|
estimated glomerular filtration rate
|
Facility
|
OP
|
$53.00
|
|
| Hospital Charge Code |
2299444
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$50.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$45.05
|
| Rate for Payer: First Health Commercial |
$47.70
|
| Rate for Payer: First Health Workers Compensation |
$20.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$47.70
|
| Rate for Payer: GEHA Commercial |
$42.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$47.70
|
| Rate for Payer: Humana ChoiceCare |
$13.78
|
| Rate for Payer: Multiplan All |
$48.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.80
|
| Rate for Payer: OMNI Networks Commercial |
$37.10
|
| Rate for Payer: One Health Plan PPO/POS |
$47.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$50.35
|
| Rate for Payer: Three Rivers Provider Network All |
$39.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$46.64
|
| Rate for Payer: United Healthcare Commercial |
$45.05
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$49.29
|
| Rate for Payer: Zelis Auto |
$21.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$26.50
|
| Rate for Payer: Zelis Worker's Compensation |
$14.47
|
|
|
estimated glomerular filtration rate
|
Facility
|
IP
|
$53.00
|
|
| Hospital Charge Code |
2299444
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.47 |
| Max. Negotiated Rate |
$50.35 |
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$45.05
|
| Rate for Payer: First Health Commercial |
$47.70
|
| Rate for Payer: First Health Workers Compensation |
$20.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$47.70
|
| Rate for Payer: GEHA Commercial |
$37.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$47.70
|
| Rate for Payer: Multiplan All |
$48.23
|
| Rate for Payer: OMNI Networks Commercial |
$37.10
|
| Rate for Payer: One Health Plan PPO/POS |
$47.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$50.35
|
| Rate for Payer: Three Rivers Provider Network All |
$39.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$49.29
|
| Rate for Payer: Zelis Auto |
$21.20
|
| Rate for Payer: Zelis Worker's Compensation |
$14.47
|
|
|
ESTRADIOL 1 MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00555088602
|
| Hospital Charge Code |
3303203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
ESTRADIOL 1 MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00555088602
|
| Hospital Charge Code |
3303203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
ESTRADIOL CYPIONATE IM 5MG/ML
|
Facility
|
IP
|
$269.00
|
|
|
Service Code
|
CPT J1000
|
| Hospital Charge Code |
3300311
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.44 |
| Max. Negotiated Rate |
$255.55 |
| Rate for Payer: Cash Price |
$161.40
|
| Rate for Payer: Cigna Commercial |
$228.65
|
| Rate for Payer: First Health Commercial |
$242.10
|
| Rate for Payer: First Health Workers Compensation |
$103.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$242.10
|
| Rate for Payer: GEHA Commercial |
$188.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$242.10
|
| Rate for Payer: Multiplan All |
$244.79
|
| Rate for Payer: OMNI Networks Commercial |
$188.30
|
| Rate for Payer: One Health Plan PPO/POS |
$242.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$255.55
|
| Rate for Payer: Three Rivers Provider Network All |
$201.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$250.17
|
| Rate for Payer: Zelis Auto |
$107.60
|
| Rate for Payer: Zelis Worker's Compensation |
$73.44
|
|
|
ESTRADIOL CYPIONATE IM 5MG/ML
|
Facility
|
OP
|
$269.00
|
|
|
Service Code
|
CPT J1000
|
| Hospital Charge Code |
3300311
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.21 |
| Max. Negotiated Rate |
$255.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$161.40
|
| Rate for Payer: Cash Price |
$161.40
|
| Rate for Payer: Cash Price |
$161.40
|
| Rate for Payer: Cigna Commercial |
$228.65
|
| Rate for Payer: First Health Commercial |
$242.10
|
| Rate for Payer: First Health Workers Compensation |
$103.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$242.10
|
| Rate for Payer: GEHA Commercial |
$54.21
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$242.10
|
| Rate for Payer: Humana ChoiceCare |
$69.94
|
| Rate for Payer: Multiplan All |
$244.79
|
| Rate for Payer: New Mexico Health Connections Medicare |
$161.40
|
| Rate for Payer: OMNI Networks Commercial |
$188.30
|
| Rate for Payer: One Health Plan PPO/POS |
$242.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$255.55
|
| Rate for Payer: Three Rivers Provider Network All |
$201.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$236.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$67.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$250.17
|
| Rate for Payer: Zelis Auto |
$107.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$134.50
|
| Rate for Payer: Zelis Worker's Compensation |
$73.44
|
|
|
estradiol free w/ total REF500649
|
Facility
|
OP
|
$442.00
|
|
|
Service Code
|
CPT 82670
|
| Hospital Charge Code |
2299710
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.75 |
| Max. Negotiated Rate |
$419.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$50.30
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$265.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$50.30
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$39.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$27.94
|
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cigna Commercial |
$375.70
|
| Rate for Payer: First Health Commercial |
$397.80
|
| Rate for Payer: First Health Workers Compensation |
$49.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$397.80
|
| Rate for Payer: GEHA Commercial |
$353.60
|
| Rate for Payer: GEHA Medicare |
$27.94
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$397.80
|
| Rate for Payer: Humana ChoiceCare |
$30.73
|
| Rate for Payer: Humana Medicare Advantage |
$27.94
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$46.94
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$40.66
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$27.94
|
| Rate for Payer: Multiplan All |
$402.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$47.50
|
| Rate for Payer: OMNI Networks Commercial |
$309.40
|
| Rate for Payer: One Health Plan PPO/POS |
$397.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$46.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$40.66
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$27.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$419.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$55.88
|
| Rate for Payer: Three Rivers Provider Network All |
$331.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$27.38
|
| Rate for Payer: United Healthcare Commercial |
$375.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$40.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$411.06
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$27.94
|
| Rate for Payer: Zelis Auto |
$176.80
|
| Rate for Payer: Zelis Medicare |
$23.75
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.53
|
| Rate for Payer: Zelis Worker's Compensation |
$34.76
|
|
|
estradiol free w/ total REF500649
|
Facility
|
IP
|
$442.00
|
|
|
Service Code
|
CPT 82670
|
| Hospital Charge Code |
2299710
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$34.76 |
| Max. Negotiated Rate |
$419.90 |
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cigna Commercial |
$375.70
|
| Rate for Payer: First Health Commercial |
$397.80
|
| Rate for Payer: First Health Workers Compensation |
$49.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$397.80
|
| Rate for Payer: GEHA Commercial |
$309.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$397.80
|
| Rate for Payer: Multiplan All |
$402.22
|
| Rate for Payer: OMNI Networks Commercial |
$309.40
|
| Rate for Payer: One Health Plan PPO/POS |
$397.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$419.90
|
| Rate for Payer: Three Rivers Provider Network All |
$331.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$411.06
|
| Rate for Payer: Zelis Auto |
$176.80
|
| Rate for Payer: Zelis Worker's Compensation |
$34.76
|
|
|
estradiol REF004515
|
Facility
|
OP
|
$442.00
|
|
|
Service Code
|
CPT 82670
|
| Hospital Charge Code |
2299093
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.75 |
| Max. Negotiated Rate |
$419.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$50.30
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$265.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$50.30
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$39.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$27.94
|
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cigna Commercial |
$375.70
|
| Rate for Payer: First Health Commercial |
$397.80
|
| Rate for Payer: First Health Workers Compensation |
$49.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$397.80
|
| Rate for Payer: GEHA Commercial |
$353.60
|
| Rate for Payer: GEHA Medicare |
$27.94
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$397.80
|
| Rate for Payer: Humana ChoiceCare |
$30.73
|
| Rate for Payer: Humana Medicare Advantage |
$27.94
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$46.94
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$40.66
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$27.94
|
| Rate for Payer: Multiplan All |
$402.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$47.50
|
| Rate for Payer: OMNI Networks Commercial |
$309.40
|
| Rate for Payer: One Health Plan PPO/POS |
$397.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$46.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$40.66
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$27.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$419.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$55.88
|
| Rate for Payer: Three Rivers Provider Network All |
$331.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$27.38
|
| Rate for Payer: United Healthcare Commercial |
$375.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$40.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$411.06
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$27.94
|
| Rate for Payer: Zelis Auto |
$176.80
|
| Rate for Payer: Zelis Medicare |
$23.75
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.53
|
| Rate for Payer: Zelis Worker's Compensation |
$34.76
|
|
|
estradiol REF004515
|
Facility
|
IP
|
$442.00
|
|
|
Service Code
|
CPT 82670
|
| Hospital Charge Code |
2299093
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$34.76 |
| Max. Negotiated Rate |
$419.90 |
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cigna Commercial |
$375.70
|
| Rate for Payer: First Health Commercial |
$397.80
|
| Rate for Payer: First Health Workers Compensation |
$49.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$397.80
|
| Rate for Payer: GEHA Commercial |
$309.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$397.80
|
| Rate for Payer: Multiplan All |
$402.22
|
| Rate for Payer: OMNI Networks Commercial |
$309.40
|
| Rate for Payer: One Health Plan PPO/POS |
$397.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$419.90
|
| Rate for Payer: Three Rivers Provider Network All |
$331.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$411.06
|
| Rate for Payer: Zelis Auto |
$176.80
|
| Rate for Payer: Zelis Worker's Compensation |
$34.76
|
|
|
ESTRADIOL VALERATE 20MG/ML
|
Facility
|
OP
|
$208.00
|
|
|
Service Code
|
CPT J1380
|
| Hospital Charge Code |
3301597
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.97 |
| Max. Negotiated Rate |
$197.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$124.80
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cigna Commercial |
$176.80
|
| Rate for Payer: First Health Commercial |
$187.20
|
| Rate for Payer: First Health Workers Compensation |
$80.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$187.20
|
| Rate for Payer: GEHA Commercial |
$7.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$187.20
|
| Rate for Payer: Humana ChoiceCare |
$54.08
|
| Rate for Payer: Multiplan All |
$189.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$124.80
|
| Rate for Payer: OMNI Networks Commercial |
$145.60
|
| Rate for Payer: One Health Plan PPO/POS |
$187.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$197.60
|
| Rate for Payer: Three Rivers Provider Network All |
$156.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$183.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$52.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$193.44
|
| Rate for Payer: Zelis Auto |
$83.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$104.00
|
| Rate for Payer: Zelis Worker's Compensation |
$56.78
|
|
|
ESTRADIOL VALERATE 20MG/ML
|
Facility
|
IP
|
$208.00
|
|
|
Service Code
|
CPT J1380
|
| Hospital Charge Code |
3301597
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.78 |
| Max. Negotiated Rate |
$197.60 |
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cigna Commercial |
$176.80
|
| Rate for Payer: First Health Commercial |
$187.20
|
| Rate for Payer: First Health Workers Compensation |
$80.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$187.20
|
| Rate for Payer: GEHA Commercial |
$145.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$187.20
|
| Rate for Payer: Multiplan All |
$189.28
|
| Rate for Payer: OMNI Networks Commercial |
$145.60
|
| Rate for Payer: One Health Plan PPO/POS |
$187.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$197.60
|
| Rate for Payer: Three Rivers Provider Network All |
$156.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$193.44
|
| Rate for Payer: Zelis Auto |
$83.20
|
| Rate for Payer: Zelis Worker's Compensation |
$56.78
|
|
|
ESTRADIOL VALERATE IM 40MG/ML
|
Facility
|
OP
|
$209.00
|
|
|
Service Code
|
CPT J1380
|
| Hospital Charge Code |
3300312
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.97 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$125.40
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$177.65
|
| Rate for Payer: First Health Commercial |
$188.10
|
| Rate for Payer: First Health Workers Compensation |
$80.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$188.10
|
| Rate for Payer: GEHA Commercial |
$7.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$188.10
|
| Rate for Payer: Humana ChoiceCare |
$54.34
|
| Rate for Payer: Multiplan All |
$190.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$125.40
|
| Rate for Payer: OMNI Networks Commercial |
$146.30
|
| Rate for Payer: One Health Plan PPO/POS |
$188.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$198.55
|
| Rate for Payer: Three Rivers Provider Network All |
$156.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$183.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$52.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$194.37
|
| Rate for Payer: Zelis Auto |
$83.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$104.50
|
| Rate for Payer: Zelis Worker's Compensation |
$57.06
|
|
|
ESTRADIOL VALERATE IM 40MG/ML
|
Facility
|
IP
|
$209.00
|
|
|
Service Code
|
CPT J1380
|
| Hospital Charge Code |
3300312
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.06 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$177.65
|
| Rate for Payer: First Health Commercial |
$188.10
|
| Rate for Payer: First Health Workers Compensation |
$80.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$188.10
|
| Rate for Payer: GEHA Commercial |
$146.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$188.10
|
| Rate for Payer: Multiplan All |
$190.19
|
| Rate for Payer: OMNI Networks Commercial |
$146.30
|
| Rate for Payer: One Health Plan PPO/POS |
$188.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$198.55
|
| Rate for Payer: Three Rivers Provider Network All |
$156.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$194.37
|
| Rate for Payer: Zelis Auto |
$83.60
|
| Rate for Payer: Zelis Worker's Compensation |
$57.06
|
|
|
estriol REF004614
|
Facility
|
OP
|
$187.00
|
|
|
Service Code
|
CPT 82677
|
| Hospital Charge Code |
22990361
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.55 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$43.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$112.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$43.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$34.48
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$24.18
|
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cigna Commercial |
$158.95
|
| Rate for Payer: First Health Commercial |
$168.30
|
| Rate for Payer: First Health Workers Compensation |
$42.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$168.30
|
| Rate for Payer: GEHA Commercial |
$149.60
|
| Rate for Payer: GEHA Medicare |
$24.18
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$168.30
|
| Rate for Payer: Humana ChoiceCare |
$26.60
|
| Rate for Payer: Humana Medicare Advantage |
$24.18
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$40.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$35.19
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$24.18
|
| Rate for Payer: Multiplan All |
$170.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$41.11
|
| Rate for Payer: OMNI Networks Commercial |
$130.90
|
| Rate for Payer: One Health Plan PPO/POS |
$168.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$40.63
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$35.19
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$24.18
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$177.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$48.36
|
| Rate for Payer: Three Rivers Provider Network All |
$140.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$23.70
|
| Rate for Payer: United Healthcare Commercial |
$158.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$35.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.18
|
| Rate for Payer: United Payors & United Providers UP&UP |
$173.91
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$24.18
|
| Rate for Payer: Zelis Auto |
$74.80
|
| Rate for Payer: Zelis Medicare |
$20.55
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$29.02
|
| Rate for Payer: Zelis Worker's Compensation |
$30.25
|
|
|
estriol REF004614
|
Facility
|
IP
|
$187.00
|
|
|
Service Code
|
CPT 82677
|
| Hospital Charge Code |
22990361
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$30.25 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cigna Commercial |
$158.95
|
| Rate for Payer: First Health Commercial |
$168.30
|
| Rate for Payer: First Health Workers Compensation |
$42.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$168.30
|
| Rate for Payer: GEHA Commercial |
$130.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$168.30
|
| Rate for Payer: Multiplan All |
$170.17
|
| Rate for Payer: OMNI Networks Commercial |
$130.90
|
| Rate for Payer: One Health Plan PPO/POS |
$168.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$177.65
|
| Rate for Payer: Three Rivers Provider Network All |
$140.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$173.91
|
| Rate for Payer: Zelis Auto |
$74.80
|
| Rate for Payer: Zelis Worker's Compensation |
$30.25
|
|
|
ESTROGENS, CONJUGATED 0.3MG TAB
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 00046110081
|
| Hospital Charge Code |
3300313
|
|
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
|
|
|
ESTROGENS, CONJUGATED 0.3MG TAB
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 00046110081
|
| Hospital Charge Code |
3300313
|
|
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
|
|
|
ESTROGENS, CONJUGATED 0.625MG TAB
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 00046087221
|
| Hospital Charge Code |
3300314
|
|
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
|
|
|
ESTROGENS, CONJUGATED 0.625MG TAB
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 00046087221
|
| Hospital Charge Code |
3300314
|
|
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
|
|
|
estrogen total REF004549
|
Facility
|
IP
|
$475.00
|
|
|
Service Code
|
CPT 82672
|
| Hospital Charge Code |
2232672
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$28.72 |
| Max. Negotiated Rate |
$451.25 |
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Commercial |
$403.75
|
| Rate for Payer: First Health Commercial |
$427.50
|
| Rate for Payer: First Health Workers Compensation |
$40.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$427.50
|
| Rate for Payer: GEHA Commercial |
$332.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$427.50
|
| Rate for Payer: Multiplan All |
$432.25
|
| Rate for Payer: OMNI Networks Commercial |
$332.50
|
| Rate for Payer: One Health Plan PPO/POS |
$427.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$451.25
|
| Rate for Payer: Three Rivers Provider Network All |
$356.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$441.75
|
| Rate for Payer: Zelis Auto |
$190.00
|
| Rate for Payer: Zelis Worker's Compensation |
$28.72
|
|
|
estrogen total REF004549
|
Facility
|
OP
|
$475.00
|
|
|
Service Code
|
CPT 82672
|
| Hospital Charge Code |
2232672
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.45 |
| Max. Negotiated Rate |
$451.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$39.06
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$285.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$39.06
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$30.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$21.70
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Commercial |
$403.75
|
| Rate for Payer: First Health Commercial |
$427.50
|
| Rate for Payer: First Health Workers Compensation |
$40.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$427.50
|
| Rate for Payer: GEHA Commercial |
$380.00
|
| Rate for Payer: GEHA Medicare |
$21.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$427.50
|
| Rate for Payer: Humana ChoiceCare |
$23.87
|
| Rate for Payer: Humana Medicare Advantage |
$21.70
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$36.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$31.57
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$21.70
|
| Rate for Payer: Multiplan All |
$432.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$36.89
|
| Rate for Payer: OMNI Networks Commercial |
$332.50
|
| Rate for Payer: One Health Plan PPO/POS |
$427.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$36.46
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$31.57
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$21.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$451.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$43.40
|
| Rate for Payer: Three Rivers Provider Network All |
$356.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$21.27
|
| Rate for Payer: United Healthcare Commercial |
$403.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.70
|
| Rate for Payer: United Payors & United Providers UP&UP |
$441.75
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$21.70
|
| Rate for Payer: Zelis Auto |
$190.00
|
| Rate for Payer: Zelis Medicare |
$18.45
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$26.04
|
| Rate for Payer: Zelis Worker's Compensation |
$28.72
|
|
|
estrone, lc/ms REF500634
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
CPT 82679
|
| Hospital Charge Code |
2299420
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$33.73 |
| Max. Negotiated Rate |
$164.35 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$147.05
|
| Rate for Payer: First Health Commercial |
$155.70
|
| Rate for Payer: First Health Workers Compensation |
$47.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$155.70
|
| Rate for Payer: GEHA Commercial |
$121.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$155.70
|
| Rate for Payer: Multiplan All |
$157.43
|
| Rate for Payer: OMNI Networks Commercial |
$121.10
|
| Rate for Payer: One Health Plan PPO/POS |
$155.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$164.35
|
| Rate for Payer: Three Rivers Provider Network All |
$129.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$160.89
|
| Rate for Payer: Zelis Auto |
$69.20
|
| Rate for Payer: Zelis Worker's Compensation |
$33.73
|
|
|
estrone, lc/ms REF500634
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
CPT 82679
|
| Hospital Charge Code |
2299420
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.21 |
| Max. Negotiated Rate |
$164.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$44.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$103.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$44.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$35.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$24.95
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$147.05
|
| Rate for Payer: First Health Commercial |
$155.70
|
| Rate for Payer: First Health Workers Compensation |
$47.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$155.70
|
| Rate for Payer: GEHA Commercial |
$138.40
|
| Rate for Payer: GEHA Medicare |
$24.95
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$155.70
|
| Rate for Payer: Humana ChoiceCare |
$27.45
|
| Rate for Payer: Humana Medicare Advantage |
$24.95
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$41.92
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$36.30
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$24.95
|
| Rate for Payer: Multiplan All |
$157.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$42.41
|
| Rate for Payer: OMNI Networks Commercial |
$121.10
|
| Rate for Payer: One Health Plan PPO/POS |
$155.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$41.92
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$36.30
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$24.95
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$164.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$49.90
|
| Rate for Payer: Three Rivers Provider Network All |
$129.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$24.45
|
| Rate for Payer: United Healthcare Commercial |
$147.05
|
| Rate for Payer: United Healthcare Managed Medicaid |
$36.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.95
|
| Rate for Payer: United Payors & United Providers UP&UP |
$160.89
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$24.95
|
| Rate for Payer: Zelis Auto |
$69.20
|
| Rate for Payer: Zelis Medicare |
$21.21
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$29.94
|
| Rate for Payer: Zelis Worker's Compensation |
$33.73
|
|
|
ETHAMBUTOL HCL 400 MG TAB
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 68850001201
|
| Hospital Charge Code |
3302890
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
