|
CLEANER HYDRO PEROXIDE SPRAY 32OZ
|
Facility
|
OP
|
$431.00
|
|
| Hospital Charge Code |
90000235
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$107.75 |
| Max. Negotiated Rate |
$409.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$258.60
|
| Rate for Payer: Cash Price |
$258.60
|
| Rate for Payer: Cigna Commercial |
$366.35
|
| Rate for Payer: First Health Commercial |
$387.90
|
| Rate for Payer: First Health Workers Compensation |
$166.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$387.90
|
| Rate for Payer: GEHA Commercial |
$344.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$387.90
|
| Rate for Payer: Humana ChoiceCare |
$112.06
|
| Rate for Payer: Multiplan All |
$392.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$258.60
|
| Rate for Payer: OMNI Networks Commercial |
$301.70
|
| Rate for Payer: One Health Plan PPO/POS |
$387.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$409.45
|
| Rate for Payer: Three Rivers Provider Network All |
$323.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$379.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$107.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$400.83
|
| Rate for Payer: Zelis Auto |
$172.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$215.50
|
| Rate for Payer: Zelis Worker's Compensation |
$117.66
|
|
|
CLEANER HYDRO PEROXIDE SPRAY 32OZ
|
Facility
|
IP
|
$431.00
|
|
| Hospital Charge Code |
90000235
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$117.66 |
| Max. Negotiated Rate |
$409.45 |
| Rate for Payer: Cash Price |
$258.60
|
| Rate for Payer: Cigna Commercial |
$366.35
|
| Rate for Payer: First Health Commercial |
$387.90
|
| Rate for Payer: First Health Workers Compensation |
$166.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$387.90
|
| Rate for Payer: GEHA Commercial |
$301.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$387.90
|
| Rate for Payer: Multiplan All |
$392.21
|
| Rate for Payer: OMNI Networks Commercial |
$301.70
|
| Rate for Payer: One Health Plan PPO/POS |
$387.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$409.45
|
| Rate for Payer: Three Rivers Provider Network All |
$323.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$400.83
|
| Rate for Payer: Zelis Auto |
$172.40
|
| Rate for Payer: Zelis Worker's Compensation |
$117.66
|
|
|
CLEANER PHYTOPLEX NO-RINSE
|
Facility
|
IP
|
$393.00
|
|
| Hospital Charge Code |
90030951
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$107.29 |
| Max. Negotiated Rate |
$373.35 |
| Rate for Payer: Cash Price |
$235.80
|
| Rate for Payer: Cigna Commercial |
$334.05
|
| Rate for Payer: First Health Commercial |
$353.70
|
| Rate for Payer: First Health Workers Compensation |
$151.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$353.70
|
| Rate for Payer: GEHA Commercial |
$275.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$353.70
|
| Rate for Payer: Multiplan All |
$357.63
|
| Rate for Payer: OMNI Networks Commercial |
$275.10
|
| Rate for Payer: One Health Plan PPO/POS |
$353.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$373.35
|
| Rate for Payer: Three Rivers Provider Network All |
$294.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$365.49
|
| Rate for Payer: Zelis Auto |
$157.20
|
| Rate for Payer: Zelis Worker's Compensation |
$107.29
|
|
|
CLEANER PHYTOPLEX NO-RINSE
|
Facility
|
OP
|
$393.00
|
|
| Hospital Charge Code |
90030951
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$98.25 |
| Max. Negotiated Rate |
$373.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$235.80
|
| Rate for Payer: Cash Price |
$235.80
|
| Rate for Payer: Cigna Commercial |
$334.05
|
| Rate for Payer: First Health Commercial |
$353.70
|
| Rate for Payer: First Health Workers Compensation |
$151.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$353.70
|
| Rate for Payer: GEHA Commercial |
$314.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$353.70
|
| Rate for Payer: Humana ChoiceCare |
$102.18
|
| Rate for Payer: Multiplan All |
$357.63
|
| Rate for Payer: New Mexico Health Connections Medicare |
$235.80
|
| Rate for Payer: OMNI Networks Commercial |
$275.10
|
| Rate for Payer: One Health Plan PPO/POS |
$353.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$373.35
|
| Rate for Payer: Three Rivers Provider Network All |
$294.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$345.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$98.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$365.49
|
| Rate for Payer: Zelis Auto |
$157.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$196.50
|
| Rate for Payer: Zelis Worker's Compensation |
$107.29
|
|
|
CLEAN OUT MASTOID CAVITY
|
Facility
|
OP
|
$414.00
|
|
|
Service Code
|
CPT 69222
|
| Hospital Charge Code |
6169222
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$113.02 |
| Max. Negotiated Rate |
$1,737.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,737.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$248.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,737.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,376.73
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$483.55
|
| Rate for Payer: Cash Price |
$248.40
|
| Rate for Payer: Cash Price |
$248.40
|
| Rate for Payer: Cigna Commercial |
$351.90
|
| Rate for Payer: First Health Commercial |
$372.60
|
| Rate for Payer: First Health Workers Compensation |
$159.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$372.60
|
| Rate for Payer: GEHA Commercial |
$331.20
|
| Rate for Payer: GEHA Medicare |
$483.55
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$372.60
|
| Rate for Payer: Humana ChoiceCare |
$531.90
|
| Rate for Payer: Humana Medicare Advantage |
$483.55
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$812.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,404.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$483.55
|
| Rate for Payer: Multiplan All |
$376.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$822.03
|
| Rate for Payer: OMNI Networks Commercial |
$289.80
|
| Rate for Payer: One Health Plan PPO/POS |
$372.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,622.00
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,404.77
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$483.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$393.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$967.10
|
| Rate for Payer: Three Rivers Provider Network All |
$310.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$473.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,404.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$483.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$385.02
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$483.55
|
| Rate for Payer: Zelis Auto |
$165.60
|
| Rate for Payer: Zelis Medicare |
$411.02
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$580.26
|
| Rate for Payer: Zelis Worker's Compensation |
$113.02
|
|
|
CLEAN OUT MASTOID CAVITY
|
Facility
|
IP
|
$414.00
|
|
|
Service Code
|
CPT 69222
|
| Hospital Charge Code |
6169222
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$113.02 |
| Max. Negotiated Rate |
$393.30 |
| Rate for Payer: Cash Price |
$248.40
|
| Rate for Payer: Cigna Commercial |
$351.90
|
| Rate for Payer: First Health Commercial |
$372.60
|
| Rate for Payer: First Health Workers Compensation |
$159.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$372.60
|
| Rate for Payer: GEHA Commercial |
$289.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$372.60
|
| Rate for Payer: Multiplan All |
$376.74
|
| Rate for Payer: OMNI Networks Commercial |
$289.80
|
| Rate for Payer: One Health Plan PPO/POS |
$372.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$393.30
|
| Rate for Payer: Three Rivers Provider Network All |
$310.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$385.02
|
| Rate for Payer: Zelis Auto |
$165.60
|
| Rate for Payer: Zelis Worker's Compensation |
$113.02
|
|
|
CLEARANCE OF AIRWAYS
|
Facility
|
IP
|
$445.00
|
|
|
Service Code
|
CPT 31720
|
| Hospital Charge Code |
4000230
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$121.48 |
| Max. Negotiated Rate |
$422.75 |
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cigna Commercial |
$378.25
|
| Rate for Payer: First Health Commercial |
$400.50
|
| Rate for Payer: First Health Workers Compensation |
$171.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$400.50
|
| Rate for Payer: GEHA Commercial |
$311.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$400.50
|
| Rate for Payer: Multiplan All |
$404.95
|
| Rate for Payer: OMNI Networks Commercial |
$311.50
|
| Rate for Payer: One Health Plan PPO/POS |
$400.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$422.75
|
| Rate for Payer: Three Rivers Provider Network All |
$333.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$413.85
|
| Rate for Payer: Zelis Auto |
$178.00
|
| Rate for Payer: Zelis Worker's Compensation |
$121.48
|
|
|
CLEARANCE OF AIRWAYS
|
Facility
|
OP
|
$445.00
|
|
|
Service Code
|
CPT 31720
|
| Hospital Charge Code |
4000230
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$121.48 |
| Max. Negotiated Rate |
$422.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$267.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$195.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$193.13
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cigna Commercial |
$378.25
|
| Rate for Payer: First Health Commercial |
$400.50
|
| Rate for Payer: First Health Workers Compensation |
$171.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$400.50
|
| Rate for Payer: GEHA Commercial |
$356.00
|
| Rate for Payer: GEHA Medicare |
$193.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$400.50
|
| Rate for Payer: Humana ChoiceCare |
$212.44
|
| Rate for Payer: Humana Medicare Advantage |
$193.13
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$324.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$199.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$193.13
|
| Rate for Payer: Multiplan All |
$404.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$328.32
|
| Rate for Payer: OMNI Networks Commercial |
$311.50
|
| Rate for Payer: One Health Plan PPO/POS |
$400.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$230.38
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$199.53
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$193.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$422.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$386.26
|
| Rate for Payer: Three Rivers Provider Network All |
$333.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$189.27
|
| Rate for Payer: United Healthcare Commercial |
$378.25
|
| Rate for Payer: United Healthcare Managed Medicaid |
$199.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$193.13
|
| Rate for Payer: United Payors & United Providers UP&UP |
$413.85
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$193.13
|
| Rate for Payer: Zelis Auto |
$178.00
|
| Rate for Payer: Zelis Medicare |
$164.16
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$231.76
|
| Rate for Payer: Zelis Worker's Compensation |
$121.48
|
|
|
CL- ECULIZUMAB 10 MG
|
Facility
|
IP
|
$702.00
|
|
|
Service Code
|
CPT J1300
|
| Hospital Charge Code |
3350360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$191.65 |
| Max. Negotiated Rate |
$666.90 |
| Rate for Payer: Cash Price |
$421.20
|
| Rate for Payer: Cigna Commercial |
$596.70
|
| Rate for Payer: First Health Commercial |
$631.80
|
| Rate for Payer: First Health Workers Compensation |
$271.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$631.80
|
| Rate for Payer: GEHA Commercial |
$491.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$631.80
|
| Rate for Payer: Multiplan All |
$638.82
|
| Rate for Payer: OMNI Networks Commercial |
$491.40
|
| Rate for Payer: One Health Plan PPO/POS |
$631.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$666.90
|
| Rate for Payer: Three Rivers Provider Network All |
$526.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$652.86
|
| Rate for Payer: Zelis Auto |
$280.80
|
| Rate for Payer: Zelis Worker's Compensation |
$191.65
|
|
|
CL- ECULIZUMAB 10 MG
|
Facility
|
OP
|
$702.00
|
|
|
Service Code
|
CPT J1300
|
| Hospital Charge Code |
3350360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$182.52 |
| Max. Negotiated Rate |
$666.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$317.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$421.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$317.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$251.79
|
| Rate for Payer: Cash Price |
$421.20
|
| Rate for Payer: Cash Price |
$421.20
|
| Rate for Payer: Cigna Commercial |
$596.70
|
| Rate for Payer: First Health Commercial |
$631.80
|
| Rate for Payer: First Health Workers Compensation |
$271.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$631.80
|
| Rate for Payer: GEHA Commercial |
$561.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$631.80
|
| Rate for Payer: Humana ChoiceCare |
$182.52
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$256.92
|
| Rate for Payer: Multiplan All |
$638.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$421.20
|
| Rate for Payer: OMNI Networks Commercial |
$491.40
|
| Rate for Payer: One Health Plan PPO/POS |
$631.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$296.65
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$256.92
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$666.90
|
| Rate for Payer: Three Rivers Provider Network All |
$526.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$617.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$256.92
|
| Rate for Payer: United Payors & United Providers UP&UP |
$652.86
|
| Rate for Payer: Zelis Auto |
$280.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$351.00
|
| Rate for Payer: Zelis Worker's Compensation |
$191.65
|
|
|
CL- ELOTUZUMAB 1 MG
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
CPT J9176
|
| Hospital Charge Code |
3350297
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.19 |
| Max. Negotiated Rate |
$18.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$11.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.43
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$7.89
|
| Rate for Payer: Cash Price |
$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 |
$8.68
|
| Rate for Payer: GEHA Medicare |
$7.89
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17.10
|
| Rate for Payer: Humana ChoiceCare |
$8.68
|
| Rate for Payer: Humana Medicare Advantage |
$7.89
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$13.26
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.58
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$7.89
|
| Rate for Payer: Multiplan All |
$17.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$13.41
|
| Rate for Payer: OMNI Networks Commercial |
$13.30
|
| Rate for Payer: One Health Plan PPO/POS |
$17.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.75
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.58
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$7.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$15.78
|
| Rate for Payer: Three Rivers Provider Network All |
$14.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.73
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17.67
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$7.89
|
| Rate for Payer: Zelis Auto |
$7.60
|
| Rate for Payer: Zelis Medicare |
$6.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$9.47
|
| Rate for Payer: Zelis Worker's Compensation |
$5.19
|
|
|
CL- ELOTUZUMAB 1 MG
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
CPT J9176
|
| Hospital Charge Code |
3350297
|
|
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- ENOXAPARIN 40MG/0.4ML - PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
3350216
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.65
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.00
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.01
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.01
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- ENOXAPARIN 40MG/0.4ML - PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
3350216
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- ENOXAPARIN SODIUM INJ 100 MG/ML
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
3350439
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.85 |
| Max. Negotiated Rate |
$96.90 |
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$86.70
|
| Rate for Payer: First Health Commercial |
$91.80
|
| Rate for Payer: First Health Workers Compensation |
$39.38
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$91.80
|
| Rate for Payer: GEHA Commercial |
$71.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$91.80
|
| Rate for Payer: Multiplan All |
$92.82
|
| Rate for Payer: OMNI Networks Commercial |
$71.40
|
| Rate for Payer: One Health Plan PPO/POS |
$91.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$96.90
|
| Rate for Payer: Three Rivers Provider Network All |
$76.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$94.86
|
| Rate for Payer: Zelis Auto |
$40.80
|
| Rate for Payer: Zelis Worker's Compensation |
$27.85
|
|
|
CL- ENOXAPARIN SODIUM INJ 100 MG/ML
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
3350439
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$96.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$61.20
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$86.70
|
| Rate for Payer: First Health Commercial |
$91.80
|
| Rate for Payer: First Health Workers Compensation |
$39.38
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$91.80
|
| Rate for Payer: GEHA Commercial |
$0.65
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$91.80
|
| Rate for Payer: Humana ChoiceCare |
$26.52
|
| Rate for Payer: Multiplan All |
$92.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$61.20
|
| Rate for Payer: OMNI Networks Commercial |
$71.40
|
| Rate for Payer: One Health Plan PPO/POS |
$91.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$96.90
|
| Rate for Payer: Three Rivers Provider Network All |
$76.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$89.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$25.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$94.86
|
| Rate for Payer: Zelis Auto |
$40.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$51.00
|
| Rate for Payer: Zelis Worker's Compensation |
$27.85
|
|
|
CL- ENOXAPARIN SODIUM INJ 60 MG/ 0.6 ML
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
3350440
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$63.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$40.20
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$56.95
|
| Rate for Payer: First Health Commercial |
$60.30
|
| Rate for Payer: First Health Workers Compensation |
$25.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$60.30
|
| Rate for Payer: GEHA Commercial |
$0.65
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$60.30
|
| Rate for Payer: Humana ChoiceCare |
$17.42
|
| Rate for Payer: Multiplan All |
$60.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$40.20
|
| Rate for Payer: OMNI Networks Commercial |
$46.90
|
| Rate for Payer: One Health Plan PPO/POS |
$60.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$63.65
|
| Rate for Payer: Three Rivers Provider Network All |
$50.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$58.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$62.31
|
| Rate for Payer: Zelis Auto |
$26.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.50
|
| Rate for Payer: Zelis Worker's Compensation |
$18.29
|
|
|
CL- ENOXAPARIN SODIUM INJ 60 MG/ 0.6 ML
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
CPT J1650
|
| Hospital Charge Code |
3350440
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.29 |
| Max. Negotiated Rate |
$63.65 |
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$56.95
|
| Rate for Payer: First Health Commercial |
$60.30
|
| Rate for Payer: First Health Workers Compensation |
$25.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$60.30
|
| Rate for Payer: GEHA Commercial |
$46.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$60.30
|
| Rate for Payer: Multiplan All |
$60.97
|
| Rate for Payer: OMNI Networks Commercial |
$46.90
|
| Rate for Payer: One Health Plan PPO/POS |
$60.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$63.65
|
| Rate for Payer: Three Rivers Provider Network All |
$50.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$62.31
|
| Rate for Payer: Zelis Auto |
$26.80
|
| Rate for Payer: Zelis Worker's Compensation |
$18.29
|
|
|
CL- EPINEPHRINE 0.15MG AUTO INJ. - PEDI
|
Facility
|
OP
|
$1,056.00
|
|
|
Service Code
|
CPT J0171
|
| Hospital Charge Code |
3350211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$1,003.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$633.60
|
| Rate for Payer: Cash Price |
$633.60
|
| Rate for Payer: Cigna Commercial |
$897.60
|
| Rate for Payer: First Health Commercial |
$950.40
|
| Rate for Payer: First Health Workers Compensation |
$407.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$950.40
|
| Rate for Payer: GEHA Commercial |
$844.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$950.40
|
| Rate for Payer: Humana ChoiceCare |
$274.56
|
| Rate for Payer: Multiplan All |
$960.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$633.60
|
| Rate for Payer: OMNI Networks Commercial |
$739.20
|
| Rate for Payer: One Health Plan PPO/POS |
$950.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,003.20
|
| Rate for Payer: Three Rivers Provider Network All |
$792.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$929.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$264.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$982.08
|
| Rate for Payer: Zelis Auto |
$422.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$528.00
|
| Rate for Payer: Zelis Worker's Compensation |
$288.29
|
|
|
CL- EPINEPHRINE 0.15MG AUTO INJ. - PEDI
|
Facility
|
IP
|
$1,056.00
|
|
|
Service Code
|
CPT J0171
|
| Hospital Charge Code |
3350211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$288.29 |
| Max. Negotiated Rate |
$1,003.20 |
| Rate for Payer: Cash Price |
$633.60
|
| Rate for Payer: Cigna Commercial |
$897.60
|
| Rate for Payer: First Health Commercial |
$950.40
|
| Rate for Payer: First Health Workers Compensation |
$407.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$950.40
|
| Rate for Payer: GEHA Commercial |
$739.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$950.40
|
| Rate for Payer: Multiplan All |
$960.96
|
| Rate for Payer: OMNI Networks Commercial |
$739.20
|
| Rate for Payer: One Health Plan PPO/POS |
$950.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,003.20
|
| Rate for Payer: Three Rivers Provider Network All |
$792.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$982.08
|
| Rate for Payer: Zelis Auto |
$422.40
|
| Rate for Payer: Zelis Worker's Compensation |
$288.29
|
|
|
CL- EPINEPHRINE AUTO-INJECTOR 0.3MG
|
Facility
|
OP
|
$964.00
|
|
|
Service Code
|
CPT J0171
|
| Hospital Charge Code |
3350160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$241.00 |
| Max. Negotiated Rate |
$915.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$578.40
|
| Rate for Payer: Cash Price |
$578.40
|
| Rate for Payer: Cigna Commercial |
$819.40
|
| Rate for Payer: First Health Commercial |
$867.60
|
| Rate for Payer: First Health Workers Compensation |
$372.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$867.60
|
| Rate for Payer: GEHA Commercial |
$771.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$867.60
|
| Rate for Payer: Humana ChoiceCare |
$250.64
|
| Rate for Payer: Multiplan All |
$877.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$578.40
|
| Rate for Payer: OMNI Networks Commercial |
$674.80
|
| Rate for Payer: One Health Plan PPO/POS |
$867.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$915.80
|
| Rate for Payer: Three Rivers Provider Network All |
$723.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$848.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$241.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$896.52
|
| Rate for Payer: Zelis Auto |
$385.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$482.00
|
| Rate for Payer: Zelis Worker's Compensation |
$263.17
|
|
|
CL- EPINEPHRINE AUTO-INJECTOR 0.3MG
|
Facility
|
IP
|
$964.00
|
|
|
Service Code
|
CPT J0171
|
| Hospital Charge Code |
3350160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$263.17 |
| Max. Negotiated Rate |
$915.80 |
| Rate for Payer: Cash Price |
$578.40
|
| Rate for Payer: Cigna Commercial |
$819.40
|
| Rate for Payer: First Health Commercial |
$867.60
|
| Rate for Payer: First Health Workers Compensation |
$372.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$867.60
|
| Rate for Payer: GEHA Commercial |
$674.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$867.60
|
| Rate for Payer: Multiplan All |
$877.24
|
| Rate for Payer: OMNI Networks Commercial |
$674.80
|
| Rate for Payer: One Health Plan PPO/POS |
$867.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$915.80
|
| Rate for Payer: Three Rivers Provider Network All |
$723.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$896.52
|
| Rate for Payer: Zelis Auto |
$385.60
|
| Rate for Payer: Zelis Worker's Compensation |
$263.17
|
|
|
CL- EPINEPHRINE INJ 1MG/ML - 30ML VIAL
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
CPT J0171
|
| Hospital Charge Code |
3350034
|
|
Hospital Revenue Code
|
636
|
| 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 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- EPINEPHRINE INJ 1MG/ML - 30ML VIAL
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
CPT J0171
|
| Hospital Charge Code |
3350034
|
|
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- EPINEPHRINE SQ/IM INJ - 1MG/ML
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
CPT J0171
|
| Hospital Charge Code |
3350033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.55 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$11.05
|
| Rate for Payer: First Health Commercial |
$11.70
|
| Rate for Payer: First Health Workers Compensation |
$5.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11.70
|
| Rate for Payer: GEHA Commercial |
$9.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11.70
|
| Rate for Payer: Multiplan All |
$11.83
|
| Rate for Payer: OMNI Networks Commercial |
$9.10
|
| Rate for Payer: One Health Plan PPO/POS |
$11.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12.35
|
| Rate for Payer: Three Rivers Provider Network All |
$9.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12.09
|
| Rate for Payer: Zelis Auto |
$5.20
|
| Rate for Payer: Zelis Worker's Compensation |
$3.55
|
|
