|
FLUCONAZOLE TAB 100MG
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
NDC 68084072801
|
| Hospital Charge Code |
3300344
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
FLUDROCORTISONE ACETATE TAB 0.1MG
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 00555099702
|
| Hospital Charge Code |
3300345
|
|
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
|
|
|
FLUDROCORTISONE ACETATE TAB 0.1MG
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 00555099702
|
| Hospital Charge Code |
3300345
|
|
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
|
|
|
FLUID PRESSURE MUSCLE
|
Facility
|
OP
|
$281.00
|
|
|
Service Code
|
CPT 20950
|
| Hospital Charge Code |
6120950
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$76.71 |
| Max. Negotiated Rate |
$1,336.18 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$147.18
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$168.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$147.18
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$116.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$668.09
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cigna Commercial |
$238.85
|
| Rate for Payer: First Health Commercial |
$252.90
|
| Rate for Payer: First Health Workers Compensation |
$108.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$252.90
|
| Rate for Payer: GEHA Commercial |
$224.80
|
| Rate for Payer: GEHA Medicare |
$668.09
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$252.90
|
| Rate for Payer: Humana ChoiceCare |
$734.90
|
| Rate for Payer: Humana Medicare Advantage |
$668.09
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,122.39
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$118.97
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$668.09
|
| Rate for Payer: Multiplan All |
$255.71
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,135.75
|
| Rate for Payer: OMNI Networks Commercial |
$196.70
|
| Rate for Payer: One Health Plan PPO/POS |
$252.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$137.37
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$118.97
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$668.09
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$266.95
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,336.18
|
| Rate for Payer: Three Rivers Provider Network All |
$210.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$654.73
|
| Rate for Payer: United Healthcare Managed Medicaid |
$118.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$668.09
|
| Rate for Payer: United Payors & United Providers UP&UP |
$261.33
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$668.09
|
| Rate for Payer: Zelis Auto |
$112.40
|
| Rate for Payer: Zelis Medicare |
$567.88
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$801.71
|
| Rate for Payer: Zelis Worker's Compensation |
$76.71
|
|
|
FLUID PRESSURE MUSCLE
|
Facility
|
IP
|
$281.00
|
|
|
Service Code
|
CPT 20950
|
| Hospital Charge Code |
6120950
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$76.71 |
| Max. Negotiated Rate |
$266.95 |
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cigna Commercial |
$238.85
|
| Rate for Payer: First Health Commercial |
$252.90
|
| Rate for Payer: First Health Workers Compensation |
$108.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$252.90
|
| Rate for Payer: GEHA Commercial |
$196.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$252.90
|
| Rate for Payer: Multiplan All |
$255.71
|
| Rate for Payer: OMNI Networks Commercial |
$196.70
|
| Rate for Payer: One Health Plan PPO/POS |
$252.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$266.95
|
| Rate for Payer: Three Rivers Provider Network All |
$210.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$261.33
|
| Rate for Payer: Zelis Auto |
$112.40
|
| Rate for Payer: Zelis Worker's Compensation |
$76.71
|
|
|
FLUMAZENIL - 0.5MG / 5ML
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
NDC 00143978410
|
| Hospital Charge Code |
3300346
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.92 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$34.00
|
| Rate for Payer: First Health Commercial |
$36.00
|
| Rate for Payer: First Health Workers Compensation |
$15.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.00
|
| Rate for Payer: GEHA Commercial |
$28.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.00
|
| Rate for Payer: Multiplan All |
$36.40
|
| Rate for Payer: OMNI Networks Commercial |
$28.00
|
| Rate for Payer: One Health Plan PPO/POS |
$36.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.00
|
| Rate for Payer: Three Rivers Provider Network All |
$30.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$37.20
|
| Rate for Payer: Zelis Auto |
$16.00
|
| Rate for Payer: Zelis Worker's Compensation |
$10.92
|
|
|
FLUMAZENIL - 0.5MG / 5ML
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
NDC 00143978410
|
| Hospital Charge Code |
3300346
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$34.00
|
| Rate for Payer: First Health Commercial |
$36.00
|
| Rate for Payer: First Health Workers Compensation |
$15.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.00
|
| Rate for Payer: GEHA Commercial |
$32.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.00
|
| Rate for Payer: Humana ChoiceCare |
$10.40
|
| Rate for Payer: Multiplan All |
$36.40
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.00
|
| Rate for Payer: OMNI Networks Commercial |
$28.00
|
| Rate for Payer: One Health Plan PPO/POS |
$36.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.00
|
| Rate for Payer: Three Rivers Provider Network All |
$30.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$35.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$37.20
|
| Rate for Payer: Zelis Auto |
$16.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.00
|
| Rate for Payer: Zelis Worker's Compensation |
$10.92
|
|
|
flunitrazepam urine screen REF808417
|
Facility
|
OP
|
$417.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
2200225
|
|
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
|
|
|
flunitrazepam urine screen REF808417
|
Facility
|
IP
|
$417.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
2200225
|
|
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
|
|
|
FLUOCINONIDE OINT 0.05%
|
Facility
|
IP
|
$360.00
|
|
|
Service Code
|
NDC 00093026415
|
| Hospital Charge Code |
3300347
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.28 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$306.00
|
| Rate for Payer: First Health Commercial |
$324.00
|
| Rate for Payer: First Health Workers Compensation |
$139.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$324.00
|
| Rate for Payer: GEHA Commercial |
$252.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$324.00
|
| Rate for Payer: Multiplan All |
$327.60
|
| Rate for Payer: OMNI Networks Commercial |
$252.00
|
| Rate for Payer: One Health Plan PPO/POS |
$324.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$342.00
|
| Rate for Payer: Three Rivers Provider Network All |
$270.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$334.80
|
| Rate for Payer: Zelis Auto |
$144.00
|
| Rate for Payer: Zelis Worker's Compensation |
$98.28
|
|
|
FLUOCINONIDE OINT 0.05%
|
Facility
|
OP
|
$360.00
|
|
|
Service Code
|
NDC 00093026415
|
| Hospital Charge Code |
3300347
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.00 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$216.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$306.00
|
| Rate for Payer: First Health Commercial |
$324.00
|
| Rate for Payer: First Health Workers Compensation |
$139.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$324.00
|
| Rate for Payer: GEHA Commercial |
$288.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$324.00
|
| Rate for Payer: Humana ChoiceCare |
$93.60
|
| Rate for Payer: Multiplan All |
$327.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$216.00
|
| Rate for Payer: OMNI Networks Commercial |
$252.00
|
| Rate for Payer: One Health Plan PPO/POS |
$324.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$342.00
|
| Rate for Payer: Three Rivers Provider Network All |
$270.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$316.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$90.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$334.80
|
| Rate for Payer: Zelis Auto |
$144.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$180.00
|
| Rate for Payer: Zelis Worker's Compensation |
$98.28
|
|
|
FLUORESCEIN INJ 500 MG/5 ML
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
NDC 17478025310
|
| Hospital Charge Code |
3302848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.33 |
| Max. Negotiated Rate |
$189.05 |
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$169.15
|
| Rate for Payer: First Health Commercial |
$179.10
|
| Rate for Payer: First Health Workers Compensation |
$76.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$179.10
|
| Rate for Payer: GEHA Commercial |
$139.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$179.10
|
| Rate for Payer: Multiplan All |
$181.09
|
| Rate for Payer: OMNI Networks Commercial |
$139.30
|
| Rate for Payer: One Health Plan PPO/POS |
$179.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$189.05
|
| Rate for Payer: Three Rivers Provider Network All |
$149.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$185.07
|
| Rate for Payer: Zelis Auto |
$79.60
|
| Rate for Payer: Zelis Worker's Compensation |
$54.33
|
|
|
FLUORESCEIN INJ 500 MG/5 ML
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
NDC 17478025310
|
| Hospital Charge Code |
3302848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.75 |
| Max. Negotiated Rate |
$189.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$169.15
|
| Rate for Payer: First Health Commercial |
$179.10
|
| Rate for Payer: First Health Workers Compensation |
$76.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$179.10
|
| Rate for Payer: GEHA Commercial |
$159.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$179.10
|
| Rate for Payer: Humana ChoiceCare |
$51.74
|
| Rate for Payer: Multiplan All |
$181.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$119.40
|
| Rate for Payer: OMNI Networks Commercial |
$139.30
|
| Rate for Payer: One Health Plan PPO/POS |
$179.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$189.05
|
| Rate for Payer: Three Rivers Provider Network All |
$149.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$175.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$49.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$185.07
|
| Rate for Payer: Zelis Auto |
$79.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$99.50
|
| Rate for Payer: Zelis Worker's Compensation |
$54.33
|
|
|
FLUORESCEIN OPTH STRIPS 1MG
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 17238090099
|
| Hospital Charge Code |
3300348
|
|
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
|
|
|
FLUORESCEIN OPTH STRIPS 1MG
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 17238090099
|
| Hospital Charge Code |
3300348
|
|
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
|
|
|
FLUORESCEIN/PROPARACAINE OPHTH SOLN
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
NDC 59390020505
|
| Hospital Charge Code |
3302811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.75 |
| Max. Negotiated Rate |
$189.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$169.15
|
| Rate for Payer: First Health Commercial |
$179.10
|
| Rate for Payer: First Health Workers Compensation |
$76.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$179.10
|
| Rate for Payer: GEHA Commercial |
$159.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$179.10
|
| Rate for Payer: Humana ChoiceCare |
$51.74
|
| Rate for Payer: Multiplan All |
$181.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$119.40
|
| Rate for Payer: OMNI Networks Commercial |
$139.30
|
| Rate for Payer: One Health Plan PPO/POS |
$179.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$189.05
|
| Rate for Payer: Three Rivers Provider Network All |
$149.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$175.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$49.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$185.07
|
| Rate for Payer: Zelis Auto |
$79.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$99.50
|
| Rate for Payer: Zelis Worker's Compensation |
$54.33
|
|
|
FLUORESCEIN/PROPARACAINE OPHTH SOLN
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
NDC 59390020505
|
| Hospital Charge Code |
3302811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.33 |
| Max. Negotiated Rate |
$189.05 |
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$169.15
|
| Rate for Payer: First Health Commercial |
$179.10
|
| Rate for Payer: First Health Workers Compensation |
$76.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$179.10
|
| Rate for Payer: GEHA Commercial |
$139.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$179.10
|
| Rate for Payer: Multiplan All |
$181.09
|
| Rate for Payer: OMNI Networks Commercial |
$139.30
|
| Rate for Payer: One Health Plan PPO/POS |
$179.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$189.05
|
| Rate for Payer: Three Rivers Provider Network All |
$149.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$185.07
|
| Rate for Payer: Zelis Auto |
$79.60
|
| Rate for Payer: Zelis Worker's Compensation |
$54.33
|
|
|
FLUORO CENTRL VAD PLACEMNT - ADD ON
|
Facility
|
IP
|
$1,138.00
|
|
|
Service Code
|
CPT 77001
|
| Hospital Charge Code |
2407258
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$86.56 |
| Max. Negotiated Rate |
$1,081.10 |
| Rate for Payer: Cash Price |
$682.80
|
| Rate for Payer: Cash Price |
$682.80
|
| Rate for Payer: Cigna Commercial |
$967.30
|
| Rate for Payer: First Health Commercial |
$1,024.20
|
| Rate for Payer: First Health Workers Compensation |
$122.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,024.20
|
| Rate for Payer: GEHA Commercial |
$796.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,024.20
|
| Rate for Payer: Multiplan All |
$1,035.58
|
| Rate for Payer: OMNI Networks Commercial |
$796.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,024.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,081.10
|
| Rate for Payer: Three Rivers Provider Network All |
$853.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,058.34
|
| Rate for Payer: Zelis Auto |
$455.20
|
| Rate for Payer: Zelis Worker's Compensation |
$86.56
|
|
|
FLUORO CENTRL VAD PLACEMNT - ADD ON
|
Facility
|
OP
|
$1,138.00
|
|
|
Service Code
|
CPT 77001
|
| Hospital Charge Code |
2407258
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$86.56 |
| Max. Negotiated Rate |
$1,081.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$682.80
|
| Rate for Payer: Cash Price |
$682.80
|
| Rate for Payer: Cash Price |
$682.80
|
| Rate for Payer: Cigna Commercial |
$967.30
|
| Rate for Payer: First Health Commercial |
$1,024.20
|
| Rate for Payer: First Health Workers Compensation |
$122.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,024.20
|
| Rate for Payer: GEHA Commercial |
$910.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,024.20
|
| Rate for Payer: Humana ChoiceCare |
$295.88
|
| Rate for Payer: Multiplan All |
$1,035.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$682.80
|
| Rate for Payer: OMNI Networks Commercial |
$796.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,024.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,081.10
|
| Rate for Payer: Three Rivers Provider Network All |
$853.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,001.44
|
| Rate for Payer: United Healthcare Commercial |
$967.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$284.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,058.34
|
| Rate for Payer: Zelis Auto |
$455.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$569.00
|
| Rate for Payer: Zelis Worker's Compensation |
$86.56
|
|
|
FLUORO CENTRL VAD PLACEMNT - ADD ON
|
Facility
|
OP
|
$1,138.00
|
|
|
Service Code
|
CPT 77001
|
| Hospital Charge Code |
2677001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$86.56 |
| Max. Negotiated Rate |
$1,081.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$682.80
|
| Rate for Payer: Cash Price |
$682.80
|
| Rate for Payer: Cash Price |
$682.80
|
| Rate for Payer: Cigna Commercial |
$967.30
|
| Rate for Payer: First Health Commercial |
$1,024.20
|
| Rate for Payer: First Health Workers Compensation |
$122.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,024.20
|
| Rate for Payer: GEHA Commercial |
$910.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,024.20
|
| Rate for Payer: Humana ChoiceCare |
$295.88
|
| Rate for Payer: Multiplan All |
$1,035.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$682.80
|
| Rate for Payer: OMNI Networks Commercial |
$796.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,024.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,081.10
|
| Rate for Payer: Three Rivers Provider Network All |
$853.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,001.44
|
| Rate for Payer: United Healthcare Commercial |
$967.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$284.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,058.34
|
| Rate for Payer: Zelis Auto |
$455.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$569.00
|
| Rate for Payer: Zelis Worker's Compensation |
$86.56
|
|
|
FLUORO CENTRL VAD PLACEMNT - ADD ON
|
Facility
|
IP
|
$1,138.00
|
|
|
Service Code
|
CPT 77001
|
| Hospital Charge Code |
2677001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$86.56 |
| Max. Negotiated Rate |
$1,081.10 |
| Rate for Payer: Cash Price |
$682.80
|
| Rate for Payer: Cash Price |
$682.80
|
| Rate for Payer: Cigna Commercial |
$967.30
|
| Rate for Payer: First Health Commercial |
$1,024.20
|
| Rate for Payer: First Health Workers Compensation |
$122.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,024.20
|
| Rate for Payer: GEHA Commercial |
$796.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,024.20
|
| Rate for Payer: Multiplan All |
$1,035.58
|
| Rate for Payer: OMNI Networks Commercial |
$796.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,024.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,081.10
|
| Rate for Payer: Three Rivers Provider Network All |
$853.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,058.34
|
| Rate for Payer: Zelis Auto |
$455.20
|
| Rate for Payer: Zelis Worker's Compensation |
$86.56
|
|
|
FLUORO DX/THER SPINE/PARASPINAL - ADD ON
|
Facility
|
IP
|
$1,078.00
|
|
|
Service Code
|
CPT 77003
|
| Hospital Charge Code |
2407239
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.92 |
| Max. Negotiated Rate |
$1,024.10 |
| Rate for Payer: Cash Price |
$646.80
|
| Rate for Payer: Cash Price |
$646.80
|
| Rate for Payer: Cigna Commercial |
$916.30
|
| Rate for Payer: First Health Commercial |
$970.20
|
| Rate for Payer: First Health Workers Compensation |
$127.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$970.20
|
| Rate for Payer: GEHA Commercial |
$754.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$970.20
|
| Rate for Payer: Multiplan All |
$980.98
|
| Rate for Payer: OMNI Networks Commercial |
$754.60
|
| Rate for Payer: One Health Plan PPO/POS |
$970.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,024.10
|
| Rate for Payer: Three Rivers Provider Network All |
$808.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,002.54
|
| Rate for Payer: Zelis Auto |
$431.20
|
| Rate for Payer: Zelis Worker's Compensation |
$89.92
|
|
|
FLUORO DX/THER SPINE/PARASPINAL - ADD ON
|
Facility
|
OP
|
$1,078.00
|
|
|
Service Code
|
CPT 77003
|
| Hospital Charge Code |
2407239
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.92 |
| Max. Negotiated Rate |
$1,024.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$646.80
|
| Rate for Payer: Cash Price |
$646.80
|
| Rate for Payer: Cash Price |
$646.80
|
| Rate for Payer: Cigna Commercial |
$916.30
|
| Rate for Payer: First Health Commercial |
$970.20
|
| Rate for Payer: First Health Workers Compensation |
$127.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$970.20
|
| Rate for Payer: GEHA Commercial |
$862.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$970.20
|
| Rate for Payer: Humana ChoiceCare |
$280.28
|
| Rate for Payer: Multiplan All |
$980.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$646.80
|
| Rate for Payer: OMNI Networks Commercial |
$754.60
|
| Rate for Payer: One Health Plan PPO/POS |
$970.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,024.10
|
| Rate for Payer: Three Rivers Provider Network All |
$808.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$948.64
|
| Rate for Payer: United Healthcare Commercial |
$916.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$269.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,002.54
|
| Rate for Payer: Zelis Auto |
$431.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$539.00
|
| Rate for Payer: Zelis Worker's Compensation |
$89.92
|
|
|
FLUOROSCOPY<1 HR
|
Facility
|
OP
|
$1,006.00
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
2400233
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$62.76 |
| Max. Negotiated Rate |
$955.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$239.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$603.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$239.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$189.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$229.52
|
| Rate for Payer: Cash Price |
$603.60
|
| Rate for Payer: Cash Price |
$603.60
|
| Rate for Payer: Cigna Commercial |
$855.10
|
| Rate for Payer: First Health Commercial |
$905.40
|
| Rate for Payer: First Health Workers Compensation |
$88.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$905.40
|
| Rate for Payer: GEHA Commercial |
$804.80
|
| Rate for Payer: GEHA Medicare |
$229.52
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$905.40
|
| Rate for Payer: Humana ChoiceCare |
$252.47
|
| Rate for Payer: Humana Medicare Advantage |
$229.52
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$385.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$193.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$229.52
|
| Rate for Payer: Multiplan All |
$915.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$390.18
|
| Rate for Payer: OMNI Networks Commercial |
$704.20
|
| Rate for Payer: One Health Plan PPO/POS |
$905.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$223.26
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$193.36
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$229.52
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$955.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$459.04
|
| Rate for Payer: Three Rivers Provider Network All |
$754.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$224.93
|
| Rate for Payer: United Healthcare Commercial |
$855.10
|
| Rate for Payer: United Healthcare Managed Medicaid |
$193.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$229.52
|
| Rate for Payer: United Payors & United Providers UP&UP |
$935.58
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$229.52
|
| Rate for Payer: Zelis Auto |
$402.40
|
| Rate for Payer: Zelis Medicare |
$195.09
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$275.42
|
| Rate for Payer: Zelis Worker's Compensation |
$62.76
|
|
|
FLUOROSCOPY<1 HR
|
Facility
|
IP
|
$1,006.00
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
2400233
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$62.76 |
| Max. Negotiated Rate |
$955.70 |
| Rate for Payer: Cash Price |
$603.60
|
| Rate for Payer: Cash Price |
$603.60
|
| Rate for Payer: Cigna Commercial |
$855.10
|
| Rate for Payer: First Health Commercial |
$905.40
|
| Rate for Payer: First Health Workers Compensation |
$88.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$905.40
|
| Rate for Payer: GEHA Commercial |
$704.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$905.40
|
| Rate for Payer: Multiplan All |
$915.46
|
| Rate for Payer: OMNI Networks Commercial |
$704.20
|
| Rate for Payer: One Health Plan PPO/POS |
$905.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$955.70
|
| Rate for Payer: Three Rivers Provider Network All |
$754.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$935.58
|
| Rate for Payer: Zelis Auto |
$402.40
|
| Rate for Payer: Zelis Worker's Compensation |
$62.76
|
|
