|
CL- JUVEDERM ULTRA PLUS XC- 1ML VIAL
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3350199
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$142.00 |
| Max. Negotiated Rate |
$539.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$340.80
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$482.80
|
| Rate for Payer: First Health Commercial |
$511.20
|
| Rate for Payer: First Health Workers Compensation |
$219.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$511.20
|
| Rate for Payer: GEHA Commercial |
$454.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$511.20
|
| Rate for Payer: Humana ChoiceCare |
$147.68
|
| Rate for Payer: Multiplan All |
$516.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$340.80
|
| Rate for Payer: OMNI Networks Commercial |
$397.60
|
| Rate for Payer: One Health Plan PPO/POS |
$511.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$539.60
|
| Rate for Payer: Three Rivers Provider Network All |
$426.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$499.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$142.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$528.24
|
| Rate for Payer: Zelis Auto |
$227.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$284.00
|
| Rate for Payer: Zelis Worker's Compensation |
$155.06
|
|
|
CL- JUVEDERM ULTRA XC 1ML
|
Facility
|
IP
|
$568.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3350198
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$155.06 |
| Max. Negotiated Rate |
$539.60 |
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$482.80
|
| Rate for Payer: First Health Commercial |
$511.20
|
| Rate for Payer: First Health Workers Compensation |
$219.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$511.20
|
| Rate for Payer: GEHA Commercial |
$397.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$511.20
|
| Rate for Payer: Multiplan All |
$516.88
|
| Rate for Payer: OMNI Networks Commercial |
$397.60
|
| Rate for Payer: One Health Plan PPO/POS |
$511.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$539.60
|
| Rate for Payer: Three Rivers Provider Network All |
$426.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$528.24
|
| Rate for Payer: Zelis Auto |
$227.20
|
| Rate for Payer: Zelis Worker's Compensation |
$155.06
|
|
|
CL- JUVEDERM ULTRA XC 1ML
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3350198
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$142.00 |
| Max. Negotiated Rate |
$539.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$340.80
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$482.80
|
| Rate for Payer: First Health Commercial |
$511.20
|
| Rate for Payer: First Health Workers Compensation |
$219.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$511.20
|
| Rate for Payer: GEHA Commercial |
$454.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$511.20
|
| Rate for Payer: Humana ChoiceCare |
$147.68
|
| Rate for Payer: Multiplan All |
$516.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$340.80
|
| Rate for Payer: OMNI Networks Commercial |
$397.60
|
| Rate for Payer: One Health Plan PPO/POS |
$511.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$539.60
|
| Rate for Payer: Three Rivers Provider Network All |
$426.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$499.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$142.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$528.24
|
| Rate for Payer: Zelis Auto |
$227.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$284.00
|
| Rate for Payer: Zelis Worker's Compensation |
$155.06
|
|
|
CL- JUVEDERM VOLBELLA - 1 SYRINGE
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3350431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$142.00 |
| Max. Negotiated Rate |
$539.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$340.80
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$482.80
|
| Rate for Payer: First Health Commercial |
$511.20
|
| Rate for Payer: First Health Workers Compensation |
$219.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$511.20
|
| Rate for Payer: GEHA Commercial |
$454.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$511.20
|
| Rate for Payer: Humana ChoiceCare |
$147.68
|
| Rate for Payer: Multiplan All |
$516.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$340.80
|
| Rate for Payer: OMNI Networks Commercial |
$397.60
|
| Rate for Payer: One Health Plan PPO/POS |
$511.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$539.60
|
| Rate for Payer: Three Rivers Provider Network All |
$426.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$499.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$142.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$528.24
|
| Rate for Payer: Zelis Auto |
$227.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$284.00
|
| Rate for Payer: Zelis Worker's Compensation |
$155.06
|
|
|
CL- JUVEDERM VOLBELLA - 1 SYRINGE
|
Facility
|
IP
|
$568.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3350431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$155.06 |
| Max. Negotiated Rate |
$539.60 |
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$482.80
|
| Rate for Payer: First Health Commercial |
$511.20
|
| Rate for Payer: First Health Workers Compensation |
$219.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$511.20
|
| Rate for Payer: GEHA Commercial |
$397.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$511.20
|
| Rate for Payer: Multiplan All |
$516.88
|
| Rate for Payer: OMNI Networks Commercial |
$397.60
|
| Rate for Payer: One Health Plan PPO/POS |
$511.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$539.60
|
| Rate for Payer: Three Rivers Provider Network All |
$426.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$528.24
|
| Rate for Payer: Zelis Auto |
$227.20
|
| Rate for Payer: Zelis Worker's Compensation |
$155.06
|
|
|
CL- JUVEDERM VOLUMA XC
|
Facility
|
IP
|
$690.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3350250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$188.37 |
| Max. Negotiated Rate |
$655.50 |
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cigna Commercial |
$586.50
|
| Rate for Payer: First Health Commercial |
$621.00
|
| Rate for Payer: First Health Workers Compensation |
$266.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$621.00
|
| Rate for Payer: GEHA Commercial |
$483.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$621.00
|
| Rate for Payer: Multiplan All |
$627.90
|
| Rate for Payer: OMNI Networks Commercial |
$483.00
|
| Rate for Payer: One Health Plan PPO/POS |
$621.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$655.50
|
| Rate for Payer: Three Rivers Provider Network All |
$517.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$641.70
|
| Rate for Payer: Zelis Auto |
$276.00
|
| Rate for Payer: Zelis Worker's Compensation |
$188.37
|
|
|
CL- JUVEDERM VOLUMA XC
|
Facility
|
OP
|
$690.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3350250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$172.50 |
| Max. Negotiated Rate |
$655.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$414.00
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cigna Commercial |
$586.50
|
| Rate for Payer: First Health Commercial |
$621.00
|
| Rate for Payer: First Health Workers Compensation |
$266.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$621.00
|
| Rate for Payer: GEHA Commercial |
$552.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$621.00
|
| Rate for Payer: Humana ChoiceCare |
$179.40
|
| Rate for Payer: Multiplan All |
$627.90
|
| Rate for Payer: New Mexico Health Connections Medicare |
$414.00
|
| Rate for Payer: OMNI Networks Commercial |
$483.00
|
| Rate for Payer: One Health Plan PPO/POS |
$621.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$655.50
|
| Rate for Payer: Three Rivers Provider Network All |
$517.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$607.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$172.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$641.70
|
| Rate for Payer: Zelis Auto |
$276.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$345.00
|
| Rate for Payer: Zelis Worker's Compensation |
$188.37
|
|
|
CL- KENALOG 40MG/ML
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
CPT J3301
|
| Hospital Charge Code |
3350090
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$30.40 |
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$27.20
|
| Rate for Payer: First Health Commercial |
$28.80
|
| Rate for Payer: First Health Workers Compensation |
$12.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$28.80
|
| Rate for Payer: GEHA Commercial |
$22.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$28.80
|
| Rate for Payer: Multiplan All |
$29.12
|
| Rate for Payer: OMNI Networks Commercial |
$22.40
|
| Rate for Payer: One Health Plan PPO/POS |
$28.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$30.40
|
| Rate for Payer: Three Rivers Provider Network All |
$24.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$29.76
|
| Rate for Payer: Zelis Auto |
$12.80
|
| Rate for Payer: Zelis Worker's Compensation |
$8.74
|
|
|
CL- KENALOG 40MG/ML
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
CPT J3301
|
| Hospital Charge Code |
3350090
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$30.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$27.20
|
| Rate for Payer: First Health Commercial |
$28.80
|
| Rate for Payer: First Health Workers Compensation |
$12.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$28.80
|
| Rate for Payer: GEHA Commercial |
$0.92
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$28.80
|
| Rate for Payer: Humana ChoiceCare |
$8.32
|
| Rate for Payer: Multiplan All |
$29.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$19.20
|
| Rate for Payer: OMNI Networks Commercial |
$22.40
|
| Rate for Payer: One Health Plan PPO/POS |
$28.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$30.40
|
| Rate for Payer: Three Rivers Provider Network All |
$24.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$28.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$29.76
|
| Rate for Payer: Zelis Auto |
$12.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$16.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.74
|
|
|
CL- KETOROLAC 15MG/ML INJ
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
3350532
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$0.29
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$0.33
|
| Rate for Payer: GEHA Medicare |
$0.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Humana ChoiceCare |
$0.32
|
| Rate for Payer: Humana Medicare Advantage |
$0.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$0.49
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$0.29
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.49
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$0.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$0.58
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$0.29
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Medicare |
$0.25
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.35
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
CL- KETOROLAC 15MG/ML INJ
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
3350532
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$4.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
CL- KETOROLAC IM INJ 60MG/2ML
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
3350048
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$9.50 |
| 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 Medicare Advantage |
$0.29
|
| 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 |
$0.33
|
| Rate for Payer: GEHA Medicare |
$0.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Humana ChoiceCare |
$0.32
|
| Rate for Payer: Humana Medicare Advantage |
$0.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$0.49
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$0.29
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.49
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$0.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$0.58
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$0.29
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Medicare |
$0.25
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.35
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
CL- KETOROLAC IM INJ 60MG/2ML
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
3350048
|
|
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- KETOROLAC INJ 30MG/ML
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
3350049
|
|
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
|
|
|
CL- KETOROLAC INJ 30MG/ML
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
3350049
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$0.29
|
| Rate for Payer: Cash Price |
$7.80
|
| 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 |
$0.33
|
| Rate for Payer: GEHA Medicare |
$0.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11.70
|
| Rate for Payer: Humana ChoiceCare |
$0.32
|
| Rate for Payer: Humana Medicare Advantage |
$0.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$0.49
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$0.29
|
| Rate for Payer: Multiplan All |
$11.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.49
|
| Rate for Payer: OMNI Networks Commercial |
$9.10
|
| Rate for Payer: One Health Plan PPO/POS |
$11.70
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$0.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$0.58
|
| Rate for Payer: Three Rivers Provider Network All |
$9.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12.09
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$0.29
|
| Rate for Payer: Zelis Auto |
$5.20
|
| Rate for Payer: Zelis Medicare |
$0.25
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.35
|
| Rate for Payer: Zelis Worker's Compensation |
$3.55
|
|
|
CL- LANREOTIDE 1 MG
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
CPT J1930
|
| Hospital Charge Code |
3350361
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.29 |
| Max. Negotiated Rate |
$70.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$70.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$40.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$70.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$55.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$34.05
|
| 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 |
$37.45
|
| Rate for Payer: GEHA Medicare |
$34.05
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$60.30
|
| Rate for Payer: Humana ChoiceCare |
$37.45
|
| Rate for Payer: Humana Medicare Advantage |
$34.05
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$57.20
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$56.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$34.05
|
| Rate for Payer: Multiplan All |
$60.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$57.88
|
| Rate for Payer: OMNI Networks Commercial |
$46.90
|
| Rate for Payer: One Health Plan PPO/POS |
$60.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$65.34
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$56.59
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$34.05
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$63.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$68.10
|
| Rate for Payer: Three Rivers Provider Network All |
$50.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$33.37
|
| Rate for Payer: United Healthcare Managed Medicaid |
$56.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$34.05
|
| Rate for Payer: United Payors & United Providers UP&UP |
$62.31
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$34.05
|
| Rate for Payer: Zelis Auto |
$26.80
|
| Rate for Payer: Zelis Medicare |
$28.94
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$40.86
|
| Rate for Payer: Zelis Worker's Compensation |
$18.29
|
|
|
CL- LANREOTIDE 1 MG
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
CPT J1930
|
| Hospital Charge Code |
3350361
|
|
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- L.E.T. Gel - 3ml prefilled syringe
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350402
|
|
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- L.E.T. Gel - 3ml prefilled syringe
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350402
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.50 |
| 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: 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 |
$81.60
|
| 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- LEUCOVORIN CALCIUM 50 MG
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
3350325
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.00
|
| 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 |
$3.54
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Humana ChoiceCare |
$2.60
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.00
|
| 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: TriWest Veterans Administration/VAPC3 |
$8.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
CL- LEUCOVORIN CALCIUM 50 MG
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
3350325
|
|
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- LEUPROLIDE ACE 22.5 MG INJ KIT
|
Facility
|
IP
|
$347.00
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
3350099
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.73 |
| Max. Negotiated Rate |
$329.65 |
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cigna Commercial |
$294.95
|
| Rate for Payer: First Health Commercial |
$312.30
|
| Rate for Payer: First Health Workers Compensation |
$133.98
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$312.30
|
| Rate for Payer: GEHA Commercial |
$242.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$312.30
|
| Rate for Payer: Multiplan All |
$315.77
|
| Rate for Payer: OMNI Networks Commercial |
$242.90
|
| Rate for Payer: One Health Plan PPO/POS |
$312.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$329.65
|
| Rate for Payer: Three Rivers Provider Network All |
$260.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$322.71
|
| Rate for Payer: Zelis Auto |
$138.80
|
| Rate for Payer: Zelis Worker's Compensation |
$94.73
|
|
|
CL- LEUPROLIDE ACE 22.5 MG INJ KIT
|
Facility
|
OP
|
$347.00
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
3350099
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.73 |
| Max. Negotiated Rate |
$352.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$342.25
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$208.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$342.25
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$271.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$176.45
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cash Price |
$208.20
|
| Rate for Payer: Cigna Commercial |
$294.95
|
| Rate for Payer: First Health Commercial |
$312.30
|
| Rate for Payer: First Health Workers Compensation |
$133.98
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$312.30
|
| Rate for Payer: GEHA Commercial |
$194.09
|
| Rate for Payer: GEHA Medicare |
$176.45
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$312.30
|
| Rate for Payer: Humana ChoiceCare |
$194.09
|
| Rate for Payer: Humana Medicare Advantage |
$176.45
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$296.44
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$276.66
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$176.45
|
| Rate for Payer: Multiplan All |
$315.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$299.96
|
| Rate for Payer: OMNI Networks Commercial |
$242.90
|
| Rate for Payer: One Health Plan PPO/POS |
$312.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$319.44
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$276.66
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$176.45
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$329.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$352.90
|
| Rate for Payer: Three Rivers Provider Network All |
$260.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$172.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$276.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$176.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$322.71
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$176.45
|
| Rate for Payer: Zelis Auto |
$138.80
|
| Rate for Payer: Zelis Medicare |
$149.98
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$211.74
|
| Rate for Payer: Zelis Worker's Compensation |
$94.73
|
|
|
CL- LEUPROLIDE ACETATE 3.75MG KIT PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
33505450
|
|
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- LEUPROLIDE ACETATE 3.75MG KIT PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
33505450
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$3,460.64 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,220.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,220.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$966.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,730.32
|
| 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 |
$1,903.35
|
| Rate for Payer: GEHA Medicare |
$1,730.32
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$1,903.35
|
| Rate for Payer: Humana Medicare Advantage |
$1,730.32
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,906.94
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$986.22
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,730.32
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,941.54
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,138.73
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$986.22
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,730.32
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,460.64
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,695.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$986.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,730.32
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,730.32
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Medicare |
$1,470.77
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,076.38
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
