|
CL- LIDOCAINE 2% JELLY 6 ML PREFILL SYR
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350251
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.83 |
| Max. Negotiated Rate |
$34.20 |
| 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 |
$25.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$32.40
|
| Rate for Payer: Multiplan All |
$32.76
|
| 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: United Payors & United Providers UP&UP |
$33.48
|
| Rate for Payer: Zelis Auto |
$14.40
|
| Rate for Payer: Zelis Worker's Compensation |
$9.83
|
|
|
CL- LIDOCAINE 2% W/EPI (PER 5 ML)
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
CPT J2004
|
| Hospital Charge Code |
3350057
|
|
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% W/EPI (PER 5 ML)
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
CPT J2004
|
| Hospital Charge Code |
3350057
|
|
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 4% 5ML
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.28 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cigna Commercial |
$28.90
|
| Rate for Payer: First Health Commercial |
$30.60
|
| Rate for Payer: First Health Workers Compensation |
$13.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$30.60
|
| Rate for Payer: GEHA Commercial |
$23.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$30.60
|
| Rate for Payer: Multiplan All |
$30.94
|
| Rate for Payer: OMNI Networks Commercial |
$23.80
|
| Rate for Payer: One Health Plan PPO/POS |
$30.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$32.30
|
| Rate for Payer: Three Rivers Provider Network All |
$25.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$31.62
|
| Rate for Payer: Zelis Auto |
$13.60
|
| Rate for Payer: Zelis Worker's Compensation |
$9.28
|
|
|
CL- LIDOCAINE 4% 5ML
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$20.40
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cigna Commercial |
$28.90
|
| Rate for Payer: First Health Commercial |
$30.60
|
| Rate for Payer: First Health Workers Compensation |
$13.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$30.60
|
| Rate for Payer: GEHA Commercial |
$27.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$30.60
|
| Rate for Payer: Humana ChoiceCare |
$8.84
|
| Rate for Payer: Multiplan All |
$30.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$20.40
|
| Rate for Payer: OMNI Networks Commercial |
$23.80
|
| Rate for Payer: One Health Plan PPO/POS |
$30.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$32.30
|
| Rate for Payer: Three Rivers Provider Network All |
$25.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$29.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$31.62
|
| Rate for Payer: Zelis Auto |
$13.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.28
|
|
|
CL- LIDOCAINE VISCOUS 2% - ORAL
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350055
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$8.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Humana ChoiceCare |
$2.86
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.60
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
CL- LIDOCAINE VISCOUS 2% - ORAL
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350055
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$7.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
CL- LOPERAMIDE LIQ 1MG/5ML
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 50383061804
|
| Hospital Charge Code |
3350058
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$4.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Humana ChoiceCare |
$1.30
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.00
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
CL- LOPERAMIDE LIQ 1MG/5ML
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 50383061804
|
| Hospital Charge Code |
3350058
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
CL- LOSARTAN 50 MG TAB
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 00904704861
|
| Hospital Charge Code |
3350518
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.92
|
| Rate for Payer: Cash Price |
$1.92
|
| Rate for Payer: Cigna Commercial |
$2.72
|
| Rate for Payer: First Health Commercial |
$2.88
|
| Rate for Payer: First Health Workers Compensation |
$1.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.88
|
| Rate for Payer: GEHA Commercial |
$2.56
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.88
|
| Rate for Payer: Humana ChoiceCare |
$0.83
|
| Rate for Payer: Multiplan All |
$2.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.92
|
| Rate for Payer: OMNI Networks Commercial |
$2.24
|
| Rate for Payer: One Health Plan PPO/POS |
$2.88
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.04
|
| Rate for Payer: Three Rivers Provider Network All |
$2.40
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.82
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.80
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.98
|
| Rate for Payer: Zelis Auto |
$1.28
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$0.87
|
|
|
CL- LOSARTAN 50 MG TAB
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 00904704861
|
| Hospital Charge Code |
3350518
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Cash Price |
$1.92
|
| Rate for Payer: Cigna Commercial |
$2.72
|
| Rate for Payer: First Health Commercial |
$2.88
|
| Rate for Payer: First Health Workers Compensation |
$1.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.88
|
| Rate for Payer: GEHA Commercial |
$2.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.88
|
| Rate for Payer: Multiplan All |
$2.91
|
| Rate for Payer: OMNI Networks Commercial |
$2.24
|
| Rate for Payer: One Health Plan PPO/POS |
$2.88
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.04
|
| Rate for Payer: Three Rivers Provider Network All |
$2.40
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.98
|
| Rate for Payer: Zelis Auto |
$1.28
|
| Rate for Payer: Zelis Worker's Compensation |
$0.87
|
|
|
CL- LUGOLS SOLUTION
|
Facility
|
IP
|
$257.00
|
|
|
Service Code
|
NDC 48433023015
|
| Hospital Charge Code |
3350249
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.16 |
| Max. Negotiated Rate |
$244.15 |
| Rate for Payer: Cash Price |
$154.20
|
| Rate for Payer: Cigna Commercial |
$218.45
|
| Rate for Payer: First Health Commercial |
$231.30
|
| Rate for Payer: First Health Workers Compensation |
$99.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$231.30
|
| Rate for Payer: GEHA Commercial |
$179.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$231.30
|
| Rate for Payer: Multiplan All |
$233.87
|
| Rate for Payer: OMNI Networks Commercial |
$179.90
|
| Rate for Payer: One Health Plan PPO/POS |
$231.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$244.15
|
| Rate for Payer: Three Rivers Provider Network All |
$192.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$239.01
|
| Rate for Payer: Zelis Auto |
$102.80
|
| Rate for Payer: Zelis Worker's Compensation |
$70.16
|
|
|
CL- LUGOLS SOLUTION
|
Facility
|
OP
|
$257.00
|
|
|
Service Code
|
NDC 48433023015
|
| Hospital Charge Code |
3350249
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.25 |
| Max. Negotiated Rate |
$244.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$154.20
|
| Rate for Payer: Cash Price |
$154.20
|
| Rate for Payer: Cigna Commercial |
$218.45
|
| Rate for Payer: First Health Commercial |
$231.30
|
| Rate for Payer: First Health Workers Compensation |
$99.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$231.30
|
| Rate for Payer: GEHA Commercial |
$205.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$231.30
|
| Rate for Payer: Humana ChoiceCare |
$66.82
|
| Rate for Payer: Multiplan All |
$233.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$154.20
|
| Rate for Payer: OMNI Networks Commercial |
$179.90
|
| Rate for Payer: One Health Plan PPO/POS |
$231.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$244.15
|
| Rate for Payer: Three Rivers Provider Network All |
$192.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$226.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$64.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$239.01
|
| Rate for Payer: Zelis Auto |
$102.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$128.50
|
| Rate for Payer: Zelis Worker's Compensation |
$70.16
|
|
|
CL- LUSPATERCEPT-AAMT 25 MG VIAL
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
CPT J0896
|
| Hospital Charge Code |
3350442
|
|
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- LUSPATERCEPT-AAMT 25 MG VIAL
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
CPT J0896
|
| Hospital Charge Code |
3350442
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$83.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$54.57
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$54.57
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$43.23
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$41.98
|
| Rate for Payer: Cash Price |
$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 |
$46.18
|
| Rate for Payer: GEHA Medicare |
$41.98
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Humana ChoiceCare |
$46.18
|
| Rate for Payer: Humana Medicare Advantage |
$41.98
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$70.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$44.11
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$41.98
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$71.37
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$50.93
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$44.11
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$41.98
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$83.96
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$41.14
|
| Rate for Payer: United Healthcare Managed Medicaid |
$44.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.98
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$41.98
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Medicare |
$35.68
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$50.38
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
CL- MAG AL PLUS 200-200-20MG/ML - 30ML
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
CL- MAG AL PLUS 200-200-20MG/ML - 30ML
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
CL- MAGNESIUM 500 MG IVPB
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
CPT J3475
|
| Hospital Charge Code |
3350418
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$21.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$13.80
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cigna Commercial |
$19.55
|
| Rate for Payer: First Health Commercial |
$20.70
|
| Rate for Payer: First Health Workers Compensation |
$8.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$20.70
|
| Rate for Payer: GEHA Commercial |
$0.53
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$20.70
|
| Rate for Payer: Humana ChoiceCare |
$5.98
|
| Rate for Payer: Multiplan All |
$20.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$13.80
|
| Rate for Payer: OMNI Networks Commercial |
$16.10
|
| Rate for Payer: One Health Plan PPO/POS |
$20.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$21.85
|
| Rate for Payer: Three Rivers Provider Network All |
$17.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$20.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$21.39
|
| Rate for Payer: Zelis Auto |
$9.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$11.50
|
| Rate for Payer: Zelis Worker's Compensation |
$6.28
|
|
|
CL- MAGNESIUM 500 MG IVPB
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
CPT J3475
|
| Hospital Charge Code |
3350418
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.28 |
| Max. Negotiated Rate |
$21.85 |
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cigna Commercial |
$19.55
|
| Rate for Payer: First Health Commercial |
$20.70
|
| Rate for Payer: First Health Workers Compensation |
$8.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$20.70
|
| Rate for Payer: GEHA Commercial |
$16.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$20.70
|
| Rate for Payer: Multiplan All |
$20.93
|
| Rate for Payer: OMNI Networks Commercial |
$16.10
|
| Rate for Payer: One Health Plan PPO/POS |
$20.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$21.85
|
| Rate for Payer: Three Rivers Provider Network All |
$17.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$21.39
|
| Rate for Payer: Zelis Auto |
$9.20
|
| Rate for Payer: Zelis Worker's Compensation |
$6.28
|
|
|
CL- MEDROXYPROGESTERONE IM 150MG/ML
|
Facility
|
IP
|
$406.65
|
|
|
Service Code
|
CPT J1050
|
| Hospital Charge Code |
3350059
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$111.02 |
| Max. Negotiated Rate |
$386.32 |
| Rate for Payer: Cash Price |
$243.99
|
| Rate for Payer: Cigna Commercial |
$345.65
|
| Rate for Payer: First Health Commercial |
$365.99
|
| Rate for Payer: First Health Workers Compensation |
$157.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$365.99
|
| Rate for Payer: GEHA Commercial |
$284.65
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$365.99
|
| Rate for Payer: Multiplan All |
$370.05
|
| Rate for Payer: OMNI Networks Commercial |
$284.65
|
| Rate for Payer: One Health Plan PPO/POS |
$365.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$386.32
|
| Rate for Payer: Three Rivers Provider Network All |
$304.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$378.18
|
| Rate for Payer: Zelis Auto |
$162.66
|
| Rate for Payer: Zelis Worker's Compensation |
$111.02
|
|
|
CL- MEDROXYPROGESTERONE IM 150MG/ML
|
Facility
|
OP
|
$406.65
|
|
|
Service Code
|
CPT J1050
|
| Hospital Charge Code |
3350059
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$101.66 |
| Max. Negotiated Rate |
$386.32 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$243.99
|
| Rate for Payer: Cash Price |
$243.99
|
| Rate for Payer: Cigna Commercial |
$345.65
|
| Rate for Payer: First Health Commercial |
$365.99
|
| Rate for Payer: First Health Workers Compensation |
$157.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$365.99
|
| Rate for Payer: GEHA Commercial |
$325.32
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$365.99
|
| Rate for Payer: Humana ChoiceCare |
$105.73
|
| Rate for Payer: Multiplan All |
$370.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$243.99
|
| Rate for Payer: OMNI Networks Commercial |
$284.65
|
| Rate for Payer: One Health Plan PPO/POS |
$365.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$386.32
|
| Rate for Payer: Three Rivers Provider Network All |
$304.99
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$357.85
|
| Rate for Payer: United Healthcare Managed Medicaid |
$101.66
|
| Rate for Payer: United Payors & United Providers UP&UP |
$378.18
|
| Rate for Payer: Zelis Auto |
$162.66
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$203.32
|
| Rate for Payer: Zelis Worker's Compensation |
$111.02
|
|
|
CL- MENACTRA
|
Facility
|
OP
|
$772.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
3350429
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$111.49 |
| Max. Negotiated Rate |
$733.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$140.73
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$463.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$140.73
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$111.49
|
| Rate for Payer: Cash Price |
$463.20
|
| Rate for Payer: Cash Price |
$463.20
|
| Rate for Payer: Cigna Commercial |
$656.20
|
| Rate for Payer: First Health Commercial |
$694.80
|
| Rate for Payer: First Health Workers Compensation |
$298.07
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$694.80
|
| Rate for Payer: GEHA Commercial |
$617.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$694.80
|
| Rate for Payer: Humana ChoiceCare |
$200.72
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$113.76
|
| Rate for Payer: Multiplan All |
$702.52
|
| Rate for Payer: New Mexico Health Connections Medicare |
$463.20
|
| Rate for Payer: OMNI Networks Commercial |
$540.40
|
| Rate for Payer: One Health Plan PPO/POS |
$694.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$131.35
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$113.76
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$733.40
|
| Rate for Payer: Three Rivers Provider Network All |
$579.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$679.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$113.76
|
| Rate for Payer: United Payors & United Providers UP&UP |
$717.96
|
| Rate for Payer: Zelis Auto |
$308.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$386.00
|
| Rate for Payer: Zelis Worker's Compensation |
$210.76
|
|
|
CL- MENACTRA
|
Facility
|
IP
|
$772.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
3350429
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$210.76 |
| Max. Negotiated Rate |
$733.40 |
| Rate for Payer: Cash Price |
$463.20
|
| Rate for Payer: Cigna Commercial |
$656.20
|
| Rate for Payer: First Health Commercial |
$694.80
|
| Rate for Payer: First Health Workers Compensation |
$298.07
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$694.80
|
| Rate for Payer: GEHA Commercial |
$540.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$694.80
|
| Rate for Payer: Multiplan All |
$702.52
|
| Rate for Payer: OMNI Networks Commercial |
$540.40
|
| Rate for Payer: One Health Plan PPO/POS |
$694.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$733.40
|
| Rate for Payer: Three Rivers Provider Network All |
$579.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$717.96
|
| Rate for Payer: Zelis Auto |
$308.80
|
| Rate for Payer: Zelis Worker's Compensation |
$210.76
|
|
|
CL- MESNA 200 MG
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
CPT J9209
|
| Hospital Charge Code |
3350330
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$2.05
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Humana ChoiceCare |
$1.56
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.60
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
CL- MESNA 200 MG
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
CPT J9209
|
| Hospital Charge Code |
3350330
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
