|
ED- DC DIPHENOX/ATROPINE 2.5-0.025MG
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 59762106101
|
| Hospital Charge Code |
3302874
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| 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: 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 |
$9.60
|
| 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
|
|
|
ED- DC DIPHENOX/ATROPINE 2.5-0.025MG
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 59762106101
|
| Hospital Charge Code |
3302874
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
ED- DC HYDROcodone-ACETAMIN 5-325MG TAB
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 68084089501
|
| Hospital Charge Code |
3302869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.37 |
| Max. Negotiated Rate |
$25.65 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$22.95
|
| Rate for Payer: First Health Commercial |
$24.30
|
| Rate for Payer: First Health Workers Compensation |
$10.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$24.30
|
| Rate for Payer: GEHA Commercial |
$18.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$24.30
|
| Rate for Payer: Multiplan All |
$24.57
|
| Rate for Payer: OMNI Networks Commercial |
$18.90
|
| Rate for Payer: One Health Plan PPO/POS |
$24.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$25.65
|
| Rate for Payer: Three Rivers Provider Network All |
$20.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$25.11
|
| Rate for Payer: Zelis Auto |
$10.80
|
| Rate for Payer: Zelis Worker's Compensation |
$7.37
|
|
|
ED- DC HYDROcodone-ACETAMIN 5-325MG TAB
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 68084089501
|
| Hospital Charge Code |
3302869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$25.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$22.95
|
| Rate for Payer: First Health Commercial |
$24.30
|
| Rate for Payer: First Health Workers Compensation |
$10.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$24.30
|
| Rate for Payer: GEHA Commercial |
$21.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$24.30
|
| Rate for Payer: Humana ChoiceCare |
$7.02
|
| Rate for Payer: Multiplan All |
$24.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$16.20
|
| Rate for Payer: OMNI Networks Commercial |
$18.90
|
| Rate for Payer: One Health Plan PPO/POS |
$24.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$25.65
|
| Rate for Payer: Three Rivers Provider Network All |
$20.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$23.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$25.11
|
| Rate for Payer: Zelis Auto |
$10.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$13.50
|
| Rate for Payer: Zelis Worker's Compensation |
$7.37
|
|
|
ED- DC LORazepam 0.5MG TAB
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 00904600761
|
| Hospital Charge Code |
3302877
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
ED- DC LORazepam 0.5MG TAB
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 00904600761
|
| Hospital Charge Code |
3302877
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| 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: 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 |
$9.60
|
| 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
|
|
|
ED- DC LORazepam 1 MG TAB
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 60687035501
|
| Hospital Charge Code |
3303013
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
ED- DC LORazepam 1 MG TAB
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 60687035501
|
| Hospital Charge Code |
3303013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.25 |
| 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: 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 |
$7.20
|
| 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
|
|
|
ED- DC ONDANSETRON ODT 4MG TAB
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
CPT Q0162
|
| Hospital Charge Code |
3302871
|
|
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
|
|
|
ED- DC ONDANSETRON ODT 4MG TAB
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
CPT Q0162
|
| Hospital Charge Code |
3302871
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| 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 |
$0.01
|
| 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
|
|
|
ED- DC ONDANSETRON PEDS 2 MG ODT DOSE
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
CPT S0119
|
| Hospital Charge Code |
3303173
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
ED- DC ONDANSETRON PEDS 2 MG ODT DOSE
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
CPT S0119
|
| Hospital Charge Code |
3303173
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
ED- DC oxyCODONE IR TAB 5MG
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00406055262
|
| Hospital Charge Code |
3302876
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.75 |
| Max. Negotiated Rate |
$14.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$12.75
|
| Rate for Payer: First Health Commercial |
$13.50
|
| Rate for Payer: First Health Workers Compensation |
$5.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$13.50
|
| Rate for Payer: GEHA Commercial |
$12.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$13.50
|
| Rate for Payer: Humana ChoiceCare |
$3.90
|
| Rate for Payer: Multiplan All |
$13.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.00
|
| Rate for Payer: OMNI Networks Commercial |
$10.50
|
| Rate for Payer: One Health Plan PPO/POS |
$13.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$14.25
|
| Rate for Payer: Three Rivers Provider Network All |
$11.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.95
|
| Rate for Payer: Zelis Auto |
$6.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.50
|
| Rate for Payer: Zelis Worker's Compensation |
$4.09
|
|
|
ED- DC oxyCODONE IR TAB 5MG
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00406055262
|
| Hospital Charge Code |
3302876
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$14.25 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$12.75
|
| Rate for Payer: First Health Commercial |
$13.50
|
| Rate for Payer: First Health Workers Compensation |
$5.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$13.50
|
| Rate for Payer: GEHA Commercial |
$10.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$13.50
|
| Rate for Payer: Multiplan All |
$13.65
|
| Rate for Payer: OMNI Networks Commercial |
$10.50
|
| Rate for Payer: One Health Plan PPO/POS |
$13.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$14.25
|
| Rate for Payer: Three Rivers Provider Network All |
$11.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.95
|
| Rate for Payer: Zelis Auto |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.09
|
|
|
ED- DC oxyCODONE W/ACETAMIN 5-325MG TAB
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 68084035511
|
| Hospital Charge Code |
3302875
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| 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: 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 |
$9.60
|
| 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
|
|
|
ED- DC oxyCODONE W/ACETAMIN 5-325MG TAB
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 68084035511
|
| Hospital Charge Code |
3302875
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
ED- DC traMADol HCL 50MG TAB
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 57664037708
|
| Hospital Charge Code |
3302872
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
ED- DC traMADol HCL 50MG TAB
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 57664037708
|
| Hospital Charge Code |
3302872
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| 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: 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 |
$9.60
|
| 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
|
|
|
ED DVT FOCUSED STUDY
|
Facility
|
IP
|
$1,366.00
|
|
|
Service Code
|
CPT 93971
|
| Hospital Charge Code |
8193971
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$372.92 |
| Max. Negotiated Rate |
$1,297.70 |
| Rate for Payer: Cash Price |
$819.60
|
| Rate for Payer: Cigna Commercial |
$1,161.10
|
| Rate for Payer: First Health Commercial |
$1,229.40
|
| Rate for Payer: First Health Workers Compensation |
$527.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,229.40
|
| Rate for Payer: GEHA Commercial |
$956.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,229.40
|
| Rate for Payer: Multiplan All |
$1,243.06
|
| Rate for Payer: OMNI Networks Commercial |
$956.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,229.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,297.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,024.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,270.38
|
| Rate for Payer: Zelis Auto |
$546.40
|
| Rate for Payer: Zelis Worker's Compensation |
$372.92
|
|
|
ED DVT FOCUSED STUDY
|
Facility
|
OP
|
$1,366.00
|
|
|
Service Code
|
CPT 93971
|
| Hospital Charge Code |
8193971
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$85.82 |
| Max. Negotiated Rate |
$1,297.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$819.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$115.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$100.97
|
| Rate for Payer: Cash Price |
$819.60
|
| Rate for Payer: Cash Price |
$819.60
|
| Rate for Payer: Cigna Commercial |
$1,161.10
|
| Rate for Payer: First Health Commercial |
$1,229.40
|
| Rate for Payer: First Health Workers Compensation |
$527.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,229.40
|
| Rate for Payer: GEHA Commercial |
$1,092.80
|
| Rate for Payer: GEHA Medicare |
$100.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,229.40
|
| Rate for Payer: Humana ChoiceCare |
$111.07
|
| Rate for Payer: Humana Medicare Advantage |
$100.97
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$169.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$117.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$100.97
|
| Rate for Payer: Multiplan All |
$1,243.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$171.65
|
| Rate for Payer: OMNI Networks Commercial |
$956.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,229.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$136.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$117.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$100.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,297.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$201.94
|
| Rate for Payer: Three Rivers Provider Network All |
$1,024.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$117.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,270.38
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$100.97
|
| Rate for Payer: Zelis Auto |
$546.40
|
| Rate for Payer: Zelis Medicare |
$85.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$121.16
|
| Rate for Payer: Zelis Worker's Compensation |
$372.92
|
|
|
ED FAST EXAM COMPLETE
|
Facility
|
OP
|
$2,153.00
|
|
|
Service Code
|
CPT 93308
|
| Hospital Charge Code |
8193308
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$195.09 |
| Max. Negotiated Rate |
$2,045.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$396.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,291.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$396.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$314.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$229.52
|
| Rate for Payer: Cash Price |
$1,291.80
|
| Rate for Payer: Cash Price |
$1,291.80
|
| Rate for Payer: Cigna Commercial |
$1,830.05
|
| Rate for Payer: First Health Commercial |
$1,937.70
|
| Rate for Payer: First Health Workers Compensation |
$831.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,937.70
|
| Rate for Payer: GEHA Commercial |
$1,722.40
|
| Rate for Payer: GEHA Medicare |
$229.52
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,937.70
|
| Rate for Payer: Humana ChoiceCare |
$252.47
|
| Rate for Payer: Humana Medicare Advantage |
$229.52
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$385.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$320.57
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$229.52
|
| Rate for Payer: Multiplan All |
$1,959.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$390.18
|
| Rate for Payer: OMNI Networks Commercial |
$1,507.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,937.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$370.15
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$320.57
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$229.52
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,045.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$459.04
|
| Rate for Payer: Three Rivers Provider Network All |
$1,614.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$224.93
|
| Rate for Payer: United Healthcare Managed Medicaid |
$320.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$229.52
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,002.29
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$229.52
|
| Rate for Payer: Zelis Auto |
$861.20
|
| Rate for Payer: Zelis Medicare |
$195.09
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$275.42
|
| Rate for Payer: Zelis Worker's Compensation |
$587.77
|
|
|
ED FAST EXAM COMPLETE
|
Facility
|
IP
|
$2,153.00
|
|
|
Service Code
|
CPT 93308
|
| Hospital Charge Code |
8193308
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$587.77 |
| Max. Negotiated Rate |
$2,045.35 |
| Rate for Payer: Cash Price |
$1,291.80
|
| Rate for Payer: Cigna Commercial |
$1,830.05
|
| Rate for Payer: First Health Commercial |
$1,937.70
|
| Rate for Payer: First Health Workers Compensation |
$831.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,937.70
|
| Rate for Payer: GEHA Commercial |
$1,507.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,937.70
|
| Rate for Payer: Multiplan All |
$1,959.23
|
| Rate for Payer: OMNI Networks Commercial |
$1,507.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,937.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,045.35
|
| Rate for Payer: Three Rivers Provider Network All |
$1,614.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,002.29
|
| Rate for Payer: Zelis Auto |
$861.20
|
| Rate for Payer: Zelis Worker's Compensation |
$587.77
|
|
|
ED GALLBLADDER
|
Facility
|
OP
|
$1,238.30
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
8180003
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$81.14 |
| Max. Negotiated Rate |
$1,176.38 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$742.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$115.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$100.97
|
| Rate for Payer: Cash Price |
$742.98
|
| Rate for Payer: Cash Price |
$742.98
|
| Rate for Payer: Cigna Commercial |
$1,052.56
|
| Rate for Payer: First Health Commercial |
$1,114.47
|
| Rate for Payer: First Health Workers Compensation |
$114.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,114.47
|
| Rate for Payer: GEHA Commercial |
$990.64
|
| Rate for Payer: GEHA Medicare |
$100.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,114.47
|
| Rate for Payer: Humana ChoiceCare |
$111.07
|
| Rate for Payer: Humana Medicare Advantage |
$100.97
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$169.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$117.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$100.97
|
| Rate for Payer: Multiplan All |
$1,126.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$171.65
|
| Rate for Payer: OMNI Networks Commercial |
$866.81
|
| Rate for Payer: One Health Plan PPO/POS |
$1,114.47
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$136.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$117.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$100.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,176.38
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$201.94
|
| Rate for Payer: Three Rivers Provider Network All |
$928.73
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$117.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,151.62
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$100.97
|
| Rate for Payer: Zelis Auto |
$495.32
|
| Rate for Payer: Zelis Medicare |
$85.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$121.16
|
| Rate for Payer: Zelis Worker's Compensation |
$81.14
|
|
|
ED GALLBLADDER
|
Facility
|
IP
|
$1,238.30
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
8180003
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$81.14 |
| Max. Negotiated Rate |
$1,176.38 |
| Rate for Payer: Cash Price |
$742.98
|
| Rate for Payer: Cash Price |
$742.98
|
| Rate for Payer: Cigna Commercial |
$1,052.56
|
| Rate for Payer: First Health Commercial |
$1,114.47
|
| Rate for Payer: First Health Workers Compensation |
$114.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,114.47
|
| Rate for Payer: GEHA Commercial |
$866.81
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,114.47
|
| Rate for Payer: Multiplan All |
$1,126.85
|
| Rate for Payer: OMNI Networks Commercial |
$866.81
|
| Rate for Payer: One Health Plan PPO/POS |
$1,114.47
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,176.38
|
| Rate for Payer: Three Rivers Provider Network All |
$928.73
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,151.62
|
| Rate for Payer: Zelis Auto |
$495.32
|
| Rate for Payer: Zelis Worker's Compensation |
$81.14
|
|
|
ED KIDNEY/RENAL/AORTA
|
Facility
|
OP
|
$1,013.00
|
|
|
Service Code
|
CPT 76775
|
| Hospital Charge Code |
8176775
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$73.82 |
| Max. Negotiated Rate |
$962.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$607.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$115.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$100.97
|
| Rate for Payer: Cash Price |
$607.80
|
| Rate for Payer: Cash Price |
$607.80
|
| Rate for Payer: Cigna Commercial |
$861.05
|
| Rate for Payer: First Health Commercial |
$911.70
|
| Rate for Payer: First Health Workers Compensation |
$104.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$911.70
|
| Rate for Payer: GEHA Commercial |
$810.40
|
| Rate for Payer: GEHA Medicare |
$100.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$911.70
|
| Rate for Payer: Humana ChoiceCare |
$111.07
|
| Rate for Payer: Humana Medicare Advantage |
$100.97
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$169.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$117.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$100.97
|
| Rate for Payer: Multiplan All |
$921.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$171.65
|
| Rate for Payer: OMNI Networks Commercial |
$709.10
|
| Rate for Payer: One Health Plan PPO/POS |
$911.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$136.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$117.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$100.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$962.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$201.94
|
| Rate for Payer: Three Rivers Provider Network All |
$759.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$117.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$942.09
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$100.97
|
| Rate for Payer: Zelis Auto |
$405.20
|
| Rate for Payer: Zelis Medicare |
$85.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$121.16
|
| Rate for Payer: Zelis Worker's Compensation |
$73.82
|
|
