|
FERRITIN (Vitros)
|
Facility
|
OP
|
$237.00
|
|
|
Service Code
|
CPT 82728
|
| Hospital Charge Code |
2232211
|
|
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
|
|
|
FERROUS GLUCONATE TAB 324MG
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 20555001900
|
| Hospital Charge Code |
3300333
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
FERROUS GLUCONATE TAB 324MG
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 20555001900
|
| Hospital Charge Code |
3300333
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
FERROUS SULFATE 325MG TAB
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 00904759161
|
| Hospital Charge Code |
3300334
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
FERROUS SULFATE 325MG TAB
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 00904759161
|
| Hospital Charge Code |
3300334
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$4.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Humana ChoiceCare |
$1.30
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.00
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
FERROUS SULFATE-VIT C-FOLIC ACID TAB CR
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 00074707930
|
| Hospital Charge Code |
3300335
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$7.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
FERROUS SULFATE-VIT C-FOLIC ACID TAB CR
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 00074707930
|
| Hospital Charge Code |
3300335
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$8.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Humana ChoiceCare |
$2.86
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.60
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
FETAL SHUNT PLACEMENT, W/US
|
Facility
|
IP
|
$967.00
|
|
|
Service Code
|
CPT 59076
|
| Hospital Charge Code |
6159076
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$263.99 |
| Max. Negotiated Rate |
$918.65 |
| Rate for Payer: Cash Price |
$580.20
|
| Rate for Payer: Cigna Commercial |
$821.95
|
| Rate for Payer: First Health Commercial |
$870.30
|
| Rate for Payer: First Health Workers Compensation |
$373.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$870.30
|
| Rate for Payer: GEHA Commercial |
$676.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$870.30
|
| Rate for Payer: Multiplan All |
$879.97
|
| Rate for Payer: OMNI Networks Commercial |
$676.90
|
| Rate for Payer: One Health Plan PPO/POS |
$870.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$918.65
|
| Rate for Payer: Three Rivers Provider Network All |
$725.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$899.31
|
| Rate for Payer: Zelis Auto |
$386.80
|
| Rate for Payer: Zelis Worker's Compensation |
$263.99
|
|
|
FETAL SHUNT PLACEMENT, W/US
|
Facility
|
OP
|
$967.00
|
|
|
Service Code
|
CPT 59076
|
| Hospital Charge Code |
6159076
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$245.51 |
| Max. Negotiated Rate |
$918.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$344.62
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$580.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$344.62
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$273.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$288.84
|
| Rate for Payer: Cash Price |
$580.20
|
| Rate for Payer: Cash Price |
$580.20
|
| Rate for Payer: Cigna Commercial |
$821.95
|
| Rate for Payer: First Health Commercial |
$870.30
|
| Rate for Payer: First Health Workers Compensation |
$373.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$870.30
|
| Rate for Payer: GEHA Commercial |
$773.60
|
| Rate for Payer: GEHA Medicare |
$288.84
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$870.30
|
| Rate for Payer: Humana ChoiceCare |
$317.72
|
| Rate for Payer: Humana Medicare Advantage |
$288.84
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$485.25
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$278.57
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$288.84
|
| Rate for Payer: Multiplan All |
$879.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$491.03
|
| Rate for Payer: OMNI Networks Commercial |
$676.90
|
| Rate for Payer: One Health Plan PPO/POS |
$870.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$321.65
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$278.57
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$288.84
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$918.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$577.68
|
| Rate for Payer: Three Rivers Provider Network All |
$725.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$283.06
|
| Rate for Payer: United Healthcare Managed Medicaid |
$278.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$288.84
|
| Rate for Payer: United Payors & United Providers UP&UP |
$899.31
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$288.84
|
| Rate for Payer: Zelis Auto |
$386.80
|
| Rate for Payer: Zelis Medicare |
$245.51
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$346.61
|
| Rate for Payer: Zelis Worker's Compensation |
$263.99
|
|
|
FEXOFENADINE HCL TAB 180MG
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 51079054801
|
| Hospital Charge Code |
3300337
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$8.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Humana ChoiceCare |
$2.86
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.60
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
FEXOFENADINE HCL TAB 180MG
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 51079054801
|
| Hospital Charge Code |
3300337
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$7.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
FEXOFENADINE HCL TAB 60MG
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 51079054720
|
| Hospital Charge Code |
3300338
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$7.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
FEXOFENADINE HCL TAB 60MG
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 51079054720
|
| Hospital Charge Code |
3300338
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$8.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Humana ChoiceCare |
$2.86
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.60
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
FEXOFENADINE ODT 30MG
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 00088111330
|
| Hospital Charge Code |
3300336
|
|
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
|
|
|
FEXOFENADINE ODT 30MG
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 00088111330
|
| Hospital Charge Code |
3300336
|
|
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
|
|
|
FEXOFENADN-PSEUDOEPHEDRIN 60-120MG
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 00088109047
|
| Hospital Charge Code |
3300339
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
FEXOFENADN-PSEUDOEPHEDRIN 60-120MG
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 00088109047
|
| Hospital Charge Code |
3300339
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.00 |
| 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: 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 |
$16.00
|
| 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
|
|
|
FIBERTAK CURVED KIT
|
Facility
|
OP
|
$1,030.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006765
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$257.50 |
| Max. Negotiated Rate |
$978.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$618.00
|
| Rate for Payer: Cash Price |
$618.00
|
| Rate for Payer: Cash Price |
$618.00
|
| Rate for Payer: Cigna Commercial |
$875.50
|
| Rate for Payer: First Health Commercial |
$927.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$927.00
|
| Rate for Payer: GEHA Commercial |
$824.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$927.00
|
| Rate for Payer: Humana ChoiceCare |
$267.80
|
| Rate for Payer: Multiplan All |
$937.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$618.00
|
| Rate for Payer: OMNI Networks Commercial |
$721.00
|
| Rate for Payer: One Health Plan PPO/POS |
$927.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$978.50
|
| Rate for Payer: Three Rivers Provider Network All |
$772.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$906.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$257.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$957.90
|
| Rate for Payer: Zelis Auto |
$412.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$515.00
|
|
|
FIBERTAK CURVED KIT
|
Facility
|
IP
|
$1,030.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006765
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$412.00 |
| Max. Negotiated Rate |
$978.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$824.00
|
| Rate for Payer: Cash Price |
$618.00
|
| Rate for Payer: Cash Price |
$618.00
|
| Rate for Payer: Cigna Commercial |
$875.50
|
| Rate for Payer: First Health Commercial |
$927.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$927.00
|
| Rate for Payer: GEHA Commercial |
$721.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$927.00
|
| Rate for Payer: Multiplan All |
$937.30
|
| Rate for Payer: OMNI Networks Commercial |
$721.00
|
| Rate for Payer: One Health Plan PPO/POS |
$927.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$978.50
|
| Rate for Payer: Three Rivers Provider Network All |
$772.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$957.90
|
| Rate for Payer: Zelis Auto |
$412.00
|
|
|
FIBERTAPE 1.7MM WHITE/BLK
|
Facility
|
OP
|
$411.50
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006669
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$102.88 |
| Max. Negotiated Rate |
$390.93 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$246.90
|
| Rate for Payer: Cash Price |
$246.90
|
| Rate for Payer: Cigna Commercial |
$349.77
|
| Rate for Payer: First Health Commercial |
$370.35
|
| Rate for Payer: First Health Workers Compensation |
$158.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$370.35
|
| Rate for Payer: GEHA Commercial |
$329.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$370.35
|
| Rate for Payer: Humana ChoiceCare |
$106.99
|
| Rate for Payer: Multiplan All |
$374.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$246.90
|
| Rate for Payer: OMNI Networks Commercial |
$288.05
|
| Rate for Payer: One Health Plan PPO/POS |
$370.35
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$390.93
|
| Rate for Payer: Three Rivers Provider Network All |
$308.62
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$362.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$102.88
|
| Rate for Payer: United Payors & United Providers UP&UP |
$382.69
|
| Rate for Payer: Zelis Auto |
$164.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$205.75
|
| Rate for Payer: Zelis Worker's Compensation |
$112.34
|
|
|
FIBERTAPE 1.7MM WHITE/BLK
|
Facility
|
IP
|
$411.50
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006669
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$112.34 |
| Max. Negotiated Rate |
$390.93 |
| Rate for Payer: Cash Price |
$246.90
|
| Rate for Payer: Cigna Commercial |
$349.77
|
| Rate for Payer: First Health Commercial |
$370.35
|
| Rate for Payer: First Health Workers Compensation |
$158.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$370.35
|
| Rate for Payer: GEHA Commercial |
$288.05
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$370.35
|
| Rate for Payer: Multiplan All |
$374.46
|
| Rate for Payer: OMNI Networks Commercial |
$288.05
|
| Rate for Payer: One Health Plan PPO/POS |
$370.35
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$390.93
|
| Rate for Payer: Three Rivers Provider Network All |
$308.62
|
| Rate for Payer: United Payors & United Providers UP&UP |
$382.69
|
| Rate for Payer: Zelis Auto |
$164.60
|
| Rate for Payer: Zelis Worker's Compensation |
$112.34
|
|
|
FIBERTAPE 2MM BLUE SUTURE
|
Facility
|
IP
|
$411.50
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7005201
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$112.34 |
| Max. Negotiated Rate |
$390.93 |
| Rate for Payer: Cash Price |
$246.90
|
| Rate for Payer: Cigna Commercial |
$349.77
|
| Rate for Payer: First Health Commercial |
$370.35
|
| Rate for Payer: First Health Workers Compensation |
$158.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$370.35
|
| Rate for Payer: GEHA Commercial |
$288.05
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$370.35
|
| Rate for Payer: Multiplan All |
$374.46
|
| Rate for Payer: OMNI Networks Commercial |
$288.05
|
| Rate for Payer: One Health Plan PPO/POS |
$370.35
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$390.93
|
| Rate for Payer: Three Rivers Provider Network All |
$308.62
|
| Rate for Payer: United Payors & United Providers UP&UP |
$382.69
|
| Rate for Payer: Zelis Auto |
$164.60
|
| Rate for Payer: Zelis Worker's Compensation |
$112.34
|
|
|
FIBERTAPE 2MM BLUE SUTURE
|
Facility
|
OP
|
$411.50
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7005201
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$102.88 |
| Max. Negotiated Rate |
$390.93 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$246.90
|
| Rate for Payer: Cash Price |
$246.90
|
| Rate for Payer: Cigna Commercial |
$349.77
|
| Rate for Payer: First Health Commercial |
$370.35
|
| Rate for Payer: First Health Workers Compensation |
$158.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$370.35
|
| Rate for Payer: GEHA Commercial |
$329.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$370.35
|
| Rate for Payer: Humana ChoiceCare |
$106.99
|
| Rate for Payer: Multiplan All |
$374.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$246.90
|
| Rate for Payer: OMNI Networks Commercial |
$288.05
|
| Rate for Payer: One Health Plan PPO/POS |
$370.35
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$390.93
|
| Rate for Payer: Three Rivers Provider Network All |
$308.62
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$362.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$102.88
|
| Rate for Payer: United Payors & United Providers UP&UP |
$382.69
|
| Rate for Payer: Zelis Auto |
$164.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$205.75
|
| Rate for Payer: Zelis Worker's Compensation |
$112.34
|
|
|
FIBERTAPE 2MM BLUE SUTURE 1/2 CIRLCE NEE
|
Facility
|
OP
|
$411.50
|
|
| Hospital Charge Code |
7005202
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$102.88 |
| Max. Negotiated Rate |
$390.93 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$246.90
|
| Rate for Payer: Cash Price |
$246.90
|
| Rate for Payer: Cigna Commercial |
$349.77
|
| Rate for Payer: First Health Commercial |
$370.35
|
| Rate for Payer: First Health Workers Compensation |
$158.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$370.35
|
| Rate for Payer: GEHA Commercial |
$329.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$370.35
|
| Rate for Payer: Humana ChoiceCare |
$106.99
|
| Rate for Payer: Multiplan All |
$374.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$246.90
|
| Rate for Payer: OMNI Networks Commercial |
$288.05
|
| Rate for Payer: One Health Plan PPO/POS |
$370.35
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$390.93
|
| Rate for Payer: Three Rivers Provider Network All |
$308.62
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$362.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$102.88
|
| Rate for Payer: United Payors & United Providers UP&UP |
$382.69
|
| Rate for Payer: Zelis Auto |
$164.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$205.75
|
| Rate for Payer: Zelis Worker's Compensation |
$112.34
|
|
|
FIBERTAPE 2MM BLUE SUTURE 1/2 CIRLCE NEE
|
Facility
|
IP
|
$411.50
|
|
| Hospital Charge Code |
7005202
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$112.34 |
| Max. Negotiated Rate |
$390.93 |
| Rate for Payer: Cash Price |
$246.90
|
| Rate for Payer: Cigna Commercial |
$349.77
|
| Rate for Payer: First Health Commercial |
$370.35
|
| Rate for Payer: First Health Workers Compensation |
$158.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$370.35
|
| Rate for Payer: GEHA Commercial |
$288.05
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$370.35
|
| Rate for Payer: Multiplan All |
$374.46
|
| Rate for Payer: OMNI Networks Commercial |
$288.05
|
| Rate for Payer: One Health Plan PPO/POS |
$370.35
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$390.93
|
| Rate for Payer: Three Rivers Provider Network All |
$308.62
|
| Rate for Payer: United Payors & United Providers UP&UP |
$382.69
|
| Rate for Payer: Zelis Auto |
$164.60
|
| Rate for Payer: Zelis Worker's Compensation |
$112.34
|
|
