|
DIBUCAINE OINTMENT 1%
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
NDC 00536121195
|
| Hospital Charge Code |
3305025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.25 |
| Max. Negotiated Rate |
$57.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$36.60
|
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Cigna Commercial |
$51.85
|
| Rate for Payer: First Health Commercial |
$54.90
|
| Rate for Payer: First Health Workers Compensation |
$23.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$54.90
|
| Rate for Payer: GEHA Commercial |
$48.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$54.90
|
| Rate for Payer: Humana ChoiceCare |
$15.86
|
| Rate for Payer: Multiplan All |
$55.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$36.60
|
| Rate for Payer: OMNI Networks Commercial |
$42.70
|
| Rate for Payer: One Health Plan PPO/POS |
$54.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$57.95
|
| Rate for Payer: Three Rivers Provider Network All |
$45.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$53.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$15.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$56.73
|
| Rate for Payer: Zelis Auto |
$24.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$30.50
|
| Rate for Payer: Zelis Worker's Compensation |
$16.65
|
|
|
DICLOFENAC 75 MG DR TAB
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 00228255106
|
| Hospital Charge Code |
3300250
|
|
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
|
|
|
DICLOFENAC 75 MG DR TAB
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 00228255106
|
| Hospital Charge Code |
3300250
|
|
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
|
|
|
DICLOFENAC POTASSIUM TAB 50MG
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 51079046620
|
| Hospital Charge Code |
3300248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: First Health Commercial |
$12.60
|
| Rate for Payer: First Health Workers Compensation |
$5.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12.60
|
| Rate for Payer: GEHA Commercial |
$9.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12.60
|
| Rate for Payer: Multiplan All |
$12.74
|
| Rate for Payer: OMNI Networks Commercial |
$9.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.02
|
| Rate for Payer: Zelis Auto |
$5.60
|
| Rate for Payer: Zelis Worker's Compensation |
$3.82
|
|
|
DICLOFENAC POTASSIUM TAB 50MG
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 51079046620
|
| Hospital Charge Code |
3300248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: First Health Commercial |
$12.60
|
| Rate for Payer: First Health Workers Compensation |
$5.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12.60
|
| Rate for Payer: GEHA Commercial |
$11.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12.60
|
| Rate for Payer: Humana ChoiceCare |
$3.64
|
| Rate for Payer: Multiplan All |
$12.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.40
|
| Rate for Payer: OMNI Networks Commercial |
$9.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.02
|
| Rate for Payer: Zelis Auto |
$5.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.82
|
|
|
DICLOFENAC SODIUM GEL 1%
|
Facility
|
OP
|
$206.00
|
|
|
Service Code
|
NDC 69097072044
|
| Hospital Charge Code |
3300249
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.50 |
| Max. Negotiated Rate |
$195.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$123.60
|
| Rate for Payer: Cash Price |
$123.60
|
| Rate for Payer: Cigna Commercial |
$175.10
|
| Rate for Payer: First Health Commercial |
$185.40
|
| Rate for Payer: First Health Workers Compensation |
$79.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$185.40
|
| Rate for Payer: GEHA Commercial |
$164.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$185.40
|
| Rate for Payer: Humana ChoiceCare |
$53.56
|
| Rate for Payer: Multiplan All |
$187.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$123.60
|
| Rate for Payer: OMNI Networks Commercial |
$144.20
|
| Rate for Payer: One Health Plan PPO/POS |
$185.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$195.70
|
| Rate for Payer: Three Rivers Provider Network All |
$154.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$181.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$51.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$191.58
|
| Rate for Payer: Zelis Auto |
$82.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$103.00
|
| Rate for Payer: Zelis Worker's Compensation |
$56.24
|
|
|
DICLOFENAC SODIUM GEL 1%
|
Facility
|
IP
|
$206.00
|
|
|
Service Code
|
NDC 69097072044
|
| Hospital Charge Code |
3300249
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.24 |
| Max. Negotiated Rate |
$195.70 |
| Rate for Payer: Cash Price |
$123.60
|
| Rate for Payer: Cigna Commercial |
$175.10
|
| Rate for Payer: First Health Commercial |
$185.40
|
| Rate for Payer: First Health Workers Compensation |
$79.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$185.40
|
| Rate for Payer: GEHA Commercial |
$144.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$185.40
|
| Rate for Payer: Multiplan All |
$187.46
|
| Rate for Payer: OMNI Networks Commercial |
$144.20
|
| Rate for Payer: One Health Plan PPO/POS |
$185.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$195.70
|
| Rate for Payer: Three Rivers Provider Network All |
$154.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$191.58
|
| Rate for Payer: Zelis Auto |
$82.40
|
| Rate for Payer: Zelis Worker's Compensation |
$56.24
|
|
|
DICYCLOMINE HCL CAP 10MG
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 60687036901
|
| Hospital Charge Code |
3300251
|
|
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
|
|
|
DICYCLOMINE HCL CAP 10MG
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 60687036901
|
| Hospital Charge Code |
3300251
|
|
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
|
|
|
DICYCLOMINE HCL INJ 10MG/ML
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
CPT J0500
|
| Hospital Charge Code |
3300252
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.89 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$208.25
|
| Rate for Payer: First Health Commercial |
$220.50
|
| Rate for Payer: First Health Workers Compensation |
$94.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$220.50
|
| Rate for Payer: GEHA Commercial |
$171.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$220.50
|
| Rate for Payer: Multiplan All |
$222.95
|
| Rate for Payer: OMNI Networks Commercial |
$171.50
|
| Rate for Payer: One Health Plan PPO/POS |
$220.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$232.75
|
| Rate for Payer: Three Rivers Provider Network All |
$183.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$227.85
|
| Rate for Payer: Zelis Auto |
$98.00
|
| Rate for Payer: Zelis Worker's Compensation |
$66.89
|
|
|
DICYCLOMINE HCL INJ 10MG/ML
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
CPT J0500
|
| Hospital Charge Code |
3300252
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.50 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$147.00
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$208.25
|
| Rate for Payer: First Health Commercial |
$220.50
|
| Rate for Payer: First Health Workers Compensation |
$94.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$220.50
|
| Rate for Payer: GEHA Commercial |
$12.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$220.50
|
| Rate for Payer: Humana ChoiceCare |
$63.70
|
| Rate for Payer: Multiplan All |
$222.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$147.00
|
| Rate for Payer: OMNI Networks Commercial |
$171.50
|
| Rate for Payer: One Health Plan PPO/POS |
$220.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$232.75
|
| Rate for Payer: Three Rivers Provider Network All |
$183.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$215.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$61.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$227.85
|
| Rate for Payer: Zelis Auto |
$98.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$122.50
|
| Rate for Payer: Zelis Worker's Compensation |
$66.89
|
|
|
DIGIT NERVE SURGERY ADD-ON
|
Facility
|
IP
|
$448.00
|
|
|
Service Code
|
CPT 64778
|
| Hospital Charge Code |
6164778
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$122.30 |
| Max. Negotiated Rate |
$425.60 |
| Rate for Payer: Cash Price |
$268.80
|
| Rate for Payer: Cigna Commercial |
$380.80
|
| Rate for Payer: First Health Commercial |
$403.20
|
| Rate for Payer: First Health Workers Compensation |
$172.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$403.20
|
| Rate for Payer: GEHA Commercial |
$313.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$403.20
|
| Rate for Payer: Multiplan All |
$407.68
|
| Rate for Payer: OMNI Networks Commercial |
$313.60
|
| Rate for Payer: One Health Plan PPO/POS |
$403.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$425.60
|
| Rate for Payer: Three Rivers Provider Network All |
$336.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$416.64
|
| Rate for Payer: Zelis Auto |
$179.20
|
| Rate for Payer: Zelis Worker's Compensation |
$122.30
|
|
|
DIGIT NERVE SURGERY ADD-ON
|
Facility
|
OP
|
$448.00
|
|
|
Service Code
|
CPT 64778
|
| Hospital Charge Code |
6164778
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$116.48 |
| Max. Negotiated Rate |
$1,892.76 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,892.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$268.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,892.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,499.44
|
| Rate for Payer: Cash Price |
$268.80
|
| Rate for Payer: Cash Price |
$268.80
|
| Rate for Payer: Cigna Commercial |
$380.80
|
| Rate for Payer: First Health Commercial |
$403.20
|
| Rate for Payer: First Health Workers Compensation |
$172.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$403.20
|
| Rate for Payer: GEHA Commercial |
$358.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$403.20
|
| Rate for Payer: Humana ChoiceCare |
$116.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,529.98
|
| Rate for Payer: Multiplan All |
$407.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$268.80
|
| Rate for Payer: OMNI Networks Commercial |
$313.60
|
| Rate for Payer: One Health Plan PPO/POS |
$403.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,766.58
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,529.98
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$425.60
|
| Rate for Payer: Three Rivers Provider Network All |
$336.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$394.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,529.98
|
| Rate for Payer: United Payors & United Providers UP&UP |
$416.64
|
| Rate for Payer: Zelis Auto |
$179.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$224.00
|
| Rate for Payer: Zelis Worker's Compensation |
$122.30
|
|
|
DIGOXIN IMMUNE FAB FOR INJ 40MG
|
Facility
|
IP
|
$8,945.00
|
|
|
Service Code
|
CPT J1162
|
| Hospital Charge Code |
3300253
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,441.99 |
| Max. Negotiated Rate |
$8,497.75 |
| Rate for Payer: Cash Price |
$5,367.00
|
| Rate for Payer: Cigna Commercial |
$7,603.25
|
| Rate for Payer: First Health Commercial |
$8,050.50
|
| Rate for Payer: First Health Workers Compensation |
$3,453.66
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,050.50
|
| Rate for Payer: GEHA Commercial |
$6,261.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,050.50
|
| Rate for Payer: Multiplan All |
$8,139.95
|
| Rate for Payer: OMNI Networks Commercial |
$6,261.50
|
| Rate for Payer: One Health Plan PPO/POS |
$8,050.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,497.75
|
| Rate for Payer: Three Rivers Provider Network All |
$6,708.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,318.85
|
| Rate for Payer: Zelis Auto |
$3,578.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2,441.99
|
|
|
DIGOXIN IMMUNE FAB FOR INJ 40MG
|
Facility
|
OP
|
$8,945.00
|
|
|
Service Code
|
CPT J1162
|
| Hospital Charge Code |
3300253
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,441.99 |
| Max. Negotiated Rate |
$10,336.46 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$3,541.97
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,367.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$3,541.97
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2,805.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5,168.23
|
| Rate for Payer: Cash Price |
$5,367.00
|
| Rate for Payer: Cash Price |
$5,367.00
|
| Rate for Payer: Cigna Commercial |
$7,603.25
|
| Rate for Payer: First Health Commercial |
$8,050.50
|
| Rate for Payer: First Health Workers Compensation |
$3,453.66
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,050.50
|
| Rate for Payer: GEHA Commercial |
$5,685.05
|
| Rate for Payer: GEHA Medicare |
$5,168.23
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,050.50
|
| Rate for Payer: Humana ChoiceCare |
$5,685.05
|
| Rate for Payer: Humana Medicare Advantage |
$5,168.23
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8,682.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,863.09
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5,168.23
|
| Rate for Payer: Multiplan All |
$8,139.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8,785.99
|
| Rate for Payer: OMNI Networks Commercial |
$6,261.50
|
| Rate for Payer: One Health Plan PPO/POS |
$8,050.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$3,305.83
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,863.09
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5,168.23
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,497.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10,336.46
|
| Rate for Payer: Three Rivers Provider Network All |
$6,708.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,064.87
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,863.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,168.23
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,318.85
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5,168.23
|
| Rate for Payer: Zelis Auto |
$3,578.00
|
| Rate for Payer: Zelis Medicare |
$4,393.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,201.88
|
| Rate for Payer: Zelis Worker's Compensation |
$2,441.99
|
|
|
DIGOXIN (LAnoxIN) 0.125MG TAB
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00904592161
|
| Hospital Charge Code |
3300255
|
|
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
|
|
|
DIGOXIN (LAnoxIN) 0.125MG TAB
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00904592161
|
| Hospital Charge Code |
3300255
|
|
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
|
|
|
DIGOXIN (LAnoxIN) 0.5MG/2ML IV PUSH
|
Facility
|
IP
|
$44.00
|
|
|
Service Code
|
CPT J1160
|
| Hospital Charge Code |
3300254
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.01 |
| Max. Negotiated Rate |
$41.80 |
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$37.40
|
| Rate for Payer: First Health Commercial |
$39.60
|
| Rate for Payer: First Health Workers Compensation |
$16.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$39.60
|
| Rate for Payer: GEHA Commercial |
$30.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$39.60
|
| Rate for Payer: Multiplan All |
$40.04
|
| Rate for Payer: OMNI Networks Commercial |
$30.80
|
| Rate for Payer: One Health Plan PPO/POS |
$39.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$41.80
|
| Rate for Payer: Three Rivers Provider Network All |
$33.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$40.92
|
| Rate for Payer: Zelis Auto |
$17.60
|
| Rate for Payer: Zelis Worker's Compensation |
$12.01
|
|
|
DIGOXIN (LAnoxIN) 0.5MG/2ML IV PUSH
|
Facility
|
OP
|
$44.00
|
|
|
Service Code
|
CPT J1160
|
| Hospital Charge Code |
3300254
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.96 |
| Max. Negotiated Rate |
$41.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$21.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$26.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$21.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.77
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$37.40
|
| Rate for Payer: First Health Commercial |
$39.60
|
| Rate for Payer: First Health Workers Compensation |
$16.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$39.60
|
| Rate for Payer: GEHA Commercial |
$9.96
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$39.60
|
| Rate for Payer: Humana ChoiceCare |
$11.44
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$17.11
|
| Rate for Payer: Multiplan All |
$40.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$26.40
|
| Rate for Payer: OMNI Networks Commercial |
$30.80
|
| Rate for Payer: One Health Plan PPO/POS |
$39.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$19.75
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$17.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$41.80
|
| Rate for Payer: Three Rivers Provider Network All |
$33.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$38.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$17.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$40.92
|
| Rate for Payer: Zelis Auto |
$17.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.01
|
|
|
DIGOXIN (Vitros)
|
Facility
|
OP
|
$190.00
|
|
|
Service Code
|
CPT 80162
|
| Hospital Charge Code |
2232220
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.29 |
| Max. Negotiated Rate |
$180.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$23.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$114.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$23.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$18.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$13.28
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cigna Commercial |
$161.50
|
| Rate for Payer: First Health Commercial |
$171.00
|
| Rate for Payer: First Health Workers Compensation |
$23.64
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$171.00
|
| Rate for Payer: GEHA Commercial |
$152.00
|
| Rate for Payer: GEHA Medicare |
$13.28
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$171.00
|
| Rate for Payer: Humana ChoiceCare |
$14.61
|
| Rate for Payer: Humana Medicare Advantage |
$13.28
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$22.31
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$19.33
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$13.28
|
| Rate for Payer: Multiplan All |
$172.90
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.58
|
| Rate for Payer: OMNI Networks Commercial |
$133.00
|
| Rate for Payer: One Health Plan PPO/POS |
$171.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$22.32
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$19.33
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$13.28
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$180.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$26.56
|
| Rate for Payer: Three Rivers Provider Network All |
$142.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.01
|
| Rate for Payer: United Healthcare Commercial |
$161.50
|
| Rate for Payer: United Healthcare Managed Medicaid |
$19.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.28
|
| Rate for Payer: United Payors & United Providers UP&UP |
$176.70
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$13.28
|
| Rate for Payer: Zelis Auto |
$76.00
|
| Rate for Payer: Zelis Medicare |
$11.29
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.94
|
| Rate for Payer: Zelis Worker's Compensation |
$16.72
|
|
|
DIGOXIN (Vitros)
|
Facility
|
IP
|
$190.00
|
|
|
Service Code
|
CPT 80162
|
| Hospital Charge Code |
2232220
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.72 |
| Max. Negotiated Rate |
$180.50 |
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cigna Commercial |
$161.50
|
| Rate for Payer: First Health Commercial |
$171.00
|
| Rate for Payer: First Health Workers Compensation |
$23.64
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$171.00
|
| Rate for Payer: GEHA Commercial |
$133.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$171.00
|
| Rate for Payer: Multiplan All |
$172.90
|
| Rate for Payer: OMNI Networks Commercial |
$133.00
|
| Rate for Payer: One Health Plan PPO/POS |
$171.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$180.50
|
| Rate for Payer: Three Rivers Provider Network All |
$142.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$176.70
|
| Rate for Payer: Zelis Auto |
$76.00
|
| Rate for Payer: Zelis Worker's Compensation |
$16.72
|
|
|
dihydrocortisone REF500142
|
Facility
|
IP
|
$310.00
|
|
|
Service Code
|
CPT 82784
|
| Hospital Charge Code |
2299835
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.84 |
| Max. Negotiated Rate |
$294.50 |
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$263.50
|
| Rate for Payer: First Health Commercial |
$279.00
|
| Rate for Payer: First Health Workers Compensation |
$15.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$279.00
|
| Rate for Payer: GEHA Commercial |
$217.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$279.00
|
| Rate for Payer: Multiplan All |
$282.10
|
| Rate for Payer: OMNI Networks Commercial |
$217.00
|
| Rate for Payer: One Health Plan PPO/POS |
$279.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$294.50
|
| Rate for Payer: Three Rivers Provider Network All |
$232.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$288.30
|
| Rate for Payer: Zelis Auto |
$124.00
|
| Rate for Payer: Zelis Worker's Compensation |
$10.84
|
|
|
dihydrocortisone REF500142
|
Facility
|
OP
|
$310.00
|
|
|
Service Code
|
CPT 82784
|
| Hospital Charge Code |
2299835
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.91 |
| Max. Negotiated Rate |
$294.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$16.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$186.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$16.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$13.26
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$9.30
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$263.50
|
| Rate for Payer: First Health Commercial |
$279.00
|
| Rate for Payer: First Health Workers Compensation |
$15.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$279.00
|
| Rate for Payer: GEHA Commercial |
$248.00
|
| Rate for Payer: GEHA Medicare |
$9.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$279.00
|
| Rate for Payer: Humana ChoiceCare |
$10.23
|
| Rate for Payer: Humana Medicare Advantage |
$9.30
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$15.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$13.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$9.30
|
| Rate for Payer: Multiplan All |
$282.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$15.81
|
| Rate for Payer: OMNI Networks Commercial |
$217.00
|
| Rate for Payer: One Health Plan PPO/POS |
$279.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$15.62
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$13.53
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$9.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$294.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$18.60
|
| Rate for Payer: Three Rivers Provider Network All |
$232.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.11
|
| Rate for Payer: United Healthcare Commercial |
$263.50
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.30
|
| Rate for Payer: United Payors & United Providers UP&UP |
$288.30
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$9.30
|
| Rate for Payer: Zelis Auto |
$124.00
|
| Rate for Payer: Zelis Medicare |
$7.91
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$11.16
|
| Rate for Payer: Zelis Worker's Compensation |
$10.84
|
|
|
dihydrotestosterone (dht) REF500142
|
Facility
|
OP
|
$165.00
|
|
|
Service Code
|
CPT 82642
|
| Hospital Charge Code |
2200589
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.43 |
| Max. Negotiated Rate |
$156.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$99.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$29.28
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$140.25
|
| Rate for Payer: First Health Commercial |
$148.50
|
| Rate for Payer: First Health Workers Compensation |
$34.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$148.50
|
| Rate for Payer: GEHA Commercial |
$132.00
|
| Rate for Payer: GEHA Medicare |
$29.28
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$148.50
|
| Rate for Payer: Humana ChoiceCare |
$32.21
|
| Rate for Payer: Humana Medicare Advantage |
$29.28
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$49.19
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$29.28
|
| Rate for Payer: Multiplan All |
$150.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$49.78
|
| Rate for Payer: OMNI Networks Commercial |
$115.50
|
| Rate for Payer: One Health Plan PPO/POS |
$148.50
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$29.28
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$156.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$58.56
|
| Rate for Payer: Three Rivers Provider Network All |
$123.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$28.69
|
| Rate for Payer: United Healthcare Commercial |
$140.25
|
| Rate for Payer: United Healthcare Managed Medicaid |
$41.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.28
|
| Rate for Payer: United Payors & United Providers UP&UP |
$153.45
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$29.28
|
| Rate for Payer: Zelis Auto |
$66.00
|
| Rate for Payer: Zelis Medicare |
$24.89
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$35.14
|
| Rate for Payer: Zelis Worker's Compensation |
$24.43
|
|
|
dihydrotestosterone (dht) REF500142
|
Facility
|
IP
|
$165.00
|
|
|
Service Code
|
CPT 82642
|
| Hospital Charge Code |
2200589
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.43 |
| Max. Negotiated Rate |
$156.75 |
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$140.25
|
| Rate for Payer: First Health Commercial |
$148.50
|
| Rate for Payer: First Health Workers Compensation |
$34.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$148.50
|
| Rate for Payer: GEHA Commercial |
$115.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$148.50
|
| Rate for Payer: Multiplan All |
$150.15
|
| Rate for Payer: OMNI Networks Commercial |
$115.50
|
| Rate for Payer: One Health Plan PPO/POS |
$148.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$156.75
|
| Rate for Payer: Three Rivers Provider Network All |
$123.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$153.45
|
| Rate for Payer: Zelis Auto |
$66.00
|
| Rate for Payer: Zelis Worker's Compensation |
$24.43
|
|
