|
CLOSURE OF SALIVARY FISTULA
|
Facility
|
OP
|
$899.00
|
|
|
Service Code
|
CPT 42600
|
| Hospital Charge Code |
6142600
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$245.43 |
| Max. Negotiated Rate |
$6,284.94 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,737.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$539.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,737.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,376.73
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,142.47
|
| Rate for Payer: Cash Price |
$539.40
|
| Rate for Payer: Cash Price |
$539.40
|
| Rate for Payer: Cigna Commercial |
$764.15
|
| Rate for Payer: First Health Commercial |
$809.10
|
| Rate for Payer: First Health Workers Compensation |
$347.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$809.10
|
| Rate for Payer: GEHA Commercial |
$719.20
|
| Rate for Payer: GEHA Medicare |
$3,142.47
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$809.10
|
| Rate for Payer: Humana ChoiceCare |
$3,456.72
|
| Rate for Payer: Humana Medicare Advantage |
$3,142.47
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,279.35
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,404.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,142.47
|
| Rate for Payer: Multiplan All |
$818.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,342.20
|
| Rate for Payer: OMNI Networks Commercial |
$629.30
|
| Rate for Payer: One Health Plan PPO/POS |
$809.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,622.00
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,404.77
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,142.47
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$854.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,284.94
|
| Rate for Payer: Three Rivers Provider Network All |
$674.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,079.62
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,404.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,142.47
|
| Rate for Payer: United Payors & United Providers UP&UP |
$836.07
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,142.47
|
| Rate for Payer: Zelis Auto |
$359.60
|
| Rate for Payer: Zelis Medicare |
$2,671.10
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,770.96
|
| Rate for Payer: Zelis Worker's Compensation |
$245.43
|
|
|
CLOSURE OF SALIVARY FISTULA
|
Facility
|
IP
|
$899.00
|
|
|
Service Code
|
CPT 42600
|
| Hospital Charge Code |
6142600
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$245.43 |
| Max. Negotiated Rate |
$854.05 |
| Rate for Payer: Cash Price |
$539.40
|
| Rate for Payer: Cigna Commercial |
$764.15
|
| Rate for Payer: First Health Commercial |
$809.10
|
| Rate for Payer: First Health Workers Compensation |
$347.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$809.10
|
| Rate for Payer: GEHA Commercial |
$629.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$809.10
|
| Rate for Payer: Multiplan All |
$818.09
|
| Rate for Payer: OMNI Networks Commercial |
$629.30
|
| Rate for Payer: One Health Plan PPO/POS |
$809.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$854.05
|
| Rate for Payer: Three Rivers Provider Network All |
$674.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$836.07
|
| Rate for Payer: Zelis Auto |
$359.60
|
| Rate for Payer: Zelis Worker's Compensation |
$245.43
|
|
|
CLOSURE URETER/BOWEL FISTULA
|
Facility
|
OP
|
$2,458.00
|
|
|
Service Code
|
CPT 50930
|
| Hospital Charge Code |
6150930
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$614.50 |
| Max. Negotiated Rate |
$2,335.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,474.80
|
| Rate for Payer: Cash Price |
$1,474.80
|
| Rate for Payer: Cigna Commercial |
$2,089.30
|
| Rate for Payer: First Health Commercial |
$2,212.20
|
| Rate for Payer: First Health Workers Compensation |
$949.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,212.20
|
| Rate for Payer: GEHA Commercial |
$1,966.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,212.20
|
| Rate for Payer: Humana ChoiceCare |
$639.08
|
| Rate for Payer: Multiplan All |
$2,236.78
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,474.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,720.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,212.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,335.10
|
| Rate for Payer: Three Rivers Provider Network All |
$1,843.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,163.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$614.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,285.94
|
| Rate for Payer: Zelis Auto |
$983.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,229.00
|
| Rate for Payer: Zelis Worker's Compensation |
$671.03
|
|
|
CLOSURE URETER/BOWEL FISTULA
|
Facility
|
IP
|
$2,458.00
|
|
|
Service Code
|
CPT 50930
|
| Hospital Charge Code |
6150930
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$671.03 |
| Max. Negotiated Rate |
$2,335.10 |
| Rate for Payer: Cash Price |
$1,474.80
|
| Rate for Payer: Cigna Commercial |
$2,089.30
|
| Rate for Payer: First Health Commercial |
$2,212.20
|
| Rate for Payer: First Health Workers Compensation |
$949.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,212.20
|
| Rate for Payer: GEHA Commercial |
$1,720.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,212.20
|
| Rate for Payer: Multiplan All |
$2,236.78
|
| Rate for Payer: OMNI Networks Commercial |
$1,720.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,212.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,335.10
|
| Rate for Payer: Three Rivers Provider Network All |
$1,843.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,285.94
|
| Rate for Payer: Zelis Auto |
$983.20
|
| Rate for Payer: Zelis Worker's Compensation |
$671.03
|
|
|
CLOSURE URETER/SKIN FISTULA
|
Facility
|
OP
|
$1,818.00
|
|
|
Service Code
|
CPT 50920
|
| Hospital Charge Code |
6150920
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$454.50 |
| Max. Negotiated Rate |
$1,727.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,090.80
|
| Rate for Payer: Cash Price |
$1,090.80
|
| Rate for Payer: Cigna Commercial |
$1,545.30
|
| Rate for Payer: First Health Commercial |
$1,636.20
|
| Rate for Payer: First Health Workers Compensation |
$701.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,636.20
|
| Rate for Payer: GEHA Commercial |
$1,454.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,636.20
|
| Rate for Payer: Humana ChoiceCare |
$472.68
|
| Rate for Payer: Multiplan All |
$1,654.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,090.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,272.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,636.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,727.10
|
| Rate for Payer: Three Rivers Provider Network All |
$1,363.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,599.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$454.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,690.74
|
| Rate for Payer: Zelis Auto |
$727.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$909.00
|
| Rate for Payer: Zelis Worker's Compensation |
$496.31
|
|
|
CLOSURE URETER/SKIN FISTULA
|
Facility
|
IP
|
$1,818.00
|
|
|
Service Code
|
CPT 50920
|
| Hospital Charge Code |
6150920
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$496.31 |
| Max. Negotiated Rate |
$1,727.10 |
| Rate for Payer: Cash Price |
$1,090.80
|
| Rate for Payer: Cigna Commercial |
$1,545.30
|
| Rate for Payer: First Health Commercial |
$1,636.20
|
| Rate for Payer: First Health Workers Compensation |
$701.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,636.20
|
| Rate for Payer: GEHA Commercial |
$1,272.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,636.20
|
| Rate for Payer: Multiplan All |
$1,654.38
|
| Rate for Payer: OMNI Networks Commercial |
$1,272.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,636.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,727.10
|
| Rate for Payer: Three Rivers Provider Network All |
$1,363.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,690.74
|
| Rate for Payer: Zelis Auto |
$727.20
|
| Rate for Payer: Zelis Worker's Compensation |
$496.31
|
|
|
CLOTRIMAZOLE CREAM 1%
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
NDC 51672127502
|
| Hospital Charge Code |
3300199
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.02 |
| Max. Negotiated Rate |
$52.25 |
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$46.75
|
| Rate for Payer: First Health Commercial |
$49.50
|
| Rate for Payer: First Health Workers Compensation |
$21.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$49.50
|
| Rate for Payer: GEHA Commercial |
$38.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$49.50
|
| Rate for Payer: Multiplan All |
$50.05
|
| Rate for Payer: OMNI Networks Commercial |
$38.50
|
| Rate for Payer: One Health Plan PPO/POS |
$49.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$52.25
|
| Rate for Payer: Three Rivers Provider Network All |
$41.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$51.15
|
| Rate for Payer: Zelis Auto |
$22.00
|
| Rate for Payer: Zelis Worker's Compensation |
$15.02
|
|
|
CLOTRIMAZOLE CREAM 1%
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
NDC 51672127502
|
| Hospital Charge Code |
3300199
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.75 |
| Max. Negotiated Rate |
$52.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$46.75
|
| Rate for Payer: First Health Commercial |
$49.50
|
| Rate for Payer: First Health Workers Compensation |
$21.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$49.50
|
| Rate for Payer: GEHA Commercial |
$44.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$49.50
|
| Rate for Payer: Humana ChoiceCare |
$14.30
|
| Rate for Payer: Multiplan All |
$50.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$33.00
|
| Rate for Payer: OMNI Networks Commercial |
$38.50
|
| Rate for Payer: One Health Plan PPO/POS |
$49.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$52.25
|
| Rate for Payer: Three Rivers Provider Network All |
$41.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$48.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$51.15
|
| Rate for Payer: Zelis Auto |
$22.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$27.50
|
| Rate for Payer: Zelis Worker's Compensation |
$15.02
|
|
|
CLOTRIMAZOLE SOLN 1%
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
NDC 00093024843
|
| Hospital Charge Code |
3300200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$45.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$40.80
|
| Rate for Payer: First Health Commercial |
$43.20
|
| Rate for Payer: First Health Workers Compensation |
$18.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$43.20
|
| Rate for Payer: GEHA Commercial |
$38.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$43.20
|
| Rate for Payer: Humana ChoiceCare |
$12.48
|
| Rate for Payer: Multiplan All |
$43.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$28.80
|
| Rate for Payer: OMNI Networks Commercial |
$33.60
|
| Rate for Payer: One Health Plan PPO/POS |
$43.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$45.60
|
| Rate for Payer: Three Rivers Provider Network All |
$36.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$42.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$44.64
|
| Rate for Payer: Zelis Auto |
$19.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$24.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.10
|
|
|
CLOTRIMAZOLE SOLN 1%
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
NDC 00093024843
|
| Hospital Charge Code |
3300200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.10 |
| Max. Negotiated Rate |
$45.60 |
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$40.80
|
| Rate for Payer: First Health Commercial |
$43.20
|
| Rate for Payer: First Health Workers Compensation |
$18.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$43.20
|
| Rate for Payer: GEHA Commercial |
$33.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$43.20
|
| Rate for Payer: Multiplan All |
$43.68
|
| Rate for Payer: OMNI Networks Commercial |
$33.60
|
| Rate for Payer: One Health Plan PPO/POS |
$43.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$45.60
|
| Rate for Payer: Three Rivers Provider Network All |
$36.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$44.64
|
| Rate for Payer: Zelis Auto |
$19.20
|
| Rate for Payer: Zelis Worker's Compensation |
$13.10
|
|
|
CLOTRIMAZOLE VAGINAL CREAM 1%
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
NDC 00085088709
|
| Hospital Charge Code |
3300201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.83 |
| Max. Negotiated Rate |
$44.65 |
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$39.95
|
| Rate for Payer: First Health Commercial |
$42.30
|
| Rate for Payer: First Health Workers Compensation |
$18.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$42.30
|
| Rate for Payer: GEHA Commercial |
$32.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$42.30
|
| Rate for Payer: Multiplan All |
$42.77
|
| Rate for Payer: OMNI Networks Commercial |
$32.90
|
| Rate for Payer: One Health Plan PPO/POS |
$42.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$44.65
|
| Rate for Payer: Three Rivers Provider Network All |
$35.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$43.71
|
| Rate for Payer: Zelis Auto |
$18.80
|
| Rate for Payer: Zelis Worker's Compensation |
$12.83
|
|
|
CLOTRIMAZOLE VAGINAL CREAM 1%
|
Facility
|
OP
|
$47.00
|
|
|
Service Code
|
NDC 00085088709
|
| Hospital Charge Code |
3300201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.75 |
| Max. Negotiated Rate |
$44.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$28.20
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$39.95
|
| Rate for Payer: First Health Commercial |
$42.30
|
| Rate for Payer: First Health Workers Compensation |
$18.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$42.30
|
| Rate for Payer: GEHA Commercial |
$37.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$42.30
|
| Rate for Payer: Humana ChoiceCare |
$12.22
|
| Rate for Payer: Multiplan All |
$42.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$28.20
|
| Rate for Payer: OMNI Networks Commercial |
$32.90
|
| Rate for Payer: One Health Plan PPO/POS |
$42.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$44.65
|
| Rate for Payer: Three Rivers Provider Network All |
$35.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$41.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$43.71
|
| Rate for Payer: Zelis Auto |
$18.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$23.50
|
| Rate for Payer: Zelis Worker's Compensation |
$12.83
|
|
|
CLOTRIMAZOLE W/BETAMETH 1-0.05%
|
Facility
|
IP
|
$346.00
|
|
|
Service Code
|
NDC 00168025815
|
| Hospital Charge Code |
3300202
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.46 |
| Max. Negotiated Rate |
$328.70 |
| Rate for Payer: Cash Price |
$207.60
|
| Rate for Payer: Cigna Commercial |
$294.10
|
| Rate for Payer: First Health Commercial |
$311.40
|
| Rate for Payer: First Health Workers Compensation |
$133.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$311.40
|
| Rate for Payer: GEHA Commercial |
$242.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$311.40
|
| Rate for Payer: Multiplan All |
$314.86
|
| Rate for Payer: OMNI Networks Commercial |
$242.20
|
| Rate for Payer: One Health Plan PPO/POS |
$311.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$328.70
|
| Rate for Payer: Three Rivers Provider Network All |
$259.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$321.78
|
| Rate for Payer: Zelis Auto |
$138.40
|
| Rate for Payer: Zelis Worker's Compensation |
$94.46
|
|
|
CLOTRIMAZOLE W/BETAMETH 1-0.05%
|
Facility
|
OP
|
$346.00
|
|
|
Service Code
|
NDC 00168025815
|
| Hospital Charge Code |
3300202
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$86.50 |
| Max. Negotiated Rate |
$328.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$207.60
|
| Rate for Payer: Cash Price |
$207.60
|
| Rate for Payer: Cigna Commercial |
$294.10
|
| Rate for Payer: First Health Commercial |
$311.40
|
| Rate for Payer: First Health Workers Compensation |
$133.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$311.40
|
| Rate for Payer: GEHA Commercial |
$276.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$311.40
|
| Rate for Payer: Humana ChoiceCare |
$89.96
|
| Rate for Payer: Multiplan All |
$314.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$207.60
|
| Rate for Payer: OMNI Networks Commercial |
$242.20
|
| Rate for Payer: One Health Plan PPO/POS |
$311.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$328.70
|
| Rate for Payer: Three Rivers Provider Network All |
$259.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$304.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$86.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$321.78
|
| Rate for Payer: Zelis Auto |
$138.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$173.00
|
| Rate for Payer: Zelis Worker's Compensation |
$94.46
|
|
|
CLO TX LATERAL MALLEOLUS DISL WO ANES
|
Facility
|
IP
|
$1,841.00
|
|
| Hospital Charge Code |
8127788
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$502.59 |
| Max. Negotiated Rate |
$1,748.95 |
| Rate for Payer: Cash Price |
$1,104.60
|
| Rate for Payer: Cigna Commercial |
$1,564.85
|
| Rate for Payer: First Health Commercial |
$1,656.90
|
| Rate for Payer: First Health Workers Compensation |
$710.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,656.90
|
| Rate for Payer: GEHA Commercial |
$1,288.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,656.90
|
| Rate for Payer: Multiplan All |
$1,675.31
|
| Rate for Payer: OMNI Networks Commercial |
$1,288.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,656.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,748.95
|
| Rate for Payer: Three Rivers Provider Network All |
$1,380.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,712.13
|
| Rate for Payer: Zelis Auto |
$736.40
|
| Rate for Payer: Zelis Worker's Compensation |
$502.59
|
|
|
CLO TX LATERAL MALLEOLUS DISL WO ANES
|
Facility
|
OP
|
$1,841.00
|
|
| Hospital Charge Code |
8127788
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$460.25 |
| Max. Negotiated Rate |
$1,748.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,104.60
|
| Rate for Payer: Cash Price |
$1,104.60
|
| Rate for Payer: Cigna Commercial |
$1,564.85
|
| Rate for Payer: First Health Commercial |
$1,656.90
|
| Rate for Payer: First Health Workers Compensation |
$710.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,656.90
|
| Rate for Payer: GEHA Commercial |
$1,472.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,656.90
|
| Rate for Payer: Humana ChoiceCare |
$478.66
|
| Rate for Payer: Multiplan All |
$1,675.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,104.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,288.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,656.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,748.95
|
| Rate for Payer: Three Rivers Provider Network All |
$1,380.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,620.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$460.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,712.13
|
| Rate for Payer: Zelis Auto |
$736.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$920.50
|
| Rate for Payer: Zelis Worker's Compensation |
$502.59
|
|
|
CL- OXALIPLATIN 0.5 MG
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
CPT J9263
|
| Hospital Charge Code |
3350342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$0.85
|
| Rate for Payer: First Health Commercial |
$0.90
|
| Rate for Payer: First Health Workers Compensation |
$0.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.90
|
| Rate for Payer: GEHA Commercial |
$0.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.90
|
| Rate for Payer: Multiplan All |
$0.91
|
| Rate for Payer: OMNI Networks Commercial |
$0.70
|
| Rate for Payer: One Health Plan PPO/POS |
$0.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.95
|
| Rate for Payer: Three Rivers Provider Network All |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.93
|
| Rate for Payer: Zelis Auto |
$0.40
|
| Rate for Payer: Zelis Worker's Compensation |
$0.27
|
|
|
CL- OXALIPLATIN 0.5 MG
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
CPT J9263
|
| Hospital Charge Code |
3350342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$0.78
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$0.78
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$0.62
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$0.85
|
| Rate for Payer: First Health Commercial |
$0.90
|
| Rate for Payer: First Health Workers Compensation |
$0.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.90
|
| Rate for Payer: GEHA Commercial |
$0.09
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.90
|
| Rate for Payer: Humana ChoiceCare |
$0.26
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$0.63
|
| Rate for Payer: Multiplan All |
$0.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.60
|
| Rate for Payer: OMNI Networks Commercial |
$0.70
|
| Rate for Payer: One Health Plan PPO/POS |
$0.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$0.73
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$0.63
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.95
|
| Rate for Payer: Three Rivers Provider Network All |
$0.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.63
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.93
|
| Rate for Payer: Zelis Auto |
$0.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.27
|
|
|
CL- Oxymetazoline 0.05% Nasal Spray
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
NDC 00904676130
|
| Hospital Charge Code |
3350072
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$14.45
|
| Rate for Payer: First Health Commercial |
$15.30
|
| Rate for Payer: First Health Workers Compensation |
$6.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15.30
|
| Rate for Payer: GEHA Commercial |
$11.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15.30
|
| Rate for Payer: Multiplan All |
$15.47
|
| Rate for Payer: OMNI Networks Commercial |
$11.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16.15
|
| Rate for Payer: Three Rivers Provider Network All |
$12.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15.81
|
| Rate for Payer: Zelis Auto |
$6.80
|
| Rate for Payer: Zelis Worker's Compensation |
$4.64
|
|
|
CL- Oxymetazoline 0.05% Nasal Spray
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
NDC 00904676130
|
| Hospital Charge Code |
3350072
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$14.45
|
| Rate for Payer: First Health Commercial |
$15.30
|
| Rate for Payer: First Health Workers Compensation |
$6.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15.30
|
| Rate for Payer: GEHA Commercial |
$13.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15.30
|
| Rate for Payer: Humana ChoiceCare |
$4.42
|
| Rate for Payer: Multiplan All |
$15.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10.20
|
| Rate for Payer: OMNI Networks Commercial |
$11.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16.15
|
| Rate for Payer: Three Rivers Provider Network All |
$12.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15.81
|
| Rate for Payer: Zelis Auto |
$6.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.50
|
| Rate for Payer: Zelis Worker's Compensation |
$4.64
|
|
|
clozapine REF706440
|
Facility
|
OP
|
$251.00
|
|
|
Service Code
|
CPT 80159
|
| Hospital Charge Code |
2299600
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.13 |
| Max. Negotiated Rate |
$238.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$36.27
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$150.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$36.27
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$28.73
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$20.15
|
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cigna Commercial |
$213.35
|
| Rate for Payer: First Health Commercial |
$225.90
|
| Rate for Payer: First Health Workers Compensation |
$31.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$225.90
|
| Rate for Payer: GEHA Commercial |
$200.80
|
| Rate for Payer: GEHA Medicare |
$20.15
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$225.90
|
| Rate for Payer: Humana ChoiceCare |
$22.16
|
| Rate for Payer: Humana Medicare Advantage |
$20.15
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$33.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$29.32
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$20.15
|
| Rate for Payer: Multiplan All |
$228.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$34.26
|
| Rate for Payer: OMNI Networks Commercial |
$175.70
|
| Rate for Payer: One Health Plan PPO/POS |
$225.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$33.85
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$29.32
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$20.15
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$238.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$40.30
|
| Rate for Payer: Three Rivers Provider Network All |
$188.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$19.75
|
| Rate for Payer: United Healthcare Commercial |
$213.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$29.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.15
|
| Rate for Payer: United Payors & United Providers UP&UP |
$233.43
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$20.15
|
| Rate for Payer: Zelis Auto |
$100.40
|
| Rate for Payer: Zelis Medicare |
$17.13
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$24.18
|
| Rate for Payer: Zelis Worker's Compensation |
$21.95
|
|
|
clozapine REF706440
|
Facility
|
IP
|
$251.00
|
|
|
Service Code
|
CPT 80159
|
| Hospital Charge Code |
2299600
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.95 |
| Max. Negotiated Rate |
$238.45 |
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cigna Commercial |
$213.35
|
| Rate for Payer: First Health Commercial |
$225.90
|
| Rate for Payer: First Health Workers Compensation |
$31.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$225.90
|
| Rate for Payer: GEHA Commercial |
$175.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$225.90
|
| Rate for Payer: Multiplan All |
$228.41
|
| Rate for Payer: OMNI Networks Commercial |
$175.70
|
| Rate for Payer: One Health Plan PPO/POS |
$225.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$238.45
|
| Rate for Payer: Three Rivers Provider Network All |
$188.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$233.43
|
| Rate for Payer: Zelis Auto |
$100.40
|
| Rate for Payer: Zelis Worker's Compensation |
$21.95
|
|
|
CL- PALONOSETRON HCL 0.25 MG/5 ML
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
CPT J2469
|
| Hospital Charge Code |
3350345
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.83 |
| Max. Negotiated Rate |
$34.20 |
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$30.60
|
| Rate for Payer: First Health Commercial |
$32.40
|
| Rate for Payer: First Health Workers Compensation |
$13.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$32.40
|
| Rate for Payer: GEHA Commercial |
$25.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$32.40
|
| Rate for Payer: Multiplan All |
$32.76
|
| Rate for Payer: OMNI Networks Commercial |
$25.20
|
| Rate for Payer: One Health Plan PPO/POS |
$32.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$34.20
|
| Rate for Payer: Three Rivers Provider Network All |
$27.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$33.48
|
| Rate for Payer: Zelis Auto |
$14.40
|
| Rate for Payer: Zelis Worker's Compensation |
$9.83
|
|
|
CL- PALONOSETRON HCL 0.25 MG/5 ML
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
CPT J2469
|
| Hospital Charge Code |
3350345
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$34.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$29.93
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$21.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$29.93
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$23.71
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$30.60
|
| Rate for Payer: First Health Commercial |
$32.40
|
| Rate for Payer: First Health Workers Compensation |
$13.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$32.40
|
| Rate for Payer: GEHA Commercial |
$0.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$32.40
|
| Rate for Payer: Humana ChoiceCare |
$9.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$24.19
|
| Rate for Payer: Multiplan All |
$32.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$21.60
|
| Rate for Payer: OMNI Networks Commercial |
$25.20
|
| Rate for Payer: One Health Plan PPO/POS |
$32.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$27.93
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$24.19
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$34.20
|
| Rate for Payer: Three Rivers Provider Network All |
$27.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$31.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$24.19
|
| Rate for Payer: United Payors & United Providers UP&UP |
$33.48
|
| Rate for Payer: Zelis Auto |
$14.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.83
|
|
|
CL- PAMIDRONATE 30 MG
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
CPT J2430
|
| Hospital Charge Code |
3350346
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.60 |
| Max. Negotiated Rate |
$46.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$41.65
|
| Rate for Payer: First Health Commercial |
$44.10
|
| Rate for Payer: First Health Workers Compensation |
$18.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$44.10
|
| Rate for Payer: GEHA Commercial |
$10.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$44.10
|
| Rate for Payer: Humana ChoiceCare |
$12.74
|
| Rate for Payer: Multiplan All |
$44.59
|
| Rate for Payer: New Mexico Health Connections Medicare |
$29.40
|
| Rate for Payer: OMNI Networks Commercial |
$34.30
|
| Rate for Payer: One Health Plan PPO/POS |
$44.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$46.55
|
| Rate for Payer: Three Rivers Provider Network All |
$36.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$43.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$45.57
|
| Rate for Payer: Zelis Auto |
$19.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$24.50
|
| Rate for Payer: Zelis Worker's Compensation |
$13.38
|
|
