|
CLOBETASOL CREAM 0.05%
|
Facility
|
OP
|
$509.00
|
|
|
Service Code
|
NDC 00168030130
|
| Hospital Charge Code |
3300191
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$127.25 |
| Max. Negotiated Rate |
$483.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$305.40
|
| Rate for Payer: Cash Price |
$305.40
|
| Rate for Payer: Cigna Commercial |
$432.65
|
| Rate for Payer: First Health Commercial |
$458.10
|
| Rate for Payer: First Health Workers Compensation |
$196.52
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$458.10
|
| Rate for Payer: GEHA Commercial |
$407.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$458.10
|
| Rate for Payer: Humana ChoiceCare |
$132.34
|
| Rate for Payer: Multiplan All |
$463.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$305.40
|
| Rate for Payer: OMNI Networks Commercial |
$356.30
|
| Rate for Payer: One Health Plan PPO/POS |
$458.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$483.55
|
| Rate for Payer: Three Rivers Provider Network All |
$381.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$447.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$127.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$473.37
|
| Rate for Payer: Zelis Auto |
$203.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$254.50
|
| Rate for Payer: Zelis Worker's Compensation |
$138.96
|
|
|
CLOBETASOL CREAM 0.05%
|
Facility
|
IP
|
$509.00
|
|
|
Service Code
|
NDC 00168030130
|
| Hospital Charge Code |
3300191
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$138.96 |
| Max. Negotiated Rate |
$483.55 |
| Rate for Payer: Cash Price |
$305.40
|
| Rate for Payer: Cigna Commercial |
$432.65
|
| Rate for Payer: First Health Commercial |
$458.10
|
| Rate for Payer: First Health Workers Compensation |
$196.52
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$458.10
|
| Rate for Payer: GEHA Commercial |
$356.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$458.10
|
| Rate for Payer: Multiplan All |
$463.19
|
| Rate for Payer: OMNI Networks Commercial |
$356.30
|
| Rate for Payer: One Health Plan PPO/POS |
$458.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$483.55
|
| Rate for Payer: Three Rivers Provider Network All |
$381.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$473.37
|
| Rate for Payer: Zelis Auto |
$203.60
|
| Rate for Payer: Zelis Worker's Compensation |
$138.96
|
|
|
CL- OCREVUS IV SOLUTION 1 MG
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT J2350
|
| Hospital Charge Code |
3350336
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.77 |
| Max. Negotiated Rate |
$166.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$107.37
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$105.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$107.37
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$85.06
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$59.41
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cigna Commercial |
$148.75
|
| Rate for Payer: First Health Commercial |
$157.50
|
| Rate for Payer: First Health Workers Compensation |
$67.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$157.50
|
| Rate for Payer: GEHA Commercial |
$65.35
|
| Rate for Payer: GEHA Medicare |
$59.41
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$157.50
|
| Rate for Payer: Humana ChoiceCare |
$65.35
|
| Rate for Payer: Humana Medicare Advantage |
$59.41
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$99.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$86.79
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$59.41
|
| Rate for Payer: Multiplan All |
$159.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$101.00
|
| Rate for Payer: OMNI Networks Commercial |
$122.50
|
| Rate for Payer: One Health Plan PPO/POS |
$157.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$100.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$86.79
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$59.41
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$166.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$118.82
|
| Rate for Payer: Three Rivers Provider Network All |
$131.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$58.22
|
| Rate for Payer: United Healthcare Managed Medicaid |
$86.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$59.41
|
| Rate for Payer: United Payors & United Providers UP&UP |
$162.75
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$59.41
|
| Rate for Payer: Zelis Auto |
$70.00
|
| Rate for Payer: Zelis Medicare |
$50.50
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$71.29
|
| Rate for Payer: Zelis Worker's Compensation |
$47.77
|
|
|
CL- OCREVUS IV SOLUTION 1 MG
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT J2350
|
| Hospital Charge Code |
3350336
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.77 |
| Max. Negotiated Rate |
$166.25 |
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cigna Commercial |
$148.75
|
| Rate for Payer: First Health Commercial |
$157.50
|
| Rate for Payer: First Health Workers Compensation |
$67.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$157.50
|
| Rate for Payer: GEHA Commercial |
$122.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$157.50
|
| Rate for Payer: Multiplan All |
$159.25
|
| Rate for Payer: OMNI Networks Commercial |
$122.50
|
| Rate for Payer: One Health Plan PPO/POS |
$157.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$166.25
|
| Rate for Payer: Three Rivers Provider Network All |
$131.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$162.75
|
| Rate for Payer: Zelis Auto |
$70.00
|
| Rate for Payer: Zelis Worker's Compensation |
$47.77
|
|
|
CL- OCTAGAM 500 MG
|
Facility
|
OP
|
$99.00
|
|
|
Service Code
|
CPT J1568
|
| Hospital Charge Code |
3350337
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.03 |
| Max. Negotiated Rate |
$95.06 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$73.95
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$59.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$73.95
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$58.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$47.53
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$84.15
|
| Rate for Payer: First Health Commercial |
$89.10
|
| Rate for Payer: First Health Workers Compensation |
$38.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$89.10
|
| Rate for Payer: GEHA Commercial |
$52.28
|
| Rate for Payer: GEHA Medicare |
$47.53
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$89.10
|
| Rate for Payer: Humana ChoiceCare |
$52.28
|
| Rate for Payer: Humana Medicare Advantage |
$47.53
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$79.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$59.78
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$47.53
|
| Rate for Payer: Multiplan All |
$90.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$80.80
|
| Rate for Payer: OMNI Networks Commercial |
$69.30
|
| Rate for Payer: One Health Plan PPO/POS |
$89.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$69.02
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$59.78
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$47.53
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$94.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$95.06
|
| Rate for Payer: Three Rivers Provider Network All |
$74.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$46.58
|
| Rate for Payer: United Healthcare Managed Medicaid |
$59.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$92.07
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$47.53
|
| Rate for Payer: Zelis Auto |
$39.60
|
| Rate for Payer: Zelis Medicare |
$40.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$57.04
|
| Rate for Payer: Zelis Worker's Compensation |
$27.03
|
|
|
CL- OCTAGAM 500 MG
|
Facility
|
IP
|
$99.00
|
|
|
Service Code
|
CPT J1568
|
| Hospital Charge Code |
3350337
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.03 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$84.15
|
| Rate for Payer: First Health Commercial |
$89.10
|
| Rate for Payer: First Health Workers Compensation |
$38.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$89.10
|
| Rate for Payer: GEHA Commercial |
$69.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$89.10
|
| Rate for Payer: Multiplan All |
$90.09
|
| Rate for Payer: OMNI Networks Commercial |
$69.30
|
| Rate for Payer: One Health Plan PPO/POS |
$89.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$94.05
|
| Rate for Payer: Three Rivers Provider Network All |
$74.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$92.07
|
| Rate for Payer: Zelis Auto |
$39.60
|
| Rate for Payer: Zelis Worker's Compensation |
$27.03
|
|
|
CL- OCTREOTIDE ACETATE 1 MG INJ
|
Facility
|
IP
|
$603.00
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
3350358
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$164.62 |
| Max. Negotiated Rate |
$572.85 |
| Rate for Payer: Cash Price |
$361.80
|
| Rate for Payer: Cigna Commercial |
$512.55
|
| Rate for Payer: First Health Commercial |
$542.70
|
| Rate for Payer: First Health Workers Compensation |
$232.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$542.70
|
| Rate for Payer: GEHA Commercial |
$422.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$542.70
|
| Rate for Payer: Multiplan All |
$548.73
|
| Rate for Payer: OMNI Networks Commercial |
$422.10
|
| Rate for Payer: One Health Plan PPO/POS |
$542.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$572.85
|
| Rate for Payer: Three Rivers Provider Network All |
$452.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$560.79
|
| Rate for Payer: Zelis Auto |
$241.20
|
| Rate for Payer: Zelis Worker's Compensation |
$164.62
|
|
|
CL- OCTREOTIDE ACETATE 1 MG INJ
|
Facility
|
OP
|
$603.00
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
3350358
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$164.62 |
| Max. Negotiated Rate |
$572.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$217.03
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$361.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$217.03
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$171.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$203.58
|
| Rate for Payer: Cash Price |
$361.80
|
| Rate for Payer: Cash Price |
$361.80
|
| Rate for Payer: Cigna Commercial |
$512.55
|
| Rate for Payer: First Health Commercial |
$542.70
|
| Rate for Payer: First Health Workers Compensation |
$232.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$542.70
|
| Rate for Payer: GEHA Commercial |
$223.94
|
| Rate for Payer: GEHA Medicare |
$203.58
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$542.70
|
| Rate for Payer: Humana ChoiceCare |
$223.94
|
| Rate for Payer: Humana Medicare Advantage |
$203.58
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$342.01
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$175.44
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$203.58
|
| Rate for Payer: Multiplan All |
$548.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$346.09
|
| Rate for Payer: OMNI Networks Commercial |
$422.10
|
| Rate for Payer: One Health Plan PPO/POS |
$542.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$202.57
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$175.44
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$203.58
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$572.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$407.16
|
| Rate for Payer: Three Rivers Provider Network All |
$452.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$199.51
|
| Rate for Payer: United Healthcare Managed Medicaid |
$175.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$203.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$560.79
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$203.58
|
| Rate for Payer: Zelis Auto |
$241.20
|
| Rate for Payer: Zelis Medicare |
$173.04
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$244.30
|
| Rate for Payer: Zelis Worker's Compensation |
$164.62
|
|
|
CL- OFLOXACIN OTIC SOLN 0.3%
|
Facility
|
IP
|
$302.00
|
|
|
Service Code
|
NDC 60505036301
|
| Hospital Charge Code |
3350095
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.45 |
| Max. Negotiated Rate |
$286.90 |
| Rate for Payer: Cash Price |
$181.20
|
| Rate for Payer: Cigna Commercial |
$256.70
|
| Rate for Payer: First Health Commercial |
$271.80
|
| Rate for Payer: First Health Workers Compensation |
$116.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$271.80
|
| Rate for Payer: GEHA Commercial |
$211.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$271.80
|
| Rate for Payer: Multiplan All |
$274.82
|
| Rate for Payer: OMNI Networks Commercial |
$211.40
|
| Rate for Payer: One Health Plan PPO/POS |
$271.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$286.90
|
| Rate for Payer: Three Rivers Provider Network All |
$226.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$280.86
|
| Rate for Payer: Zelis Auto |
$120.80
|
| Rate for Payer: Zelis Worker's Compensation |
$82.45
|
|
|
CL- OFLOXACIN OTIC SOLN 0.3%
|
Facility
|
OP
|
$302.00
|
|
|
Service Code
|
NDC 60505036301
|
| Hospital Charge Code |
3350095
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.50 |
| Max. Negotiated Rate |
$286.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$181.20
|
| Rate for Payer: Cash Price |
$181.20
|
| Rate for Payer: Cigna Commercial |
$256.70
|
| Rate for Payer: First Health Commercial |
$271.80
|
| Rate for Payer: First Health Workers Compensation |
$116.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$271.80
|
| Rate for Payer: GEHA Commercial |
$241.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$271.80
|
| Rate for Payer: Humana ChoiceCare |
$78.52
|
| Rate for Payer: Multiplan All |
$274.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$181.20
|
| Rate for Payer: OMNI Networks Commercial |
$211.40
|
| Rate for Payer: One Health Plan PPO/POS |
$271.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$286.90
|
| Rate for Payer: Three Rivers Provider Network All |
$226.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$265.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$75.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$280.86
|
| Rate for Payer: Zelis Auto |
$120.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$151.00
|
| Rate for Payer: Zelis Worker's Compensation |
$82.45
|
|
|
CL- OLMESARTAN MEDOXOMIL TAB 20 MG
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
NDC 68462043730
|
| Hospital Charge Code |
3350069
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$29.45 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$26.35
|
| Rate for Payer: First Health Commercial |
$27.90
|
| Rate for Payer: First Health Workers Compensation |
$11.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.90
|
| Rate for Payer: GEHA Commercial |
$21.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.90
|
| Rate for Payer: Multiplan All |
$28.21
|
| Rate for Payer: OMNI Networks Commercial |
$21.70
|
| Rate for Payer: One Health Plan PPO/POS |
$27.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$29.45
|
| Rate for Payer: Three Rivers Provider Network All |
$23.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$28.83
|
| Rate for Payer: Zelis Auto |
$12.40
|
| Rate for Payer: Zelis Worker's Compensation |
$8.46
|
|
|
CL- OLMESARTAN MEDOXOMIL TAB 20 MG
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
NDC 68462043730
|
| Hospital Charge Code |
3350069
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.75 |
| Max. Negotiated Rate |
$29.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$18.60
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$26.35
|
| Rate for Payer: First Health Commercial |
$27.90
|
| Rate for Payer: First Health Workers Compensation |
$11.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.90
|
| Rate for Payer: GEHA Commercial |
$24.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.90
|
| Rate for Payer: Humana ChoiceCare |
$8.06
|
| Rate for Payer: Multiplan All |
$28.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$18.60
|
| Rate for Payer: OMNI Networks Commercial |
$21.70
|
| Rate for Payer: One Health Plan PPO/POS |
$27.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$29.45
|
| Rate for Payer: Three Rivers Provider Network All |
$23.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$27.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$28.83
|
| Rate for Payer: Zelis Auto |
$12.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.50
|
| Rate for Payer: Zelis Worker's Compensation |
$8.46
|
|
|
CL- OMALIZUMAB 150 MG
|
Facility
|
IP
|
$4,197.00
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
3350419
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,145.78 |
| Max. Negotiated Rate |
$3,987.15 |
| Rate for Payer: Cash Price |
$2,518.20
|
| Rate for Payer: Cigna Commercial |
$3,567.45
|
| Rate for Payer: First Health Commercial |
$3,777.30
|
| Rate for Payer: First Health Workers Compensation |
$1,620.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,777.30
|
| Rate for Payer: GEHA Commercial |
$2,937.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,777.30
|
| Rate for Payer: Multiplan All |
$3,819.27
|
| Rate for Payer: OMNI Networks Commercial |
$2,937.90
|
| Rate for Payer: One Health Plan PPO/POS |
$3,777.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,987.15
|
| Rate for Payer: Three Rivers Provider Network All |
$3,147.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,903.21
|
| Rate for Payer: Zelis Auto |
$1,678.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1,145.78
|
|
|
CL- OMALIZUMAB 150 MG
|
Facility
|
OP
|
$4,197.00
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
3350419
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.21 |
| Max. Negotiated Rate |
$3,987.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$43.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,518.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$43.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$34.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$44.60
|
| Rate for Payer: Cash Price |
$2,518.20
|
| Rate for Payer: Cash Price |
$2,518.20
|
| Rate for Payer: Cigna Commercial |
$3,567.45
|
| Rate for Payer: First Health Commercial |
$3,777.30
|
| Rate for Payer: First Health Workers Compensation |
$1,620.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,777.30
|
| Rate for Payer: GEHA Commercial |
$49.06
|
| Rate for Payer: GEHA Medicare |
$44.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,777.30
|
| Rate for Payer: Humana ChoiceCare |
$49.06
|
| Rate for Payer: Humana Medicare Advantage |
$44.60
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$74.93
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$34.91
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$44.60
|
| Rate for Payer: Multiplan All |
$3,819.27
|
| Rate for Payer: New Mexico Health Connections Medicare |
$75.82
|
| Rate for Payer: OMNI Networks Commercial |
$2,937.90
|
| Rate for Payer: One Health Plan PPO/POS |
$3,777.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$40.31
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$34.91
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$44.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,987.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$89.20
|
| Rate for Payer: Three Rivers Provider Network All |
$3,147.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$43.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$34.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.60
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,903.21
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$44.60
|
| Rate for Payer: Zelis Auto |
$1,678.80
|
| Rate for Payer: Zelis Medicare |
$37.91
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$53.52
|
| Rate for Payer: Zelis Worker's Compensation |
$1,145.78
|
|
|
CL- OMALIZUMAB 150 MG -- PT OWNED
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
3350415
|
|
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- OMALIZUMAB 150 MG -- PT OWNED
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
3350415
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$89.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$43.19
|
| 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 |
$43.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$34.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$44.60
|
| 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 |
$49.06
|
| Rate for Payer: GEHA Medicare |
$44.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$49.06
|
| Rate for Payer: Humana Medicare Advantage |
$44.60
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$74.93
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$34.91
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$44.60
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$75.82
|
| 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 |
$40.31
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$34.91
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$44.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$89.20
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$43.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$34.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.60
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$44.60
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Medicare |
$37.91
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$53.52
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- OMALIZUMAB 300 MG INJ
|
Facility
|
IP
|
$8,395.00
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
3350500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,291.84 |
| Max. Negotiated Rate |
$7,975.25 |
| Rate for Payer: Cash Price |
$5,037.00
|
| Rate for Payer: Cigna Commercial |
$7,135.75
|
| Rate for Payer: First Health Commercial |
$7,555.50
|
| Rate for Payer: First Health Workers Compensation |
$3,241.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,555.50
|
| Rate for Payer: GEHA Commercial |
$5,876.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,555.50
|
| Rate for Payer: Multiplan All |
$7,639.45
|
| Rate for Payer: OMNI Networks Commercial |
$5,876.50
|
| Rate for Payer: One Health Plan PPO/POS |
$7,555.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,975.25
|
| Rate for Payer: Three Rivers Provider Network All |
$6,296.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,807.35
|
| Rate for Payer: Zelis Auto |
$3,358.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2,291.84
|
|
|
CL- OMALIZUMAB 300 MG INJ
|
Facility
|
OP
|
$8,395.00
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
3350500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.21 |
| Max. Negotiated Rate |
$7,975.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$43.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,037.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$43.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$34.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$44.60
|
| Rate for Payer: Cash Price |
$5,037.00
|
| Rate for Payer: Cash Price |
$5,037.00
|
| Rate for Payer: Cigna Commercial |
$7,135.75
|
| Rate for Payer: First Health Commercial |
$7,555.50
|
| Rate for Payer: First Health Workers Compensation |
$3,241.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,555.50
|
| Rate for Payer: GEHA Commercial |
$49.06
|
| Rate for Payer: GEHA Medicare |
$44.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,555.50
|
| Rate for Payer: Humana ChoiceCare |
$49.06
|
| Rate for Payer: Humana Medicare Advantage |
$44.60
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$74.93
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$34.91
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$44.60
|
| Rate for Payer: Multiplan All |
$7,639.45
|
| Rate for Payer: New Mexico Health Connections Medicare |
$75.82
|
| Rate for Payer: OMNI Networks Commercial |
$5,876.50
|
| Rate for Payer: One Health Plan PPO/POS |
$7,555.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$40.31
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$34.91
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$44.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,975.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$89.20
|
| Rate for Payer: Three Rivers Provider Network All |
$6,296.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$43.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$34.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.60
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,807.35
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$44.60
|
| Rate for Payer: Zelis Auto |
$3,358.00
|
| Rate for Payer: Zelis Medicare |
$37.91
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$53.52
|
| Rate for Payer: Zelis Worker's Compensation |
$2,291.84
|
|
|
CL- OMALIZUMAB 75 MG
|
Facility
|
OP
|
$2,479.00
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
3350420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.21 |
| Max. Negotiated Rate |
$2,355.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$43.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,487.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$43.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$34.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$44.60
|
| Rate for Payer: Cash Price |
$1,487.40
|
| Rate for Payer: Cash Price |
$1,487.40
|
| Rate for Payer: Cigna Commercial |
$2,107.15
|
| Rate for Payer: First Health Commercial |
$2,231.10
|
| Rate for Payer: First Health Workers Compensation |
$957.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,231.10
|
| Rate for Payer: GEHA Commercial |
$49.06
|
| Rate for Payer: GEHA Medicare |
$44.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,231.10
|
| Rate for Payer: Humana ChoiceCare |
$49.06
|
| Rate for Payer: Humana Medicare Advantage |
$44.60
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$74.93
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$34.91
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$44.60
|
| Rate for Payer: Multiplan All |
$2,255.89
|
| Rate for Payer: New Mexico Health Connections Medicare |
$75.82
|
| Rate for Payer: OMNI Networks Commercial |
$1,735.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,231.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$40.31
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$34.91
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$44.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,355.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$89.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,859.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$43.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$34.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.60
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,305.47
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$44.60
|
| Rate for Payer: Zelis Auto |
$991.60
|
| Rate for Payer: Zelis Medicare |
$37.91
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$53.52
|
| Rate for Payer: Zelis Worker's Compensation |
$676.77
|
|
|
CL- OMALIZUMAB 75 MG
|
Facility
|
IP
|
$2,479.00
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
3350420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$676.77 |
| Max. Negotiated Rate |
$2,355.05 |
| Rate for Payer: Cash Price |
$1,487.40
|
| Rate for Payer: Cigna Commercial |
$2,107.15
|
| Rate for Payer: First Health Commercial |
$2,231.10
|
| Rate for Payer: First Health Workers Compensation |
$957.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,231.10
|
| Rate for Payer: GEHA Commercial |
$1,735.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,231.10
|
| Rate for Payer: Multiplan All |
$2,255.89
|
| Rate for Payer: OMNI Networks Commercial |
$1,735.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,231.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,355.05
|
| Rate for Payer: Three Rivers Provider Network All |
$1,859.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,305.47
|
| Rate for Payer: Zelis Auto |
$991.60
|
| Rate for Payer: Zelis Worker's Compensation |
$676.77
|
|
|
CL- OMALIZUMAB 75 MG -- PT OWNED
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
3350414
|
|
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- OMALIZUMAB 75 MG -- PT OWNED
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
3350414
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$89.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$43.19
|
| 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 |
$43.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$34.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$44.60
|
| 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 |
$49.06
|
| Rate for Payer: GEHA Medicare |
$44.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$49.06
|
| Rate for Payer: Humana Medicare Advantage |
$44.60
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$74.93
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$34.91
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$44.60
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$75.82
|
| 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 |
$40.31
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$34.91
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$44.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$89.20
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$43.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$34.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.60
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$44.60
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Medicare |
$37.91
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$53.52
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
clomipramine REF706465
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
2200436
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$147.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$131.75
|
| Rate for Payer: First Health Commercial |
$139.50
|
| Rate for Payer: First Health Workers Compensation |
$27.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$139.50
|
| Rate for Payer: GEHA Commercial |
$124.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$139.50
|
| Rate for Payer: Humana ChoiceCare |
$40.30
|
| Rate for Payer: Multiplan All |
$141.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$93.00
|
| Rate for Payer: OMNI Networks Commercial |
$108.50
|
| Rate for Payer: One Health Plan PPO/POS |
$139.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$147.25
|
| Rate for Payer: Three Rivers Provider Network All |
$116.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$136.40
|
| Rate for Payer: United Healthcare Commercial |
$131.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$38.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$144.15
|
| Rate for Payer: Zelis Auto |
$62.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$77.50
|
| Rate for Payer: Zelis Worker's Compensation |
$19.29
|
|
|
clomipramine REF706465
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
2200436
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$147.25 |
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$131.75
|
| Rate for Payer: First Health Commercial |
$139.50
|
| Rate for Payer: First Health Workers Compensation |
$27.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$139.50
|
| Rate for Payer: GEHA Commercial |
$108.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$139.50
|
| Rate for Payer: Multiplan All |
$141.05
|
| Rate for Payer: OMNI Networks Commercial |
$108.50
|
| Rate for Payer: One Health Plan PPO/POS |
$139.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$147.25
|
| Rate for Payer: Three Rivers Provider Network All |
$116.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$144.15
|
| Rate for Payer: Zelis Auto |
$62.00
|
| Rate for Payer: Zelis Worker's Compensation |
$19.29
|
|
|
CL- ONABOTULINUMOXINA FOR INJ 200 U
|
Facility
|
OP
|
$5,227.00
|
|
|
Service Code
|
CPT J0585
|
| Hospital Charge Code |
3350529
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.53 |
| Max. Negotiated Rate |
$4,965.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$8.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,136.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$8.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$6.62
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6.50
|
| Rate for Payer: Cash Price |
$3,136.20
|
| Rate for Payer: Cash Price |
$3,136.20
|
| Rate for Payer: Cigna Commercial |
$4,442.95
|
| Rate for Payer: First Health Commercial |
$4,704.30
|
| Rate for Payer: First Health Workers Compensation |
$2,018.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,704.30
|
| Rate for Payer: GEHA Commercial |
$7.15
|
| Rate for Payer: GEHA Medicare |
$6.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,704.30
|
| Rate for Payer: Humana ChoiceCare |
$7.15
|
| Rate for Payer: Humana Medicare Advantage |
$6.50
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$10.92
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$6.75
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6.50
|
| Rate for Payer: Multiplan All |
$4,756.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.05
|
| Rate for Payer: OMNI Networks Commercial |
$3,658.90
|
| Rate for Payer: One Health Plan PPO/POS |
$4,704.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$7.80
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$6.75
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,965.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$13.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,920.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.37
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,861.11
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6.50
|
| Rate for Payer: Zelis Auto |
$2,090.80
|
| Rate for Payer: Zelis Medicare |
$5.53
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1,426.97
|
|
