|
CL- MONOVISC 88 MG/4 ML
|
Facility
|
OP
|
$4,885.00
|
|
|
Service Code
|
CPT J7327
|
| Hospital Charge Code |
3350241
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$541.10 |
| Max. Negotiated Rate |
$4,640.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,468.52
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,931.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,468.52
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,163.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$636.59
|
| Rate for Payer: Cash Price |
$2,931.00
|
| Rate for Payer: Cash Price |
$2,931.00
|
| Rate for Payer: Cigna Commercial |
$4,152.25
|
| Rate for Payer: First Health Commercial |
$4,396.50
|
| Rate for Payer: First Health Workers Compensation |
$1,886.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,396.50
|
| Rate for Payer: GEHA Commercial |
$700.25
|
| Rate for Payer: GEHA Medicare |
$636.59
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,396.50
|
| Rate for Payer: Humana ChoiceCare |
$700.25
|
| Rate for Payer: Humana Medicare Advantage |
$636.59
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,069.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,187.05
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$636.59
|
| Rate for Payer: Multiplan All |
$4,445.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,082.20
|
| Rate for Payer: OMNI Networks Commercial |
$3,419.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4,396.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,370.61
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,187.05
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$636.59
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,640.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,273.18
|
| Rate for Payer: Three Rivers Provider Network All |
$3,663.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$623.86
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,187.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$636.59
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,543.05
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$636.59
|
| Rate for Payer: Zelis Auto |
$1,954.00
|
| Rate for Payer: Zelis Medicare |
$541.10
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$763.91
|
| Rate for Payer: Zelis Worker's Compensation |
$1,333.61
|
|
|
CL- MONOVISC 88 MG/4 ML **PT OWN MED
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J7327
|
| Hospital Charge Code |
3350242
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$1,468.52 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,468.52
|
| 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 |
$1,468.52
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,163.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$636.59
|
| 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 |
$700.25
|
| Rate for Payer: GEHA Medicare |
$636.59
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$700.25
|
| Rate for Payer: Humana Medicare Advantage |
$636.59
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,069.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,187.05
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$636.59
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,082.20
|
| 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 |
$1,370.61
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,187.05
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$636.59
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,273.18
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$623.86
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,187.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$636.59
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$636.59
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Medicare |
$541.10
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$763.91
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- MONOVISC 88 MG/4 ML **PT OWN MED
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J7327
|
| Hospital Charge Code |
3350242
|
|
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- MONSEL'S
|
Facility
|
OP
|
$165.00
|
|
|
Service Code
|
NDC 48783011208
|
| Hospital Charge Code |
3350245
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.25 |
| Max. Negotiated Rate |
$156.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$99.00
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$140.25
|
| Rate for Payer: First Health Commercial |
$148.50
|
| Rate for Payer: First Health Workers Compensation |
$63.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$148.50
|
| Rate for Payer: GEHA Commercial |
$132.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$148.50
|
| Rate for Payer: Humana ChoiceCare |
$42.90
|
| Rate for Payer: Multiplan All |
$150.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$99.00
|
| Rate for Payer: OMNI Networks Commercial |
$115.50
|
| Rate for Payer: One Health Plan PPO/POS |
$148.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$156.75
|
| Rate for Payer: Three Rivers Provider Network All |
$123.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$145.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$41.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$153.45
|
| Rate for Payer: Zelis Auto |
$66.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$82.50
|
| Rate for Payer: Zelis Worker's Compensation |
$45.05
|
|
|
CL- MONSEL'S
|
Facility
|
IP
|
$165.00
|
|
|
Service Code
|
NDC 48783011208
|
| Hospital Charge Code |
3350245
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.05 |
| Max. Negotiated Rate |
$156.75 |
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$140.25
|
| Rate for Payer: First Health Commercial |
$148.50
|
| Rate for Payer: First Health Workers Compensation |
$63.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$148.50
|
| Rate for Payer: GEHA Commercial |
$115.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$148.50
|
| Rate for Payer: Multiplan All |
$150.15
|
| Rate for Payer: OMNI Networks Commercial |
$115.50
|
| Rate for Payer: One Health Plan PPO/POS |
$148.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$156.75
|
| Rate for Payer: Three Rivers Provider Network All |
$123.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$153.45
|
| Rate for Payer: Zelis Auto |
$66.00
|
| Rate for Payer: Zelis Worker's Compensation |
$45.05
|
|
|
CL- NALOXONE 0.4 MG/mL
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
CPT J2310
|
| Hospital Charge Code |
3350410
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.74 |
| Max. Negotiated Rate |
$40.85 |
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$36.55
|
| Rate for Payer: First Health Commercial |
$38.70
|
| Rate for Payer: First Health Workers Compensation |
$16.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$38.70
|
| Rate for Payer: GEHA Commercial |
$30.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$38.70
|
| Rate for Payer: Multiplan All |
$39.13
|
| Rate for Payer: OMNI Networks Commercial |
$30.10
|
| Rate for Payer: One Health Plan PPO/POS |
$38.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$40.85
|
| Rate for Payer: Three Rivers Provider Network All |
$32.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$39.99
|
| Rate for Payer: Zelis Auto |
$17.20
|
| Rate for Payer: Zelis Worker's Compensation |
$11.74
|
|
|
CL- NALOXONE 0.4 MG/mL
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
CPT J2310
|
| Hospital Charge Code |
3350410
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.75 |
| Max. Negotiated Rate |
$40.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$25.80
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$36.55
|
| Rate for Payer: First Health Commercial |
$38.70
|
| Rate for Payer: First Health Workers Compensation |
$16.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$38.70
|
| Rate for Payer: GEHA Commercial |
$34.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$38.70
|
| Rate for Payer: Humana ChoiceCare |
$11.18
|
| Rate for Payer: Multiplan All |
$39.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.80
|
| Rate for Payer: OMNI Networks Commercial |
$30.10
|
| Rate for Payer: One Health Plan PPO/POS |
$38.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$40.85
|
| Rate for Payer: Three Rivers Provider Network All |
$32.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$37.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$39.99
|
| Rate for Payer: Zelis Auto |
$17.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.50
|
| Rate for Payer: Zelis Worker's Compensation |
$11.74
|
|
|
CL- NIFEDIPINE CAP 10MG
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 23155019401
|
| Hospital Charge Code |
3350067
|
|
Hospital Revenue Code
|
250
|
| 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: 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 |
$8.00
|
| 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- NIFEDIPINE CAP 10MG
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 23155019401
|
| Hospital Charge Code |
3350067
|
|
Hospital Revenue Code
|
250
|
| 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- NITROGLYCERIN SL TAB 0.4MG
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 00071041813
|
| Hospital Charge Code |
3350068
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
CL- NITROGLYCERIN SL TAB 0.4MG
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 00071041813
|
| Hospital Charge Code |
3350068
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$6.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Humana ChoiceCare |
$2.08
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.80
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
CL- NIVOLUMAB 1 MG
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
CPT J9299
|
| Hospital Charge Code |
3350339
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.93 |
| Max. Negotiated Rate |
$79.80 |
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$71.40
|
| Rate for Payer: First Health Commercial |
$75.60
|
| Rate for Payer: First Health Workers Compensation |
$32.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$75.60
|
| Rate for Payer: GEHA Commercial |
$58.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$75.60
|
| Rate for Payer: Multiplan All |
$76.44
|
| Rate for Payer: OMNI Networks Commercial |
$58.80
|
| Rate for Payer: One Health Plan PPO/POS |
$75.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$79.80
|
| Rate for Payer: Three Rivers Provider Network All |
$63.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$78.12
|
| Rate for Payer: Zelis Auto |
$33.60
|
| Rate for Payer: Zelis Worker's Compensation |
$22.93
|
|
|
CL- NIVOLUMAB 1 MG
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
CPT J9299
|
| Hospital Charge Code |
3350339
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.93 |
| Max. Negotiated Rate |
$79.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$38.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$38.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$30.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$32.96
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$71.40
|
| Rate for Payer: First Health Commercial |
$75.60
|
| Rate for Payer: First Health Workers Compensation |
$32.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$75.60
|
| Rate for Payer: GEHA Commercial |
$36.26
|
| Rate for Payer: GEHA Medicare |
$32.96
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$75.60
|
| Rate for Payer: Humana ChoiceCare |
$36.26
|
| Rate for Payer: Humana Medicare Advantage |
$32.96
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$55.37
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$30.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$32.96
|
| Rate for Payer: Multiplan All |
$76.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$56.03
|
| Rate for Payer: OMNI Networks Commercial |
$58.80
|
| Rate for Payer: One Health Plan PPO/POS |
$75.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$35.53
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$30.77
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$32.96
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$79.80
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$65.92
|
| Rate for Payer: Three Rivers Provider Network All |
$63.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$32.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$30.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.96
|
| Rate for Payer: United Payors & United Providers UP&UP |
$78.12
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$32.96
|
| Rate for Payer: Zelis Auto |
$33.60
|
| Rate for Payer: Zelis Medicare |
$28.02
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$39.55
|
| Rate for Payer: Zelis Worker's Compensation |
$22.93
|
|
|
CLNOSCPY, FLXBLE; W/ ABLTION OF TMR POLY
|
Facility
|
IP
|
$3,942.21
|
|
|
Service Code
|
CPT 45388
|
| Hospital Charge Code |
6145388
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,076.22 |
| Max. Negotiated Rate |
$3,745.10 |
| Rate for Payer: Cash Price |
$2,365.33
|
| Rate for Payer: Cigna Commercial |
$3,350.88
|
| Rate for Payer: First Health Commercial |
$3,547.99
|
| Rate for Payer: First Health Workers Compensation |
$1,522.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,547.99
|
| Rate for Payer: GEHA Commercial |
$2,759.55
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,547.99
|
| Rate for Payer: Multiplan All |
$3,587.41
|
| Rate for Payer: OMNI Networks Commercial |
$2,759.55
|
| Rate for Payer: One Health Plan PPO/POS |
$3,547.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,745.10
|
| Rate for Payer: Three Rivers Provider Network All |
$2,956.66
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,666.26
|
| Rate for Payer: Zelis Auto |
$1,576.88
|
| Rate for Payer: Zelis Worker's Compensation |
$1,076.22
|
|
|
CLNOSCPY, FLXBLE; W/ ABLTION OF TMR POLY
|
Facility
|
OP
|
$3,942.21
|
|
|
Service Code
|
CPT 45388
|
| Hospital Charge Code |
6145388
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$938.22 |
| Max. Negotiated Rate |
$3,745.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,184.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,365.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,184.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$938.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,119.58
|
| Rate for Payer: Cash Price |
$2,365.33
|
| Rate for Payer: Cash Price |
$2,365.33
|
| Rate for Payer: Cigna Commercial |
$3,350.88
|
| Rate for Payer: First Health Commercial |
$3,547.99
|
| Rate for Payer: First Health Workers Compensation |
$1,522.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,547.99
|
| Rate for Payer: GEHA Commercial |
$3,153.77
|
| Rate for Payer: GEHA Medicare |
$1,119.58
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,547.99
|
| Rate for Payer: Humana ChoiceCare |
$1,231.54
|
| Rate for Payer: Humana Medicare Advantage |
$1,119.58
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,880.89
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$957.33
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,119.58
|
| Rate for Payer: Multiplan All |
$3,587.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,903.29
|
| Rate for Payer: OMNI Networks Commercial |
$2,759.55
|
| Rate for Payer: One Health Plan PPO/POS |
$3,547.99
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,105.37
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$957.33
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,119.58
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,745.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$2,239.16
|
| Rate for Payer: Three Rivers Provider Network All |
$2,956.66
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,097.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$957.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,119.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,666.26
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,119.58
|
| Rate for Payer: Zelis Auto |
$1,576.88
|
| Rate for Payer: Zelis Medicare |
$951.64
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,343.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1,076.22
|
|
|
CL- NS 0.9% - 100ML
|
Facility
|
OP
|
$41.00
|
|
|
Service Code
|
NDC 00338055318
|
| Hospital Charge Code |
3350100
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$32.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Humana ChoiceCare |
$10.66
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.60
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$36.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.50
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
CL- NS 0.9% - 100ML
|
Facility
|
IP
|
$41.00
|
|
|
Service Code
|
NDC 00338055318
|
| Hospital Charge Code |
3350100
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$28.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
CL- NS 0.9% 100 mL (non IV use)
|
Facility
|
OP
|
$41.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$32.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Humana ChoiceCare |
$10.66
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.60
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$36.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.50
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
CL- NS 0.9% 100 mL (non IV use)
|
Facility
|
IP
|
$41.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$28.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
CL- NS 0.9% - 50ML
|
Facility
|
OP
|
$41.00
|
|
|
Service Code
|
NDC 00338055311
|
| Hospital Charge Code |
3350101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$32.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Humana ChoiceCare |
$10.66
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.60
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$36.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.50
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
CL- NS 0.9% - 50ML
|
Facility
|
IP
|
$41.00
|
|
|
Service Code
|
NDC 00338055311
|
| Hospital Charge Code |
3350101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$28.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
clobazam REF790500
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
CPT 80339
|
| Hospital Charge Code |
2299545
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$27.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$134.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Humana ChoiceCare |
$43.68
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$100.80
|
| Rate for Payer: OMNI Networks Commercial |
$117.60
|
| Rate for Payer: One Health Plan PPO/POS |
$151.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$147.84
|
| Rate for Payer: United Healthcare Commercial |
$142.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$84.00
|
| Rate for Payer: Zelis Worker's Compensation |
$19.29
|
|
|
clobazam REF790500
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
CPT 80339
|
| Hospital Charge Code |
2299545
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$27.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$117.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: OMNI Networks Commercial |
$117.60
|
| Rate for Payer: One Health Plan PPO/POS |
$151.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Worker's Compensation |
$19.29
|
|
|
CLOBETASOL 0.05% - 15GM/LUBRIDERM
|
Facility
|
IP
|
$193.00
|
|
| Hospital Charge Code |
3300190
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.69 |
| Max. Negotiated Rate |
$183.35 |
| Rate for Payer: Cash Price |
$115.80
|
| Rate for Payer: Cigna Commercial |
$164.05
|
| Rate for Payer: First Health Commercial |
$173.70
|
| Rate for Payer: First Health Workers Compensation |
$74.52
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$173.70
|
| Rate for Payer: GEHA Commercial |
$135.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$173.70
|
| Rate for Payer: Multiplan All |
$175.63
|
| Rate for Payer: OMNI Networks Commercial |
$135.10
|
| Rate for Payer: One Health Plan PPO/POS |
$173.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$183.35
|
| Rate for Payer: Three Rivers Provider Network All |
$144.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$179.49
|
| Rate for Payer: Zelis Auto |
$77.20
|
| Rate for Payer: Zelis Worker's Compensation |
$52.69
|
|
|
CLOBETASOL 0.05% - 15GM/LUBRIDERM
|
Facility
|
OP
|
$193.00
|
|
| Hospital Charge Code |
3300190
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.25 |
| Max. Negotiated Rate |
$183.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$115.80
|
| Rate for Payer: Cash Price |
$115.80
|
| Rate for Payer: Cigna Commercial |
$164.05
|
| Rate for Payer: First Health Commercial |
$173.70
|
| Rate for Payer: First Health Workers Compensation |
$74.52
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$173.70
|
| Rate for Payer: GEHA Commercial |
$154.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$173.70
|
| Rate for Payer: Humana ChoiceCare |
$50.18
|
| Rate for Payer: Multiplan All |
$175.63
|
| Rate for Payer: New Mexico Health Connections Medicare |
$115.80
|
| Rate for Payer: OMNI Networks Commercial |
$135.10
|
| Rate for Payer: One Health Plan PPO/POS |
$173.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$183.35
|
| Rate for Payer: Three Rivers Provider Network All |
$144.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$169.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$48.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$179.49
|
| Rate for Payer: Zelis Auto |
$77.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$96.50
|
| Rate for Payer: Zelis Worker's Compensation |
$52.69
|
|
