|
CARVEDILOL 3.125MG TAB
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 68382009201
|
| Hospital Charge Code |
3300151
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
CARVEDILOL 3.125MG TAB
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 68382009201
|
| Hospital Charge Code |
3300151
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Humana ChoiceCare |
$1.56
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.60
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
CARVEDILOL 6.25MG TAB
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 68382009301
|
| Hospital Charge Code |
3300152
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$17.10 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$15.30
|
| Rate for Payer: First Health Commercial |
$16.20
|
| Rate for Payer: First Health Workers Compensation |
$6.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$16.20
|
| Rate for Payer: GEHA Commercial |
$12.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$16.20
|
| Rate for Payer: Multiplan All |
$16.38
|
| Rate for Payer: OMNI Networks Commercial |
$12.60
|
| Rate for Payer: One Health Plan PPO/POS |
$16.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$17.10
|
| Rate for Payer: Three Rivers Provider Network All |
$13.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$16.74
|
| Rate for Payer: Zelis Auto |
$7.20
|
| Rate for Payer: Zelis Worker's Compensation |
$4.91
|
|
|
CARVEDILOL 6.25MG TAB
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 68382009301
|
| Hospital Charge Code |
3300152
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$17.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$15.30
|
| Rate for Payer: First Health Commercial |
$16.20
|
| Rate for Payer: First Health Workers Compensation |
$6.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$16.20
|
| Rate for Payer: GEHA Commercial |
$14.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$16.20
|
| Rate for Payer: Humana ChoiceCare |
$4.68
|
| Rate for Payer: Multiplan All |
$16.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10.80
|
| Rate for Payer: OMNI Networks Commercial |
$12.60
|
| Rate for Payer: One Health Plan PPO/POS |
$16.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$17.10
|
| Rate for Payer: Three Rivers Provider Network All |
$13.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$15.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$16.74
|
| Rate for Payer: Zelis Auto |
$7.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$9.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.91
|
|
|
CA SCREEN FLEXI SIGMOIDSCOPE
|
Facility
|
IP
|
$497.00
|
|
|
Service Code
|
CPT G0104
|
| Hospital Charge Code |
6100104
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$135.68 |
| Max. Negotiated Rate |
$472.15 |
| Rate for Payer: Cash Price |
$298.20
|
| Rate for Payer: Cigna Commercial |
$422.45
|
| Rate for Payer: First Health Commercial |
$447.30
|
| Rate for Payer: First Health Workers Compensation |
$191.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$447.30
|
| Rate for Payer: GEHA Commercial |
$347.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$447.30
|
| Rate for Payer: Multiplan All |
$452.27
|
| Rate for Payer: OMNI Networks Commercial |
$347.90
|
| Rate for Payer: One Health Plan PPO/POS |
$447.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$472.15
|
| Rate for Payer: Three Rivers Provider Network All |
$372.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$462.21
|
| Rate for Payer: Zelis Auto |
$198.80
|
| Rate for Payer: Zelis Worker's Compensation |
$135.68
|
|
|
CA SCREEN FLEXI SIGMOIDSCOPE
|
Facility
|
OP
|
$497.00
|
|
|
Service Code
|
CPT G0104
|
| Hospital Charge Code |
6100104
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$135.68 |
| Max. Negotiated Rate |
$1,731.42 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$376.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$298.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$376.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$298.18
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$865.71
|
| Rate for Payer: Cash Price |
$298.20
|
| Rate for Payer: Cash Price |
$298.20
|
| Rate for Payer: Cigna Commercial |
$422.45
|
| Rate for Payer: First Health Commercial |
$447.30
|
| Rate for Payer: First Health Workers Compensation |
$191.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$447.30
|
| Rate for Payer: GEHA Commercial |
$397.60
|
| Rate for Payer: GEHA Medicare |
$865.71
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$447.30
|
| Rate for Payer: Humana ChoiceCare |
$952.28
|
| Rate for Payer: Humana Medicare Advantage |
$865.71
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,454.39
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$304.25
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$865.71
|
| Rate for Payer: Multiplan All |
$452.27
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,471.71
|
| Rate for Payer: OMNI Networks Commercial |
$347.90
|
| Rate for Payer: One Health Plan PPO/POS |
$447.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$351.30
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$304.25
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$865.71
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$472.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,731.42
|
| Rate for Payer: Three Rivers Provider Network All |
$372.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$848.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$304.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$865.71
|
| Rate for Payer: United Payors & United Providers UP&UP |
$462.21
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$865.71
|
| Rate for Payer: Zelis Auto |
$198.80
|
| Rate for Payer: Zelis Medicare |
$735.85
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,038.85
|
| Rate for Payer: Zelis Worker's Compensation |
$135.68
|
|
|
CA SCREEN; PELVIC/BREAST EXAM
|
Facility
|
IP
|
$117.00
|
|
|
Service Code
|
CPT G0101
|
| Hospital Charge Code |
23500019
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$31.94 |
| Max. Negotiated Rate |
$111.15 |
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$99.45
|
| Rate for Payer: First Health Commercial |
$105.30
|
| Rate for Payer: First Health Workers Compensation |
$45.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$105.30
|
| Rate for Payer: GEHA Commercial |
$81.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$105.30
|
| Rate for Payer: Multiplan All |
$106.47
|
| Rate for Payer: OMNI Networks Commercial |
$81.90
|
| Rate for Payer: One Health Plan PPO/POS |
$105.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$111.15
|
| Rate for Payer: Three Rivers Provider Network All |
$87.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$108.81
|
| Rate for Payer: Zelis Auto |
$46.80
|
| Rate for Payer: Zelis Worker's Compensation |
$31.94
|
|
|
CA SCREEN; PELVIC/BREAST EXAM
|
Facility
|
OP
|
$117.00
|
|
|
Service Code
|
CPT G0101
|
| Hospital Charge Code |
23500019
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$29.25 |
| Max. Negotiated Rate |
$175.66 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$70.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$87.83
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$99.45
|
| Rate for Payer: First Health Commercial |
$105.30
|
| Rate for Payer: First Health Workers Compensation |
$45.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$105.30
|
| Rate for Payer: GEHA Commercial |
$93.60
|
| Rate for Payer: GEHA Medicare |
$87.83
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$105.30
|
| Rate for Payer: Humana ChoiceCare |
$96.61
|
| Rate for Payer: Humana Medicare Advantage |
$87.83
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$147.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$87.83
|
| Rate for Payer: Multiplan All |
$106.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$149.31
|
| Rate for Payer: OMNI Networks Commercial |
$81.90
|
| Rate for Payer: One Health Plan PPO/POS |
$105.30
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$87.83
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$111.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$175.66
|
| Rate for Payer: Three Rivers Provider Network All |
$87.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$86.07
|
| Rate for Payer: United Healthcare Managed Medicaid |
$29.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$87.83
|
| Rate for Payer: United Payors & United Providers UP&UP |
$108.81
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$87.83
|
| Rate for Payer: Zelis Auto |
$46.80
|
| Rate for Payer: Zelis Medicare |
$74.66
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$105.40
|
| Rate for Payer: Zelis Worker's Compensation |
$31.94
|
|
|
CASHEW NUT IGE
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299634
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.22
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: GEHA Medicare |
$5.22
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.22
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.76
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.59
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.22
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10.44
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.12
|
| Rate for Payer: United Healthcare Commercial |
$47.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.22
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Medicare |
$4.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.26
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
CASHEW NUT IGE
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299634
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
CASIRIVIMAB 300 MG/2.5 ML SUBQ INJ
|
Facility
|
OP
|
$1,370.00
|
|
|
Service Code
|
CPT M0243
|
| Hospital Charge Code |
3303074
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$356.20 |
| Max. Negotiated Rate |
$1,301.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$715.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$822.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$715.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$566.82
|
| Rate for Payer: Cash Price |
$822.00
|
| Rate for Payer: Cash Price |
$822.00
|
| Rate for Payer: Cigna Commercial |
$1,164.50
|
| Rate for Payer: First Health Commercial |
$1,233.00
|
| Rate for Payer: First Health Workers Compensation |
$528.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,233.00
|
| Rate for Payer: GEHA Commercial |
$1,096.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,233.00
|
| Rate for Payer: Humana ChoiceCare |
$356.20
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$578.36
|
| Rate for Payer: Multiplan All |
$1,246.70
|
| Rate for Payer: New Mexico Health Connections Medicare |
$822.00
|
| Rate for Payer: OMNI Networks Commercial |
$959.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,233.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$667.80
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$578.36
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,301.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,027.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,205.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$578.36
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,274.10
|
| Rate for Payer: Zelis Auto |
$548.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$685.00
|
| Rate for Payer: Zelis Worker's Compensation |
$374.01
|
|
|
CASIRIVIMAB 300 MG/2.5 ML SUBQ INJ
|
Facility
|
IP
|
$1,370.00
|
|
|
Service Code
|
CPT M0243
|
| Hospital Charge Code |
3303074
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$374.01 |
| Max. Negotiated Rate |
$1,301.50 |
| Rate for Payer: Cash Price |
$822.00
|
| Rate for Payer: Cigna Commercial |
$1,164.50
|
| Rate for Payer: First Health Commercial |
$1,233.00
|
| Rate for Payer: First Health Workers Compensation |
$528.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,233.00
|
| Rate for Payer: GEHA Commercial |
$959.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,233.00
|
| Rate for Payer: Multiplan All |
$1,246.70
|
| Rate for Payer: OMNI Networks Commercial |
$959.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,233.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,301.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,027.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,274.10
|
| Rate for Payer: Zelis Auto |
$548.00
|
| Rate for Payer: Zelis Worker's Compensation |
$374.01
|
|
|
CASIRIVIMAB 600 MG/5 ML SUBQ INJ
|
Facility
|
IP
|
$1,370.00
|
|
|
Service Code
|
CPT M0243
|
| Hospital Charge Code |
3303069
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$374.01 |
| Max. Negotiated Rate |
$1,301.50 |
| Rate for Payer: Cash Price |
$822.00
|
| Rate for Payer: Cigna Commercial |
$1,164.50
|
| Rate for Payer: First Health Commercial |
$1,233.00
|
| Rate for Payer: First Health Workers Compensation |
$528.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,233.00
|
| Rate for Payer: GEHA Commercial |
$959.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,233.00
|
| Rate for Payer: Multiplan All |
$1,246.70
|
| Rate for Payer: OMNI Networks Commercial |
$959.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,233.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,301.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,027.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,274.10
|
| Rate for Payer: Zelis Auto |
$548.00
|
| Rate for Payer: Zelis Worker's Compensation |
$374.01
|
|
|
CASIRIVIMAB 600 MG/5 ML SUBQ INJ
|
Facility
|
OP
|
$1,370.00
|
|
|
Service Code
|
CPT M0243
|
| Hospital Charge Code |
3303069
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$356.20 |
| Max. Negotiated Rate |
$1,301.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$715.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$822.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$715.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$566.82
|
| Rate for Payer: Cash Price |
$822.00
|
| Rate for Payer: Cash Price |
$822.00
|
| Rate for Payer: Cigna Commercial |
$1,164.50
|
| Rate for Payer: First Health Commercial |
$1,233.00
|
| Rate for Payer: First Health Workers Compensation |
$528.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,233.00
|
| Rate for Payer: GEHA Commercial |
$1,096.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,233.00
|
| Rate for Payer: Humana ChoiceCare |
$356.20
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$578.36
|
| Rate for Payer: Multiplan All |
$1,246.70
|
| Rate for Payer: New Mexico Health Connections Medicare |
$822.00
|
| Rate for Payer: OMNI Networks Commercial |
$959.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,233.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$667.80
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$578.36
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,301.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,027.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,205.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$578.36
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,274.10
|
| Rate for Payer: Zelis Auto |
$548.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$685.00
|
| Rate for Payer: Zelis Worker's Compensation |
$374.01
|
|
|
CASTOR OIL
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
NDC 00395051596
|
| Hospital Charge Code |
3300154
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.75 |
| Max. Negotiated Rate |
$29.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$18.60
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$26.35
|
| Rate for Payer: First Health Commercial |
$27.90
|
| Rate for Payer: First Health Workers Compensation |
$11.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.90
|
| Rate for Payer: GEHA Commercial |
$24.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.90
|
| Rate for Payer: Humana ChoiceCare |
$8.06
|
| Rate for Payer: Multiplan All |
$28.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$18.60
|
| Rate for Payer: OMNI Networks Commercial |
$21.70
|
| Rate for Payer: One Health Plan PPO/POS |
$27.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$29.45
|
| Rate for Payer: Three Rivers Provider Network All |
$23.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$27.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$28.83
|
| Rate for Payer: Zelis Auto |
$12.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.50
|
| Rate for Payer: Zelis Worker's Compensation |
$8.46
|
|
|
CASTOR OIL
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
NDC 00395051596
|
| Hospital Charge Code |
3300154
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$29.45 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$26.35
|
| Rate for Payer: First Health Commercial |
$27.90
|
| Rate for Payer: First Health Workers Compensation |
$11.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.90
|
| Rate for Payer: GEHA Commercial |
$21.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.90
|
| Rate for Payer: Multiplan All |
$28.21
|
| Rate for Payer: OMNI Networks Commercial |
$21.70
|
| Rate for Payer: One Health Plan PPO/POS |
$27.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$29.45
|
| Rate for Payer: Three Rivers Provider Network All |
$23.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$28.83
|
| Rate for Payer: Zelis Auto |
$12.40
|
| Rate for Payer: Zelis Worker's Compensation |
$8.46
|
|
|
CAST SPL SHRT ARM SPLNT ADLT F-GLSS
|
Facility
|
IP
|
$271.00
|
|
| Hospital Charge Code |
8230058
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$73.98 |
| Max. Negotiated Rate |
$257.45 |
| Rate for Payer: Cash Price |
$162.60
|
| Rate for Payer: Cigna Commercial |
$230.35
|
| Rate for Payer: First Health Commercial |
$243.90
|
| Rate for Payer: First Health Workers Compensation |
$104.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$243.90
|
| Rate for Payer: GEHA Commercial |
$189.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$243.90
|
| Rate for Payer: Multiplan All |
$246.61
|
| Rate for Payer: OMNI Networks Commercial |
$189.70
|
| Rate for Payer: One Health Plan PPO/POS |
$243.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$257.45
|
| Rate for Payer: Three Rivers Provider Network All |
$203.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$252.03
|
| Rate for Payer: Zelis Auto |
$108.40
|
| Rate for Payer: Zelis Worker's Compensation |
$73.98
|
|
|
CAST SPL SHRT ARM SPLNT ADLT F-GLSS
|
Facility
|
OP
|
$271.00
|
|
| Hospital Charge Code |
8230058
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$67.75 |
| Max. Negotiated Rate |
$257.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$162.60
|
| Rate for Payer: Cash Price |
$162.60
|
| Rate for Payer: Cigna Commercial |
$230.35
|
| Rate for Payer: First Health Commercial |
$243.90
|
| Rate for Payer: First Health Workers Compensation |
$104.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$243.90
|
| Rate for Payer: GEHA Commercial |
$216.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$243.90
|
| Rate for Payer: Humana ChoiceCare |
$70.46
|
| Rate for Payer: Multiplan All |
$246.61
|
| Rate for Payer: New Mexico Health Connections Medicare |
$162.60
|
| Rate for Payer: OMNI Networks Commercial |
$189.70
|
| Rate for Payer: One Health Plan PPO/POS |
$243.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$257.45
|
| Rate for Payer: Three Rivers Provider Network All |
$203.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$238.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$67.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$252.03
|
| Rate for Payer: Zelis Auto |
$108.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$135.50
|
| Rate for Payer: Zelis Worker's Compensation |
$73.98
|
|
|
CAST SUP LNG ARM SPLINT FBRG
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT Q4018
|
| Hospital Charge Code |
21600127
|
|
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
|
|
|
CAST SUP LNG ARM SPLINT FBRG
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT Q4018
|
| Hospital Charge Code |
21600127
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$11.50 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$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: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Humana ChoiceCare |
$11.96
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.60
|
| 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: TriWest Veterans Administration/VAPC3 |
$40.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$23.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
CAST SUP LNG ARM SPLNT PED F
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
CPT Q4020
|
| Hospital Charge Code |
21600128
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$6.25 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$21.25
|
| Rate for Payer: First Health Commercial |
$22.50
|
| Rate for Payer: First Health Workers Compensation |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22.50
|
| Rate for Payer: GEHA Commercial |
$20.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22.50
|
| Rate for Payer: Humana ChoiceCare |
$6.50
|
| Rate for Payer: Multiplan All |
$22.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$15.00
|
| Rate for Payer: OMNI Networks Commercial |
$17.50
|
| Rate for Payer: One Health Plan PPO/POS |
$22.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$23.75
|
| Rate for Payer: Three Rivers Provider Network All |
$18.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$22.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23.25
|
| Rate for Payer: Zelis Auto |
$10.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12.50
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
|
CAST SUP LNG ARM SPLNT PED F
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
CPT Q4020
|
| Hospital Charge Code |
21600128
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$6.83 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$21.25
|
| Rate for Payer: First Health Commercial |
$22.50
|
| Rate for Payer: First Health Workers Compensation |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22.50
|
| Rate for Payer: GEHA Commercial |
$17.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22.50
|
| Rate for Payer: Multiplan All |
$22.75
|
| Rate for Payer: OMNI Networks Commercial |
$17.50
|
| Rate for Payer: One Health Plan PPO/POS |
$22.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$23.75
|
| Rate for Payer: Three Rivers Provider Network All |
$18.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23.25
|
| Rate for Payer: Zelis Auto |
$10.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
|
CAST SUP LNG LEG SPLNT FBRGL
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
CPT Q4042
|
| Hospital Charge Code |
21600131
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$26.75 |
| Max. Negotiated Rate |
$101.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$90.95
|
| Rate for Payer: First Health Commercial |
$96.30
|
| Rate for Payer: First Health Workers Compensation |
$41.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$96.30
|
| Rate for Payer: GEHA Commercial |
$85.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$96.30
|
| Rate for Payer: Humana ChoiceCare |
$27.82
|
| Rate for Payer: Multiplan All |
$97.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$64.20
|
| Rate for Payer: OMNI Networks Commercial |
$74.90
|
| Rate for Payer: One Health Plan PPO/POS |
$96.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$101.65
|
| Rate for Payer: Three Rivers Provider Network All |
$80.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$94.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$99.51
|
| Rate for Payer: Zelis Auto |
$42.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$53.50
|
| Rate for Payer: Zelis Worker's Compensation |
$29.21
|
|
|
CAST SUP LNG LEG SPLNT FBRGL
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
CPT Q4042
|
| Hospital Charge Code |
21600131
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$29.21 |
| Max. Negotiated Rate |
$101.65 |
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$90.95
|
| Rate for Payer: First Health Commercial |
$96.30
|
| Rate for Payer: First Health Workers Compensation |
$41.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$96.30
|
| Rate for Payer: GEHA Commercial |
$74.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$96.30
|
| Rate for Payer: Multiplan All |
$97.37
|
| Rate for Payer: OMNI Networks Commercial |
$74.90
|
| Rate for Payer: One Health Plan PPO/POS |
$96.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$101.65
|
| Rate for Payer: Three Rivers Provider Network All |
$80.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$99.51
|
| Rate for Payer: Zelis Auto |
$42.80
|
| Rate for Payer: Zelis Worker's Compensation |
$29.21
|
|
|
CAST SUP LNG LEG SPLNT PED F
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT Q4044
|
| Hospital Charge Code |
21600132
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$21.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Worker's Compensation |
$15.29
|
|
