|
CL- ONABOTULINUMOXINA FOR INJ 200 U
|
Facility
|
IP
|
$5,227.00
|
|
|
Service Code
|
CPT J0585
|
| Hospital Charge Code |
3350529
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,426.97 |
| Max. Negotiated Rate |
$4,965.65 |
| 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 |
$3,658.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,704.30
|
| Rate for Payer: Multiplan All |
$4,756.57
|
| Rate for Payer: OMNI Networks Commercial |
$3,658.90
|
| Rate for Payer: One Health Plan PPO/POS |
$4,704.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,965.65
|
| Rate for Payer: Three Rivers Provider Network All |
$3,920.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,861.11
|
| Rate for Payer: Zelis Auto |
$2,090.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1,426.97
|
|
|
CL-ONABOTULINUMTOXINA FOR INJ 100 UNIT
|
Facility
|
OP
|
$2,460.00
|
|
|
Service Code
|
CPT J0585
|
| Hospital Charge Code |
3350525
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.53 |
| Max. Negotiated Rate |
$2,337.00 |
| 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 |
$1,476.00
|
| 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 |
$1,476.00
|
| Rate for Payer: Cash Price |
$1,476.00
|
| Rate for Payer: Cigna Commercial |
$2,091.00
|
| Rate for Payer: First Health Commercial |
$2,214.00
|
| Rate for Payer: First Health Workers Compensation |
$949.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,214.00
|
| Rate for Payer: GEHA Commercial |
$7.15
|
| Rate for Payer: GEHA Medicare |
$6.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,214.00
|
| 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 |
$2,238.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.05
|
| Rate for Payer: OMNI Networks Commercial |
$1,722.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,214.00
|
| 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 |
$2,337.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$13.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,845.00
|
| 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 |
$2,287.80
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6.50
|
| Rate for Payer: Zelis Auto |
$984.00
|
| Rate for Payer: Zelis Medicare |
$5.53
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.80
|
| Rate for Payer: Zelis Worker's Compensation |
$671.58
|
|
|
CL-ONABOTULINUMTOXINA FOR INJ 100 UNIT
|
Facility
|
IP
|
$2,460.00
|
|
|
Service Code
|
CPT J0585
|
| Hospital Charge Code |
3350525
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$671.58 |
| Max. Negotiated Rate |
$2,337.00 |
| Rate for Payer: Cash Price |
$1,476.00
|
| Rate for Payer: Cigna Commercial |
$2,091.00
|
| Rate for Payer: First Health Commercial |
$2,214.00
|
| Rate for Payer: First Health Workers Compensation |
$949.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,214.00
|
| Rate for Payer: GEHA Commercial |
$1,722.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,214.00
|
| Rate for Payer: Multiplan All |
$2,238.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,722.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,214.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,337.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,845.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,287.80
|
| Rate for Payer: Zelis Auto |
$984.00
|
| Rate for Payer: Zelis Worker's Compensation |
$671.58
|
|
|
clonazePAM 0.5MG TAB
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 16729013600
|
| Hospital Charge Code |
3300193
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
clonazePAM 0.5MG TAB
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 16729013600
|
| Hospital Charge Code |
3300193
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
CLONAZEPAM ODT 0.5 MG TAB
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 49884030802
|
| Hospital Charge Code |
3303140
|
|
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
|
|
|
CLONAZEPAM ODT 0.5 MG TAB
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 49884030802
|
| Hospital Charge Code |
3303140
|
|
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- ONDANSETRON HCL INJ 4MG/2ML (2MG/ML)
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
CPT J2405
|
| Hospital Charge Code |
3350070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$8.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
CL- ONDANSETRON HCL INJ 4MG/2ML (2MG/ML)
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
CPT J2405
|
| Hospital Charge Code |
3350070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$0.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Humana ChoiceCare |
$3.12
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.20
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
CL- ONDANSETRON ODT 4MG TAB
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
CPT Q0162
|
| Hospital Charge Code |
3350071
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Humana ChoiceCare |
$2.34
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5.40
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.50
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
CL- ONDANSETRON ODT 4MG TAB
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
CPT Q0162
|
| Hospital Charge Code |
3350071
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$6.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
cloNIDine 0.1MG/DAY WEEKLY PATCH
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
NDC 00555100916
|
| Hospital Charge Code |
3300196
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.00 |
| 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: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$64.86
|
| 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 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 |
$45.86
|
|
|
cloNIDine 0.1MG/DAY WEEKLY PATCH
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
NDC 00555100916
|
| Hospital Charge Code |
3300196
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.86 |
| Max. Negotiated Rate |
$159.60 |
| 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 |
$64.86
|
| 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 |
$45.86
|
|
|
cloNIDine 0.2MG/DAY WEEKLY PATCH
|
Facility
|
IP
|
$246.00
|
|
|
Service Code
|
NDC 00555101016
|
| Hospital Charge Code |
3300197
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.16 |
| Max. Negotiated Rate |
$233.70 |
| Rate for Payer: Cash Price |
$147.60
|
| Rate for Payer: Cigna Commercial |
$209.10
|
| Rate for Payer: First Health Commercial |
$221.40
|
| Rate for Payer: First Health Workers Compensation |
$94.98
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$221.40
|
| Rate for Payer: GEHA Commercial |
$172.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$221.40
|
| Rate for Payer: Multiplan All |
$223.86
|
| Rate for Payer: OMNI Networks Commercial |
$172.20
|
| Rate for Payer: One Health Plan PPO/POS |
$221.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$233.70
|
| Rate for Payer: Three Rivers Provider Network All |
$184.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$228.78
|
| Rate for Payer: Zelis Auto |
$98.40
|
| Rate for Payer: Zelis Worker's Compensation |
$67.16
|
|
|
cloNIDine 0.2MG/DAY WEEKLY PATCH
|
Facility
|
OP
|
$246.00
|
|
|
Service Code
|
NDC 00555101016
|
| Hospital Charge Code |
3300197
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.50 |
| Max. Negotiated Rate |
$233.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$147.60
|
| Rate for Payer: Cash Price |
$147.60
|
| Rate for Payer: Cigna Commercial |
$209.10
|
| Rate for Payer: First Health Commercial |
$221.40
|
| Rate for Payer: First Health Workers Compensation |
$94.98
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$221.40
|
| Rate for Payer: GEHA Commercial |
$196.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$221.40
|
| Rate for Payer: Humana ChoiceCare |
$63.96
|
| Rate for Payer: Multiplan All |
$223.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$147.60
|
| Rate for Payer: OMNI Networks Commercial |
$172.20
|
| Rate for Payer: One Health Plan PPO/POS |
$221.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$233.70
|
| Rate for Payer: Three Rivers Provider Network All |
$184.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$216.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$61.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$228.78
|
| Rate for Payer: Zelis Auto |
$98.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$123.00
|
| Rate for Payer: Zelis Worker's Compensation |
$67.16
|
|
|
CLONIDINE 1000MCG/10ML VIAL - EPIDURAL
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
CPT J0735
|
| Hospital Charge Code |
3305030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.99 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$64.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$91.80
|
| Rate for Payer: First Health Commercial |
$97.20
|
| Rate for Payer: First Health Workers Compensation |
$41.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$97.20
|
| Rate for Payer: GEHA Commercial |
$19.99
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$97.20
|
| Rate for Payer: Humana ChoiceCare |
$28.08
|
| Rate for Payer: Multiplan All |
$98.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$64.80
|
| Rate for Payer: OMNI Networks Commercial |
$75.60
|
| Rate for Payer: One Health Plan PPO/POS |
$97.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$102.60
|
| Rate for Payer: Three Rivers Provider Network All |
$81.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$95.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$27.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$100.44
|
| Rate for Payer: Zelis Auto |
$43.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$54.00
|
| Rate for Payer: Zelis Worker's Compensation |
$29.48
|
|
|
CLONIDINE 1000MCG/10ML VIAL - EPIDURAL
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
CPT J0735
|
| Hospital Charge Code |
3305030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.48 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$91.80
|
| Rate for Payer: First Health Commercial |
$97.20
|
| Rate for Payer: First Health Workers Compensation |
$41.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$97.20
|
| Rate for Payer: GEHA Commercial |
$75.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$97.20
|
| Rate for Payer: Multiplan All |
$98.28
|
| Rate for Payer: OMNI Networks Commercial |
$75.60
|
| Rate for Payer: One Health Plan PPO/POS |
$97.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$102.60
|
| Rate for Payer: Three Rivers Provider Network All |
$81.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$100.44
|
| Rate for Payer: Zelis Auto |
$43.20
|
| Rate for Payer: Zelis Worker's Compensation |
$29.48
|
|
|
cloNIDine HCL 0.1MG TAB
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 50268019211
|
| Hospital Charge Code |
3300194
|
|
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
|
|
|
cloNIDine HCL 0.1MG TAB
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 50268019211
|
| Hospital Charge Code |
3300194
|
|
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
|
|
|
cloNIDine HCL 0.2MG TAB
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 51079030020
|
| Hospital Charge Code |
3300195
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
cloNIDine HCL 0.2MG TAB
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 51079030020
|
| Hospital Charge Code |
3300195
|
|
Hospital Revenue Code
|
250
|
| 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: 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 |
$4.80
|
| 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
|
|
|
CLOPIDOGREL BISULFATE 75MG TAB
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 00904629461
|
| Hospital Charge Code |
3300198
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Humana ChoiceCare |
$1.82
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.20
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
CLOPIDOGREL BISULFATE 75MG TAB
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00904629461
|
| Hospital Charge Code |
3300198
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$4.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
CLOPIDOGREL CYP2C19 GENOTYPE
|
Facility
|
OP
|
$990.00
|
|
|
Service Code
|
CPT 81225
|
| Hospital Charge Code |
2300073
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$232.90 |
| Max. Negotiated Rate |
$940.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$524.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$594.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$524.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$415.48
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$291.36
|
| Rate for Payer: Cash Price |
$594.00
|
| Rate for Payer: Cash Price |
$594.00
|
| Rate for Payer: Cigna Commercial |
$841.50
|
| Rate for Payer: First Health Commercial |
$891.00
|
| Rate for Payer: First Health Workers Compensation |
$329.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$891.00
|
| Rate for Payer: GEHA Commercial |
$792.00
|
| Rate for Payer: GEHA Medicare |
$291.36
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$891.00
|
| Rate for Payer: Humana ChoiceCare |
$320.50
|
| Rate for Payer: Humana Medicare Advantage |
$291.36
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$489.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$423.94
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$291.36
|
| Rate for Payer: Multiplan All |
$900.90
|
| Rate for Payer: New Mexico Health Connections Medicare |
$495.31
|
| Rate for Payer: OMNI Networks Commercial |
$693.00
|
| Rate for Payer: One Health Plan PPO/POS |
$891.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$489.50
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$423.94
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$291.36
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$940.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$582.72
|
| Rate for Payer: Three Rivers Provider Network All |
$742.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$285.53
|
| Rate for Payer: United Healthcare Commercial |
$841.50
|
| Rate for Payer: United Healthcare Managed Medicaid |
$423.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$291.36
|
| Rate for Payer: United Payors & United Providers UP&UP |
$920.70
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$291.36
|
| Rate for Payer: Zelis Auto |
$396.00
|
| Rate for Payer: Zelis Medicare |
$247.66
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$349.63
|
| Rate for Payer: Zelis Worker's Compensation |
$232.90
|
|
|
CLOPIDOGREL CYP2C19 GENOTYPE
|
Facility
|
IP
|
$990.00
|
|
|
Service Code
|
CPT 81225
|
| Hospital Charge Code |
2300073
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$232.90 |
| Max. Negotiated Rate |
$940.50 |
| Rate for Payer: Cash Price |
$594.00
|
| Rate for Payer: Cash Price |
$594.00
|
| Rate for Payer: Cigna Commercial |
$841.50
|
| Rate for Payer: First Health Commercial |
$891.00
|
| Rate for Payer: First Health Workers Compensation |
$329.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$891.00
|
| Rate for Payer: GEHA Commercial |
$693.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$891.00
|
| Rate for Payer: Multiplan All |
$900.90
|
| Rate for Payer: OMNI Networks Commercial |
$693.00
|
| Rate for Payer: One Health Plan PPO/POS |
$891.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$940.50
|
| Rate for Payer: Three Rivers Provider Network All |
$742.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$920.70
|
| Rate for Payer: Zelis Auto |
$396.00
|
| Rate for Payer: Zelis Worker's Compensation |
$232.90
|
|
