|
CL- BORTEZOMIB 0.1 MG
|
Facility
|
OP
|
$135.00
|
|
|
Service Code
|
CPT J9041
|
| Hospital Charge Code |
3350362
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.07 |
| Max. Negotiated Rate |
$128.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$69.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$81.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$69.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$55.34
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$114.75
|
| Rate for Payer: First Health Commercial |
$121.50
|
| Rate for Payer: First Health Workers Compensation |
$52.12
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$121.50
|
| Rate for Payer: GEHA Commercial |
$3.07
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$121.50
|
| Rate for Payer: Humana ChoiceCare |
$35.10
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$56.47
|
| Rate for Payer: Multiplan All |
$122.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$81.00
|
| Rate for Payer: OMNI Networks Commercial |
$94.50
|
| Rate for Payer: One Health Plan PPO/POS |
$121.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$65.20
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$56.47
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$128.25
|
| Rate for Payer: Three Rivers Provider Network All |
$101.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$118.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$56.47
|
| Rate for Payer: United Payors & United Providers UP&UP |
$125.55
|
| Rate for Payer: Zelis Auto |
$54.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$67.50
|
| Rate for Payer: Zelis Worker's Compensation |
$36.85
|
|
|
CL- BOTOX 100 UNITS -COSMETIC
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
CPT J0585
|
| Hospital Charge Code |
3350193
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$8.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$8.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$6.62
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6.50
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$7.15
|
| Rate for Payer: GEHA Medicare |
$6.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Humana ChoiceCare |
$7.15
|
| Rate for Payer: Humana Medicare Advantage |
$6.50
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$10.92
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$6.75
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6.50
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.05
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$7.80
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$6.75
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$13.00
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.37
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6.50
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Medicare |
$5.53
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.80
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
CL- BOTOX 100 UNITS -COSMETIC
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
CPT J0585
|
| Hospital Charge Code |
3350193
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$7.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
CL- BOTOX 50 UNITS- COSMETIC
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
CPT J0585
|
| Hospital Charge Code |
3350202
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$8.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$8.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$6.62
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6.50
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$7.15
|
| Rate for Payer: GEHA Medicare |
$6.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Humana ChoiceCare |
$7.15
|
| Rate for Payer: Humana Medicare Advantage |
$6.50
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$10.92
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$6.75
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6.50
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.05
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$7.80
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$6.75
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$13.00
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.37
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6.50
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Medicare |
$5.53
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.80
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
CL- BOTOX 50 UNITS- COSMETIC
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
CPT J0585
|
| Hospital Charge Code |
3350202
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$7.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
CL- BUDESONIDE 0.5MG/2ML NEB SOLN
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
CPT J7626
|
| Hospital Charge Code |
3350013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.84 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$68.00
|
| Rate for Payer: First Health Commercial |
$72.00
|
| Rate for Payer: First Health Workers Compensation |
$30.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.00
|
| Rate for Payer: GEHA Commercial |
$56.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.00
|
| Rate for Payer: Multiplan All |
$72.80
|
| Rate for Payer: OMNI Networks Commercial |
$56.00
|
| Rate for Payer: One Health Plan PPO/POS |
$72.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.00
|
| Rate for Payer: Three Rivers Provider Network All |
$60.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$74.40
|
| Rate for Payer: Zelis Auto |
$32.00
|
| Rate for Payer: Zelis Worker's Compensation |
$21.84
|
|
|
CL- BUDESONIDE 0.5MG/2ML NEB SOLN
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
CPT J7626
|
| Hospital Charge Code |
3350013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$68.00
|
| Rate for Payer: First Health Commercial |
$72.00
|
| Rate for Payer: First Health Workers Compensation |
$30.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.00
|
| Rate for Payer: GEHA Commercial |
$1.49
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.00
|
| Rate for Payer: Humana ChoiceCare |
$20.80
|
| Rate for Payer: Multiplan All |
$72.80
|
| Rate for Payer: New Mexico Health Connections Medicare |
$48.00
|
| Rate for Payer: OMNI Networks Commercial |
$56.00
|
| Rate for Payer: One Health Plan PPO/POS |
$72.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.00
|
| Rate for Payer: Three Rivers Provider Network All |
$60.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$70.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$20.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$74.40
|
| Rate for Payer: Zelis Auto |
$32.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$40.00
|
| Rate for Payer: Zelis Worker's Compensation |
$21.84
|
|
|
CL- BUPIVACAINE 0.25% INJ
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
CPT J0665
|
| Hospital Charge Code |
3350014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$14.45
|
| Rate for Payer: First Health Commercial |
$15.30
|
| Rate for Payer: First Health Workers Compensation |
$6.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15.30
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15.30
|
| Rate for Payer: Humana ChoiceCare |
$4.42
|
| Rate for Payer: Multiplan All |
$15.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10.20
|
| Rate for Payer: OMNI Networks Commercial |
$11.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16.15
|
| Rate for Payer: Three Rivers Provider Network All |
$12.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15.81
|
| Rate for Payer: Zelis Auto |
$6.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.50
|
| Rate for Payer: Zelis Worker's Compensation |
$4.64
|
|
|
CL- BUPIVACAINE 0.25% INJ
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
CPT J0665
|
| Hospital Charge Code |
3350014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$14.45
|
| Rate for Payer: First Health Commercial |
$15.30
|
| Rate for Payer: First Health Workers Compensation |
$6.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15.30
|
| Rate for Payer: GEHA Commercial |
$11.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15.30
|
| Rate for Payer: Multiplan All |
$15.47
|
| Rate for Payer: OMNI Networks Commercial |
$11.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16.15
|
| Rate for Payer: Three Rivers Provider Network All |
$12.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15.81
|
| Rate for Payer: Zelis Auto |
$6.80
|
| Rate for Payer: Zelis Worker's Compensation |
$4.64
|
|
|
CL- BUPIVACAINE 0.25% W/EPI INJ
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350015
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
CL- BUPIVACAINE 0.25% W/EPI INJ
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350015
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
CL- BUPIVACAINE 0.5% 10 ML INJ SDV
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
CPT J0665
|
| Hospital Charge Code |
3350552
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| 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: 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 |
$0.01
|
| 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 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
|
|
|
CL- BUPIVACAINE 0.5% 10 ML INJ SDV
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
CPT J0665
|
| Hospital Charge Code |
3350552
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.47 |
| Max. Negotiated Rate |
$50.35 |
| 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 |
$37.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$47.70
|
| Rate for Payer: Multiplan All |
$48.23
|
| 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: United Payors & United Providers UP&UP |
$49.29
|
| Rate for Payer: Zelis Auto |
$21.20
|
| Rate for Payer: Zelis Worker's Compensation |
$14.47
|
|
|
CL- BUPIVACAINE 0.5% (PER 5 ML)
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
CPT J0665
|
| Hospital Charge Code |
3350016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
CL- BUPIVACAINE 0.5% (PER 5 ML)
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
CPT J0665
|
| Hospital Charge Code |
3350016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Humana ChoiceCare |
$2.08
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.80
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
CL- BUPIVACAINE 0.5% W/EPI (PER 5 ML)
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 63323046357
|
| Hospital Charge Code |
3350254
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$6.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Humana ChoiceCare |
$2.08
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.80
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
CL- BUPIVACAINE 0.5% W/EPI (PER 5 ML)
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 63323046357
|
| Hospital Charge Code |
3350254
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
CL- BUPIVACAINE (PF) 0.25% 10 ML INJ
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350485
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.37 |
| Max. Negotiated Rate |
$25.65 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$22.95
|
| Rate for Payer: First Health Commercial |
$24.30
|
| Rate for Payer: First Health Workers Compensation |
$10.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$24.30
|
| Rate for Payer: GEHA Commercial |
$18.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$24.30
|
| Rate for Payer: Multiplan All |
$24.57
|
| Rate for Payer: OMNI Networks Commercial |
$18.90
|
| Rate for Payer: One Health Plan PPO/POS |
$24.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$25.65
|
| Rate for Payer: Three Rivers Provider Network All |
$20.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$25.11
|
| Rate for Payer: Zelis Auto |
$10.80
|
| Rate for Payer: Zelis Worker's Compensation |
$7.37
|
|
|
CL- BUPIVACAINE (PF) 0.25% 10 ML INJ
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350485
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$25.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$22.95
|
| Rate for Payer: First Health Commercial |
$24.30
|
| Rate for Payer: First Health Workers Compensation |
$10.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$24.30
|
| Rate for Payer: GEHA Commercial |
$21.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$24.30
|
| Rate for Payer: Humana ChoiceCare |
$7.02
|
| Rate for Payer: Multiplan All |
$24.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$16.20
|
| Rate for Payer: OMNI Networks Commercial |
$18.90
|
| Rate for Payer: One Health Plan PPO/POS |
$24.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$25.65
|
| Rate for Payer: Three Rivers Provider Network All |
$20.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$23.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$25.11
|
| Rate for Payer: Zelis Auto |
$10.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$13.50
|
| Rate for Payer: Zelis Worker's Compensation |
$7.37
|
|
|
CL- BUPRENORPHINE/NALOXONE 2-0.5 MG FILM
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 00781721664
|
| Hospital Charge Code |
3350421
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.19 |
| Max. Negotiated Rate |
$18.05 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: First Health Commercial |
$17.10
|
| Rate for Payer: First Health Workers Compensation |
$7.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$17.10
|
| Rate for Payer: GEHA Commercial |
$13.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17.10
|
| Rate for Payer: Multiplan All |
$17.29
|
| Rate for Payer: OMNI Networks Commercial |
$13.30
|
| Rate for Payer: One Health Plan PPO/POS |
$17.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18.05
|
| Rate for Payer: Three Rivers Provider Network All |
$14.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17.67
|
| Rate for Payer: Zelis Auto |
$7.60
|
| Rate for Payer: Zelis Worker's Compensation |
$5.19
|
|
|
CL- BUPRENORPHINE/NALOXONE 2-0.5 MG FILM
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 00781721664
|
| Hospital Charge Code |
3350421
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.75 |
| Max. Negotiated Rate |
$18.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$11.40
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: First Health Commercial |
$17.10
|
| Rate for Payer: First Health Workers Compensation |
$7.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$17.10
|
| Rate for Payer: GEHA Commercial |
$15.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17.10
|
| Rate for Payer: Humana ChoiceCare |
$4.94
|
| Rate for Payer: Multiplan All |
$17.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.40
|
| Rate for Payer: OMNI Networks Commercial |
$13.30
|
| Rate for Payer: One Health Plan PPO/POS |
$17.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18.05
|
| Rate for Payer: Three Rivers Provider Network All |
$14.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17.67
|
| Rate for Payer: Zelis Auto |
$7.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$9.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.19
|
|
|
CL- BUPRENORPHINE/NALOXONE 4-1 MG FILM
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
CPT J0573
|
| Hospital Charge Code |
3350422
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.55 |
| Max. Negotiated Rate |
$33.25 |
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$29.75
|
| Rate for Payer: First Health Commercial |
$31.50
|
| Rate for Payer: First Health Workers Compensation |
$13.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$31.50
|
| Rate for Payer: GEHA Commercial |
$24.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$31.50
|
| Rate for Payer: Multiplan All |
$31.85
|
| Rate for Payer: OMNI Networks Commercial |
$24.50
|
| Rate for Payer: One Health Plan PPO/POS |
$31.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$33.25
|
| Rate for Payer: Three Rivers Provider Network All |
$26.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$32.55
|
| Rate for Payer: Zelis Auto |
$14.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.55
|
|
|
CL- BUPRENORPHINE/NALOXONE 4-1 MG FILM
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
CPT J0573
|
| Hospital Charge Code |
3350422
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$33.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$29.75
|
| Rate for Payer: First Health Commercial |
$31.50
|
| Rate for Payer: First Health Workers Compensation |
$13.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$31.50
|
| Rate for Payer: GEHA Commercial |
$28.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$31.50
|
| Rate for Payer: Humana ChoiceCare |
$9.10
|
| Rate for Payer: Multiplan All |
$31.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$21.00
|
| Rate for Payer: OMNI Networks Commercial |
$24.50
|
| Rate for Payer: One Health Plan PPO/POS |
$31.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$33.25
|
| Rate for Payer: Three Rivers Provider Network All |
$26.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$30.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$32.55
|
| Rate for Payer: Zelis Auto |
$14.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.50
|
| Rate for Payer: Zelis Worker's Compensation |
$9.55
|
|
|
CL- BUPRENORPHINE/NALOXONE 8-2 MG FILM
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
CPT J0574
|
| Hospital Charge Code |
3350423
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$27.55 |
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$24.65
|
| Rate for Payer: First Health Commercial |
$26.10
|
| Rate for Payer: First Health Workers Compensation |
$11.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$26.10
|
| Rate for Payer: GEHA Commercial |
$20.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$26.10
|
| Rate for Payer: Multiplan All |
$26.39
|
| Rate for Payer: OMNI Networks Commercial |
$20.30
|
| Rate for Payer: One Health Plan PPO/POS |
$26.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$27.55
|
| Rate for Payer: Three Rivers Provider Network All |
$21.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$26.97
|
| Rate for Payer: Zelis Auto |
$11.60
|
| Rate for Payer: Zelis Worker's Compensation |
$7.92
|
|
|
CL- BUPRENORPHINE/NALOXONE 8-2 MG FILM
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
CPT J0574
|
| Hospital Charge Code |
3350423
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.25 |
| Max. Negotiated Rate |
$27.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$24.65
|
| Rate for Payer: First Health Commercial |
$26.10
|
| Rate for Payer: First Health Workers Compensation |
$11.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$26.10
|
| Rate for Payer: GEHA Commercial |
$23.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$26.10
|
| Rate for Payer: Humana ChoiceCare |
$7.54
|
| Rate for Payer: Multiplan All |
$26.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$17.40
|
| Rate for Payer: OMNI Networks Commercial |
$20.30
|
| Rate for Payer: One Health Plan PPO/POS |
$26.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$27.55
|
| Rate for Payer: Three Rivers Provider Network All |
$21.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$25.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$26.97
|
| Rate for Payer: Zelis Auto |
$11.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$14.50
|
| Rate for Payer: Zelis Worker's Compensation |
$7.92
|
|
