|
FENOFIBRATE 145MG TAB - NF
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
NDC 51079060820
|
| Hospital Charge Code |
3300324
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$25.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
FENOFIBRATE 145MG TAB - NF
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
NDC 51079060820
|
| Hospital Charge Code |
3300324
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.25 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22.20
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$29.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Humana ChoiceCare |
$9.62
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.20
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$32.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$18.50
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
fentaNYL 12MCG/HR TD PATCH
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
NDC 60505701002
|
| Hospital Charge Code |
3300329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.21 |
| Max. Negotiated Rate |
$112.10 |
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$100.30
|
| Rate for Payer: First Health Commercial |
$106.20
|
| Rate for Payer: First Health Workers Compensation |
$45.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$106.20
|
| Rate for Payer: GEHA Commercial |
$82.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$106.20
|
| Rate for Payer: Multiplan All |
$107.38
|
| Rate for Payer: OMNI Networks Commercial |
$82.60
|
| Rate for Payer: One Health Plan PPO/POS |
$106.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$112.10
|
| Rate for Payer: Three Rivers Provider Network All |
$88.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$109.74
|
| Rate for Payer: Zelis Auto |
$47.20
|
| Rate for Payer: Zelis Worker's Compensation |
$32.21
|
|
|
fentaNYL 12MCG/HR TD PATCH
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
NDC 60505701002
|
| Hospital Charge Code |
3300329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.50 |
| Max. Negotiated Rate |
$112.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$70.80
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$100.30
|
| Rate for Payer: First Health Commercial |
$106.20
|
| Rate for Payer: First Health Workers Compensation |
$45.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$106.20
|
| Rate for Payer: GEHA Commercial |
$94.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$106.20
|
| Rate for Payer: Humana ChoiceCare |
$30.68
|
| Rate for Payer: Multiplan All |
$107.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$70.80
|
| Rate for Payer: OMNI Networks Commercial |
$82.60
|
| Rate for Payer: One Health Plan PPO/POS |
$106.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$112.10
|
| Rate for Payer: Three Rivers Provider Network All |
$88.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$103.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$29.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$109.74
|
| Rate for Payer: Zelis Auto |
$47.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$59.00
|
| Rate for Payer: Zelis Worker's Compensation |
$32.21
|
|
|
fentaNYL 25MCG/HR TD PATCH
|
Facility
|
OP
|
$122.00
|
|
|
Service Code
|
NDC 47781042447
|
| Hospital Charge Code |
3300330
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.50 |
| Max. Negotiated Rate |
$115.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$103.70
|
| Rate for Payer: First Health Commercial |
$109.80
|
| Rate for Payer: First Health Workers Compensation |
$47.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$109.80
|
| Rate for Payer: GEHA Commercial |
$97.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$109.80
|
| Rate for Payer: Humana ChoiceCare |
$31.72
|
| Rate for Payer: Multiplan All |
$111.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$73.20
|
| Rate for Payer: OMNI Networks Commercial |
$85.40
|
| Rate for Payer: One Health Plan PPO/POS |
$109.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$115.90
|
| Rate for Payer: Three Rivers Provider Network All |
$91.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$107.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$30.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$113.46
|
| Rate for Payer: Zelis Auto |
$48.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$61.00
|
| Rate for Payer: Zelis Worker's Compensation |
$33.31
|
|
|
fentaNYL 25MCG/HR TD PATCH
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
NDC 47781042447
|
| Hospital Charge Code |
3300330
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.31 |
| Max. Negotiated Rate |
$115.90 |
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$103.70
|
| Rate for Payer: First Health Commercial |
$109.80
|
| Rate for Payer: First Health Workers Compensation |
$47.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$109.80
|
| Rate for Payer: GEHA Commercial |
$85.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$109.80
|
| Rate for Payer: Multiplan All |
$111.02
|
| Rate for Payer: OMNI Networks Commercial |
$85.40
|
| Rate for Payer: One Health Plan PPO/POS |
$109.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$115.90
|
| Rate for Payer: Three Rivers Provider Network All |
$91.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$113.46
|
| Rate for Payer: Zelis Auto |
$48.80
|
| Rate for Payer: Zelis Worker's Compensation |
$33.31
|
|
|
fentaNYL 50MCG/HR TD PATCH
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
NDC 00378912298
|
| Hospital Charge Code |
3300331
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.60 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$132.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
fentaNYL 50MCG/HR TD PATCH
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
NDC 00378912298
|
| Hospital Charge Code |
3300331
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.25 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$113.40
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$151.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Humana ChoiceCare |
$49.14
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: New Mexico Health Connections Medicare |
$113.40
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$166.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$47.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$94.50
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
fentaNYL 75MCG/HR TD PATCH
|
Facility
|
IP
|
$257.00
|
|
|
Service Code
|
NDC 60505708300
|
| Hospital Charge Code |
3300332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.16 |
| Max. Negotiated Rate |
$244.15 |
| Rate for Payer: Cash Price |
$154.20
|
| Rate for Payer: Cigna Commercial |
$218.45
|
| Rate for Payer: First Health Commercial |
$231.30
|
| Rate for Payer: First Health Workers Compensation |
$99.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$231.30
|
| Rate for Payer: GEHA Commercial |
$179.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$231.30
|
| Rate for Payer: Multiplan All |
$233.87
|
| Rate for Payer: OMNI Networks Commercial |
$179.90
|
| Rate for Payer: One Health Plan PPO/POS |
$231.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$244.15
|
| Rate for Payer: Three Rivers Provider Network All |
$192.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$239.01
|
| Rate for Payer: Zelis Auto |
$102.80
|
| Rate for Payer: Zelis Worker's Compensation |
$70.16
|
|
|
fentaNYL 75MCG/HR TD PATCH
|
Facility
|
OP
|
$257.00
|
|
|
Service Code
|
NDC 60505708300
|
| Hospital Charge Code |
3300332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.25 |
| Max. Negotiated Rate |
$244.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$154.20
|
| Rate for Payer: Cash Price |
$154.20
|
| Rate for Payer: Cigna Commercial |
$218.45
|
| Rate for Payer: First Health Commercial |
$231.30
|
| Rate for Payer: First Health Workers Compensation |
$99.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$231.30
|
| Rate for Payer: GEHA Commercial |
$205.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$231.30
|
| Rate for Payer: Humana ChoiceCare |
$66.82
|
| Rate for Payer: Multiplan All |
$233.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$154.20
|
| Rate for Payer: OMNI Networks Commercial |
$179.90
|
| Rate for Payer: One Health Plan PPO/POS |
$231.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$244.15
|
| Rate for Payer: Three Rivers Provider Network All |
$192.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$226.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$64.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$239.01
|
| Rate for Payer: Zelis Auto |
$102.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$128.50
|
| Rate for Payer: Zelis Worker's Compensation |
$70.16
|
|
|
FENTANYL CIT 1000 MCG/ 20 ML (DRIP ONLY)
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
CPT J3010
|
| Hospital Charge Code |
3302911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$33.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$29.75
|
| Rate for Payer: First Health Commercial |
$31.50
|
| Rate for Payer: First Health Workers Compensation |
$13.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$31.50
|
| Rate for Payer: GEHA Commercial |
$1.21
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$31.50
|
| Rate for Payer: Humana ChoiceCare |
$9.10
|
| Rate for Payer: Multiplan All |
$31.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$21.00
|
| Rate for Payer: OMNI Networks Commercial |
$24.50
|
| Rate for Payer: One Health Plan PPO/POS |
$31.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$33.25
|
| Rate for Payer: Three Rivers Provider Network All |
$26.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$30.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$32.55
|
| Rate for Payer: Zelis Auto |
$14.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.50
|
| Rate for Payer: Zelis Worker's Compensation |
$9.55
|
|
|
FENTANYL CIT 1000 MCG/ 20 ML (DRIP ONLY)
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
CPT J3010
|
| Hospital Charge Code |
3302911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.55 |
| Max. Negotiated Rate |
$33.25 |
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$29.75
|
| Rate for Payer: First Health Commercial |
$31.50
|
| Rate for Payer: First Health Workers Compensation |
$13.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$31.50
|
| Rate for Payer: GEHA Commercial |
$24.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$31.50
|
| Rate for Payer: Multiplan All |
$31.85
|
| Rate for Payer: OMNI Networks Commercial |
$24.50
|
| Rate for Payer: One Health Plan PPO/POS |
$31.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$33.25
|
| Rate for Payer: Three Rivers Provider Network All |
$26.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$32.55
|
| Rate for Payer: Zelis Auto |
$14.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.55
|
|
|
FENTANYL CIT 500 MCG/ 10 ML (DRIP ONLY)
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
CPT J3010
|
| Hospital Charge Code |
3302844
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.28 |
| Max. Negotiated Rate |
$21.85 |
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cigna Commercial |
$19.55
|
| Rate for Payer: First Health Commercial |
$20.70
|
| Rate for Payer: First Health Workers Compensation |
$8.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$20.70
|
| Rate for Payer: GEHA Commercial |
$16.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$20.70
|
| Rate for Payer: Multiplan All |
$20.93
|
| Rate for Payer: OMNI Networks Commercial |
$16.10
|
| Rate for Payer: One Health Plan PPO/POS |
$20.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$21.85
|
| Rate for Payer: Three Rivers Provider Network All |
$17.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$21.39
|
| Rate for Payer: Zelis Auto |
$9.20
|
| Rate for Payer: Zelis Worker's Compensation |
$6.28
|
|
|
FENTANYL CIT 500 MCG/ 10 ML (DRIP ONLY)
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
CPT J3010
|
| Hospital Charge Code |
3302844
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$21.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$13.80
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cigna Commercial |
$19.55
|
| Rate for Payer: First Health Commercial |
$20.70
|
| Rate for Payer: First Health Workers Compensation |
$8.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$20.70
|
| Rate for Payer: GEHA Commercial |
$1.21
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$20.70
|
| Rate for Payer: Humana ChoiceCare |
$5.98
|
| Rate for Payer: Multiplan All |
$20.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$13.80
|
| Rate for Payer: OMNI Networks Commercial |
$16.10
|
| Rate for Payer: One Health Plan PPO/POS |
$20.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$21.85
|
| Rate for Payer: Three Rivers Provider Network All |
$17.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$20.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$21.39
|
| Rate for Payer: Zelis Auto |
$9.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$11.50
|
| Rate for Payer: Zelis Worker's Compensation |
$6.28
|
|
|
fentaNYL INJ 100MCG - 2ML
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
CPT J3010
|
| Hospital Charge Code |
3300326
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$14.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
|
fentaNYL INJ 100MCG - 2ML
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
CPT J3010
|
| Hospital Charge Code |
3300326
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$1.21
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Humana ChoiceCare |
$5.20
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.00
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
|
fentaNYL INJ 250MCG - 5ML
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
CPT J3010
|
| Hospital Charge Code |
3300327
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$21.25
|
| Rate for Payer: First Health Commercial |
$22.50
|
| Rate for Payer: First Health Workers Compensation |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22.50
|
| Rate for Payer: GEHA Commercial |
$1.21
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22.50
|
| Rate for Payer: Humana ChoiceCare |
$6.50
|
| Rate for Payer: Multiplan All |
$22.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$15.00
|
| Rate for Payer: OMNI Networks Commercial |
$17.50
|
| Rate for Payer: One Health Plan PPO/POS |
$22.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$23.75
|
| Rate for Payer: Three Rivers Provider Network All |
$18.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$22.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23.25
|
| Rate for Payer: Zelis Auto |
$10.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12.50
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
|
fentaNYL INJ 250MCG - 5ML
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
CPT J3010
|
| Hospital Charge Code |
3300327
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.83 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$21.25
|
| Rate for Payer: First Health Commercial |
$22.50
|
| Rate for Payer: First Health Workers Compensation |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22.50
|
| Rate for Payer: GEHA Commercial |
$17.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22.50
|
| Rate for Payer: Multiplan All |
$22.75
|
| Rate for Payer: OMNI Networks Commercial |
$17.50
|
| Rate for Payer: One Health Plan PPO/POS |
$22.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$23.75
|
| Rate for Payer: Three Rivers Provider Network All |
$18.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23.25
|
| Rate for Payer: Zelis Auto |
$10.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
|
fentanyl/norfentanyl scrn,urineREF761200
|
Facility
|
OP
|
$417.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
2200717
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$52.63 |
| Max. Negotiated Rate |
$396.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$111.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$250.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$111.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$88.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$62.14
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cigna Commercial |
$354.45
|
| Rate for Payer: First Health Commercial |
$375.30
|
| Rate for Payer: First Health Workers Compensation |
$74.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$375.30
|
| Rate for Payer: GEHA Commercial |
$333.60
|
| Rate for Payer: GEHA Medicare |
$62.14
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$375.30
|
| Rate for Payer: Humana ChoiceCare |
$68.35
|
| Rate for Payer: Humana Medicare Advantage |
$62.14
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$104.40
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$90.42
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$62.14
|
| Rate for Payer: Multiplan All |
$379.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$105.64
|
| Rate for Payer: OMNI Networks Commercial |
$291.90
|
| Rate for Payer: One Health Plan PPO/POS |
$375.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$104.40
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$90.42
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$62.14
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$396.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$124.28
|
| Rate for Payer: Three Rivers Provider Network All |
$312.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$60.90
|
| Rate for Payer: United Healthcare Commercial |
$354.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$90.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.14
|
| Rate for Payer: United Payors & United Providers UP&UP |
$387.81
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$62.14
|
| Rate for Payer: Zelis Auto |
$166.80
|
| Rate for Payer: Zelis Medicare |
$52.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$74.57
|
| Rate for Payer: Zelis Worker's Compensation |
$52.63
|
|
|
fentanyl/norfentanyl scrn,urineREF761200
|
Facility
|
IP
|
$417.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
2200717
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$52.63 |
| Max. Negotiated Rate |
$396.15 |
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cigna Commercial |
$354.45
|
| Rate for Payer: First Health Commercial |
$375.30
|
| Rate for Payer: First Health Workers Compensation |
$74.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$375.30
|
| Rate for Payer: GEHA Commercial |
$291.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$375.30
|
| Rate for Payer: Multiplan All |
$379.47
|
| Rate for Payer: OMNI Networks Commercial |
$291.90
|
| Rate for Payer: One Health Plan PPO/POS |
$375.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$396.15
|
| Rate for Payer: Three Rivers Provider Network All |
$312.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$387.81
|
| Rate for Payer: Zelis Auto |
$166.80
|
| Rate for Payer: Zelis Worker's Compensation |
$52.63
|
|
|
FERRIC CARBOXYMALTOSE 750 MG INJ
|
Facility
|
IP
|
$3,780.00
|
|
|
Service Code
|
CPT J1439
|
| Hospital Charge Code |
3303015
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,031.94 |
| Max. Negotiated Rate |
$3,591.00 |
| Rate for Payer: Cash Price |
$2,268.00
|
| Rate for Payer: Cigna Commercial |
$3,213.00
|
| Rate for Payer: First Health Commercial |
$3,402.00
|
| Rate for Payer: First Health Workers Compensation |
$1,459.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,402.00
|
| Rate for Payer: GEHA Commercial |
$2,646.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,402.00
|
| Rate for Payer: Multiplan All |
$3,439.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,646.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,402.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,591.00
|
| Rate for Payer: Three Rivers Provider Network All |
$2,835.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,515.40
|
| Rate for Payer: Zelis Auto |
$1,512.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,031.94
|
|
|
FERRIC CARBOXYMALTOSE 750 MG INJ
|
Facility
|
OP
|
$3,780.00
|
|
|
Service Code
|
CPT J1439
|
| Hospital Charge Code |
3303015
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$3,591.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,268.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1.27
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1.11
|
| Rate for Payer: Cash Price |
$2,268.00
|
| Rate for Payer: Cash Price |
$2,268.00
|
| Rate for Payer: Cigna Commercial |
$3,213.00
|
| Rate for Payer: First Health Commercial |
$3,402.00
|
| Rate for Payer: First Health Workers Compensation |
$1,459.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,402.00
|
| Rate for Payer: GEHA Commercial |
$1.22
|
| Rate for Payer: GEHA Medicare |
$1.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,402.00
|
| Rate for Payer: Humana ChoiceCare |
$1.22
|
| Rate for Payer: Humana Medicare Advantage |
$1.11
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1.86
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1.30
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1.11
|
| Rate for Payer: Multiplan All |
$3,439.80
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.89
|
| Rate for Payer: OMNI Networks Commercial |
$2,646.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,402.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1.50
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1.30
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,591.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$2.22
|
| Rate for Payer: Three Rivers Provider Network All |
$2,835.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1.09
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,515.40
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1.11
|
| Rate for Payer: Zelis Auto |
$1,512.00
|
| Rate for Payer: Zelis Medicare |
$0.94
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.33
|
| Rate for Payer: Zelis Worker's Compensation |
$1,031.94
|
|
|
ferritin REF 004598
|
Facility
|
OP
|
$237.00
|
|
|
Service Code
|
CPT 82728
|
| Hospital Charge Code |
2232301
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.59 |
| Max. Negotiated Rate |
$225.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$24.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$142.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$24.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$19.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$13.63
|
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Cigna Commercial |
$201.45
|
| Rate for Payer: First Health Commercial |
$213.30
|
| Rate for Payer: First Health Workers Compensation |
$22.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$213.30
|
| Rate for Payer: GEHA Commercial |
$189.60
|
| Rate for Payer: GEHA Medicare |
$13.63
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$213.30
|
| Rate for Payer: Humana ChoiceCare |
$14.99
|
| Rate for Payer: Humana Medicare Advantage |
$13.63
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$22.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$19.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$13.63
|
| Rate for Payer: Multiplan All |
$215.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$23.17
|
| Rate for Payer: OMNI Networks Commercial |
$165.90
|
| Rate for Payer: One Health Plan PPO/POS |
$213.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$22.90
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$19.84
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$13.63
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$225.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$27.26
|
| Rate for Payer: Three Rivers Provider Network All |
$177.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.36
|
| Rate for Payer: United Healthcare Commercial |
$201.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$19.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.63
|
| Rate for Payer: United Payors & United Providers UP&UP |
$220.41
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$13.63
|
| Rate for Payer: Zelis Auto |
$94.80
|
| Rate for Payer: Zelis Medicare |
$11.59
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$16.36
|
| Rate for Payer: Zelis Worker's Compensation |
$15.90
|
|
|
ferritin REF 004598
|
Facility
|
IP
|
$237.00
|
|
|
Service Code
|
CPT 82728
|
| Hospital Charge Code |
2232301
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.90 |
| Max. Negotiated Rate |
$225.15 |
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Cigna Commercial |
$201.45
|
| Rate for Payer: First Health Commercial |
$213.30
|
| Rate for Payer: First Health Workers Compensation |
$22.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$213.30
|
| Rate for Payer: GEHA Commercial |
$165.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$213.30
|
| Rate for Payer: Multiplan All |
$215.67
|
| Rate for Payer: OMNI Networks Commercial |
$165.90
|
| Rate for Payer: One Health Plan PPO/POS |
$213.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$225.15
|
| Rate for Payer: Three Rivers Provider Network All |
$177.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$220.41
|
| Rate for Payer: Zelis Auto |
$94.80
|
| Rate for Payer: Zelis Worker's Compensation |
$15.90
|
|
|
FERRITIN (Vitros)
|
Facility
|
IP
|
$237.00
|
|
|
Service Code
|
CPT 82728
|
| Hospital Charge Code |
2232211
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.90 |
| Max. Negotiated Rate |
$225.15 |
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Cigna Commercial |
$201.45
|
| Rate for Payer: First Health Commercial |
$213.30
|
| Rate for Payer: First Health Workers Compensation |
$22.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$213.30
|
| Rate for Payer: GEHA Commercial |
$165.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$213.30
|
| Rate for Payer: Multiplan All |
$215.67
|
| Rate for Payer: OMNI Networks Commercial |
$165.90
|
| Rate for Payer: One Health Plan PPO/POS |
$213.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$225.15
|
| Rate for Payer: Three Rivers Provider Network All |
$177.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$220.41
|
| Rate for Payer: Zelis Auto |
$94.80
|
| Rate for Payer: Zelis Worker's Compensation |
$15.90
|
|
