|
CL- LEUPROLIDE ACETATE INJ 7.5 MG
|
Facility
|
OP
|
$239.00
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
3350329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$65.25 |
| 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 |
$143.40
|
| 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 |
$143.40
|
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Cigna Commercial |
$203.15
|
| Rate for Payer: First Health Commercial |
$215.10
|
| Rate for Payer: First Health Workers Compensation |
$92.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$215.10
|
| Rate for Payer: GEHA Commercial |
$194.09
|
| Rate for Payer: GEHA Medicare |
$176.45
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$215.10
|
| 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 |
$217.49
|
| Rate for Payer: New Mexico Health Connections Medicare |
$299.96
|
| Rate for Payer: OMNI Networks Commercial |
$167.30
|
| Rate for Payer: One Health Plan PPO/POS |
$215.10
|
| 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 |
$227.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$352.90
|
| Rate for Payer: Three Rivers Provider Network All |
$179.25
|
| 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 |
$222.27
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$176.45
|
| Rate for Payer: Zelis Auto |
$95.60
|
| Rate for Payer: Zelis Medicare |
$149.98
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$211.74
|
| Rate for Payer: Zelis Worker's Compensation |
$65.25
|
|
|
CL- LEUPROLIDE ACETATE INJ 7.5 MG
|
Facility
|
IP
|
$239.00
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
3350329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$65.25 |
| Max. Negotiated Rate |
$227.05 |
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Cigna Commercial |
$203.15
|
| Rate for Payer: First Health Commercial |
$215.10
|
| Rate for Payer: First Health Workers Compensation |
$92.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$215.10
|
| Rate for Payer: GEHA Commercial |
$167.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$215.10
|
| Rate for Payer: Multiplan All |
$217.49
|
| Rate for Payer: OMNI Networks Commercial |
$167.30
|
| Rate for Payer: One Health Plan PPO/POS |
$215.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$227.05
|
| Rate for Payer: Three Rivers Provider Network All |
$179.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$222.27
|
| Rate for Payer: Zelis Auto |
$95.60
|
| Rate for Payer: Zelis Worker's Compensation |
$65.25
|
|
|
CL- LEUPROLIDE ACETATE KIT 22.5MG PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
3350238
|
|
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
|
|
|
CL- LEUPROLIDE ACETATE KIT 22.5MG PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
3350238
|
|
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- LEVALBUTEROL NEBU 0.63MG/3ML
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 00093414656
|
| Hospital Charge Code |
3350050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$31.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
CL- LEVALBUTEROL NEBU 0.63MG/3ML
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 00093414656
|
| Hospital Charge Code |
3350050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.25 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$36.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Humana ChoiceCare |
$11.70
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.00
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$39.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.50
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
CL- LEVALBUTEROL NEBU 1.25MG/3ML
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 00093414864
|
| Hospital Charge Code |
3350051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.25 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$36.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Humana ChoiceCare |
$11.70
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.00
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$39.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.50
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
CL- LEVALBUTEROL NEBU 1.25MG/3ML
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 00093414864
|
| Hospital Charge Code |
3350051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$31.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
CL- LIDO 2% JELLY 30ML
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
NDC 17478071130
|
| Hospital Charge Code |
3350112
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$98.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$62.40
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cigna Commercial |
$88.40
|
| Rate for Payer: First Health Commercial |
$93.60
|
| Rate for Payer: First Health Workers Compensation |
$40.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$93.60
|
| Rate for Payer: GEHA Commercial |
$83.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$93.60
|
| Rate for Payer: Humana ChoiceCare |
$27.04
|
| Rate for Payer: Multiplan All |
$94.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$62.40
|
| Rate for Payer: OMNI Networks Commercial |
$72.80
|
| Rate for Payer: One Health Plan PPO/POS |
$93.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$98.80
|
| Rate for Payer: Three Rivers Provider Network All |
$78.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$91.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$96.72
|
| Rate for Payer: Zelis Auto |
$41.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$52.00
|
| Rate for Payer: Zelis Worker's Compensation |
$28.39
|
|
|
CL- LIDO 2% JELLY 30ML
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
NDC 17478071130
|
| Hospital Charge Code |
3350112
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.39 |
| Max. Negotiated Rate |
$98.80 |
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cigna Commercial |
$88.40
|
| Rate for Payer: First Health Commercial |
$93.60
|
| Rate for Payer: First Health Workers Compensation |
$40.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$93.60
|
| Rate for Payer: GEHA Commercial |
$72.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$93.60
|
| Rate for Payer: Multiplan All |
$94.64
|
| Rate for Payer: OMNI Networks Commercial |
$72.80
|
| Rate for Payer: One Health Plan PPO/POS |
$93.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$98.80
|
| Rate for Payer: Three Rivers Provider Network All |
$78.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$96.72
|
| Rate for Payer: Zelis Auto |
$41.60
|
| Rate for Payer: Zelis Worker's Compensation |
$28.39
|
|
|
CL- LIDO 2% JELLY 5ML
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
NDC 17478071110
|
| Hospital Charge Code |
3350113
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.50 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$42.50
|
| Rate for Payer: First Health Commercial |
$45.00
|
| Rate for Payer: First Health Workers Compensation |
$19.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.00
|
| Rate for Payer: GEHA Commercial |
$40.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Humana ChoiceCare |
$13.00
|
| Rate for Payer: Multiplan All |
$45.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.00
|
| Rate for Payer: OMNI Networks Commercial |
$35.00
|
| Rate for Payer: One Health Plan PPO/POS |
$45.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47.50
|
| Rate for Payer: Three Rivers Provider Network All |
$37.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$44.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46.50
|
| Rate for Payer: Zelis Auto |
$20.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$25.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.65
|
|
|
CL- LIDO 2% JELLY 5ML
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
NDC 17478071110
|
| Hospital Charge Code |
3350113
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.65 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$42.50
|
| Rate for Payer: First Health Commercial |
$45.00
|
| Rate for Payer: First Health Workers Compensation |
$19.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.00
|
| Rate for Payer: GEHA Commercial |
$35.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Multiplan All |
$45.50
|
| Rate for Payer: OMNI Networks Commercial |
$35.00
|
| Rate for Payer: One Health Plan PPO/POS |
$45.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47.50
|
| Rate for Payer: Three Rivers Provider Network All |
$37.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46.50
|
| Rate for Payer: Zelis Auto |
$20.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.65
|
|
|
CL- LIDOCAINE 1% 2 ML
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
CPT J2003
|
| Hospital Charge Code |
3350270
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$14.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
|
CL- LIDOCAINE 1% 2 ML
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
CPT J2003
|
| Hospital Charge Code |
3350270
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$16.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Humana ChoiceCare |
$5.20
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.00
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
|
CL- LIDOCAINE 1% 2 ML
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350557
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$14.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
|
CL- LIDOCAINE 1% 2 ML
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350557
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$16.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Humana ChoiceCare |
$5.20
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.00
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
|
CL- LIDOCAINE 1% 50 ML
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350542
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$25.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
CL- LIDOCAINE 1% 50 ML
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350542
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.25 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22.20
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$29.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Humana ChoiceCare |
$9.62
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.20
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$32.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$18.50
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
CL- LIDOCAINE 1% INJ
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
CPT J2003
|
| Hospital Charge Code |
3350052
|
|
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- LIDOCAINE 1% INJ
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
CPT J2003
|
| Hospital Charge Code |
3350052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| 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: 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 |
$13.60
|
| 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- LIDOCAINE 1% W/EPI 20ML
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$26.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$23.80
|
| Rate for Payer: First Health Commercial |
$25.20
|
| Rate for Payer: First Health Workers Compensation |
$10.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$25.20
|
| Rate for Payer: GEHA Commercial |
$22.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$25.20
|
| Rate for Payer: Humana ChoiceCare |
$7.28
|
| Rate for Payer: Multiplan All |
$25.48
|
| Rate for Payer: New Mexico Health Connections Medicare |
$16.80
|
| Rate for Payer: OMNI Networks Commercial |
$19.60
|
| Rate for Payer: One Health Plan PPO/POS |
$25.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$26.60
|
| Rate for Payer: Three Rivers Provider Network All |
$21.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$24.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$26.04
|
| Rate for Payer: Zelis Auto |
$11.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$14.00
|
| Rate for Payer: Zelis Worker's Compensation |
$7.64
|
|
|
CL- LIDOCAINE 1% W/EPI 20ML
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.64 |
| Max. Negotiated Rate |
$26.60 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$23.80
|
| Rate for Payer: First Health Commercial |
$25.20
|
| Rate for Payer: First Health Workers Compensation |
$10.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$25.20
|
| Rate for Payer: GEHA Commercial |
$19.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$25.20
|
| Rate for Payer: Multiplan All |
$25.48
|
| Rate for Payer: OMNI Networks Commercial |
$19.60
|
| Rate for Payer: One Health Plan PPO/POS |
$25.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$26.60
|
| Rate for Payer: Three Rivers Provider Network All |
$21.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$26.04
|
| Rate for Payer: Zelis Auto |
$11.20
|
| Rate for Payer: Zelis Worker's Compensation |
$7.64
|
|
|
CL- LIDOCAINE 2% INJ
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350053
|
|
Hospital Revenue Code
|
636
|
| 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- LIDOCAINE 2% INJ
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350053
|
|
Hospital Revenue Code
|
636
|
| 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- LIDOCAINE 2% JELLY 6 ML PREFILL SYR
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350251
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$34.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$30.60
|
| Rate for Payer: First Health Commercial |
$32.40
|
| Rate for Payer: First Health Workers Compensation |
$13.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$32.40
|
| Rate for Payer: GEHA Commercial |
$28.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$32.40
|
| Rate for Payer: Humana ChoiceCare |
$9.36
|
| Rate for Payer: Multiplan All |
$32.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$21.60
|
| Rate for Payer: OMNI Networks Commercial |
$25.20
|
| Rate for Payer: One Health Plan PPO/POS |
$32.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$34.20
|
| Rate for Payer: Three Rivers Provider Network All |
$27.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$31.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$33.48
|
| Rate for Payer: Zelis Auto |
$14.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.83
|
|
