate for Payer: One Health Plan PPO/POS |
$68.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$24.47
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.19
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.57
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$72.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.14
|
| Rate for Payer: Three Rivers Provider Network All |
$57.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.28
|
| Rate for Payer: United Healthcare Commercial |
$64.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.57
|
| Rate for Payer: United Payors & United Providers UP&UP |
$70.68
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.57
|
| Rate for Payer: Zelis Auto |
$30.40
|
| Rate for Payer: Zelis Medicare |
$12.38
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.48
|
| Rate for Payer: Zelis Worker's Compensation |
$18.19
|
|
|
CARBAMAZEPINE (Vitros)
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
CPT 80156
|
| Hospital Charge Code |
2232218
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.19 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: First Health Workers Compensation |
$25.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$68.40
|
| Rate for Payer: GEHA Commercial |
$53.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$68.40
|
| Rate for Payer: Multiplan All |
$69.16
|
| Rate for Payer: OMNI Networks Commercial |
$53.20
|
| Rate for Payer: One Health Plan PPO/POS |
$68.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$72.20
|
| Rate for Payer: Three Rivers Provider Network All |
$57.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$70.68
|
| Rate for Payer: Zelis Auto |
$30.40
|
| Rate for Payer: Zelis Worker's Compensation |
$18.19
|
|
|
Carbamide Peroxide 6.5% Earwax Removal
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
NDC 78112073623
|
| Hospital Charge Code |
3301827
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$50.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$45.05
|
| Rate for Payer: First Health Commercial |
$47.70
|
| Rate for Payer: First Health Workers Compensation |
$20.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$47.70
|
| Rate for Payer: GEHA Commercial |
$42.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$47.70
|
| Rate for Payer: Humana ChoiceCare |
$13.78
|
| Rate for Payer: Multiplan All |
$48.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.80
|
| Rate for Payer: OMNI Networks Commercial |
$37.10
|
| Rate for Payer: One Health Plan PPO/POS |
$47.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$50.35
|
| Rate for Payer: Three Rivers Provider Network All |
$39.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$46.64
|
| Rate for Payer: United Healthcare Commercial |
$45.05
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$49.29
|
| Rate for Payer: Zelis Auto |
$21.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$26.50
|
| Rate for Payer: Zelis Worker's Compensation |
$14.47
|
|
