|
FOLIC ACID 1MG PER 0.2ML INJECTION
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 63323018410
|
| Hospital Charge Code |
3300358
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Humana ChoiceCare |
$5.46
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.60
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
FOLIC ACID 1MG PER 0.2ML INJECTION
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 63323018410
|
| Hospital Charge Code |
3300358
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
FOLIC ACID 1MG TAB
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 60687068101
|
| Hospital Charge Code |
3300359
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$4.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
FOLIC ACID 1MG TAB
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 60687068101
|
| Hospital Charge Code |
3300359
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Humana ChoiceCare |
$1.82
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.20
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
FOLIC ACID 400MCG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 05363084401
|
| Hospital Charge Code |
3301462
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
FOLIC ACID 400MCG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 05363084401
|
| Hospital Charge Code |
3301462
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
FOLIC ACID-PYRIDOXINE-CYANOCOBALAMIN TAB
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00525090690
|
| Hospital Charge Code |
3300360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$14.25 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$12.75
|
| Rate for Payer: First Health Commercial |
$13.50
|
| Rate for Payer: First Health Workers Compensation |
$5.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$13.50
|
| Rate for Payer: GEHA Commercial |
$10.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$13.50
|
| Rate for Payer: Multiplan All |
$13.65
|
| Rate for Payer: OMNI Networks Commercial |
$10.50
|
| Rate for Payer: One Health Plan PPO/POS |
$13.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$14.25
|
| Rate for Payer: Three Rivers Provider Network All |
$11.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.95
|
| Rate for Payer: Zelis Auto |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.09
|
|
|
FOLIC ACID-PYRIDOXINE-CYANOCOBALAMIN TAB
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00525090690
|
| Hospital Charge Code |
3300360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.75 |
| Max. Negotiated Rate |
$14.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$12.75
|
| Rate for Payer: First Health Commercial |
$13.50
|
| Rate for Payer: First Health Workers Compensation |
$5.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$13.50
|
| Rate for Payer: GEHA Commercial |
$12.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$13.50
|
| Rate for Payer: Humana ChoiceCare |
$3.90
|
| Rate for Payer: Multiplan All |
$13.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.00
|
| Rate for Payer: OMNI Networks Commercial |
$10.50
|
| Rate for Payer: One Health Plan PPO/POS |
$13.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$14.25
|
| Rate for Payer: Three Rivers Provider Network All |
$11.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.95
|
| Rate for Payer: Zelis Auto |
$6.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.50
|
| Rate for Payer: Zelis Worker's Compensation |
$4.09
|
|
|
FOLIC ACID (Vitros)
|
Facility
|
IP
|
$195.00
|
|
|
Service Code
|
CPT 82746
|
| Hospital Charge Code |
2232236
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.47 |
| Max. Negotiated Rate |
$185.25 |
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$165.75
|
| Rate for Payer: First Health Commercial |
$175.50
|
| Rate for Payer: First Health Workers Compensation |
$27.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$175.50
|
| Rate for Payer: GEHA Commercial |
$136.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$175.50
|
| Rate for Payer: Multiplan All |
$177.45
|
| Rate for Payer: OMNI Networks Commercial |
$136.50
|
| Rate for Payer: One Health Plan PPO/POS |
$175.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$185.25
|
| Rate for Payer: Three Rivers Provider Network All |
$146.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$181.35
|
| Rate for Payer: Zelis Auto |
$78.00
|
| Rate for Payer: Zelis Worker's Compensation |
$19.47
|
|
|
FOLIC ACID (Vitros)
|
Facility
|
OP
|
$195.00
|
|
|
Service Code
|
CPT 82746
|
| Hospital Charge Code |
2232236
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.49 |
| Max. Negotiated Rate |
$185.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$117.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$20.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.70
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$165.75
|
| Rate for Payer: First Health Commercial |
$175.50
|
| Rate for Payer: First Health Workers Compensation |
$27.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$175.50
|
| Rate for Payer: GEHA Commercial |
$156.00
|
| Rate for Payer: GEHA Medicare |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$175.50
|
| Rate for Payer: Humana ChoiceCare |
$16.17
|
| Rate for Payer: Humana Medicare Advantage |
$14.70
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$24.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.39
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.70
|
| Rate for Payer: Multiplan All |
$177.45
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.99
|
| Rate for Payer: OMNI Networks Commercial |
$136.50
|
| Rate for Payer: One Health Plan PPO/POS |
$175.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$24.70
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.39
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$185.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.40
|
| Rate for Payer: Three Rivers Provider Network All |
$146.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.41
|
| Rate for Payer: United Healthcare Commercial |
$165.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.70
|
| Rate for Payer: United Payors & United Providers UP&UP |
$181.35
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.70
|
| Rate for Payer: Zelis Auto |
$78.00
|
| Rate for Payer: Zelis Medicare |
$12.49
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.64
|
| Rate for Payer: Zelis Worker's Compensation |
$19.47
|
|
|
FOMEPIZOLE INJ 1GM/ML
|
Facility
|
OP
|
$44.00
|
|
|
Service Code
|
CPT J1451
|
| Hospital Charge Code |
3300361
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.34 |
| Max. Negotiated Rate |
$41.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$10.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$26.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$10.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$8.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6.28
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$37.40
|
| Rate for Payer: First Health Commercial |
$39.60
|
| Rate for Payer: First Health Workers Compensation |
$16.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$39.60
|
| Rate for Payer: GEHA Commercial |
$35.20
|
| Rate for Payer: GEHA Medicare |
$6.28
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$39.60
|
| Rate for Payer: Humana ChoiceCare |
$6.91
|
| Rate for Payer: Humana Medicare Advantage |
$6.28
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$10.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$8.45
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6.28
|
| Rate for Payer: Multiplan All |
$40.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10.68
|
| Rate for Payer: OMNI Networks Commercial |
$30.80
|
| Rate for Payer: One Health Plan PPO/POS |
$39.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$9.76
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$8.45
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6.28
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$41.80
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$12.56
|
| Rate for Payer: Three Rivers Provider Network All |
$33.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.15
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.28
|
| Rate for Payer: United Payors & United Providers UP&UP |
$40.92
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6.28
|
| Rate for Payer: Zelis Auto |
$17.60
|
| Rate for Payer: Zelis Medicare |
$5.34
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.54
|
| Rate for Payer: Zelis Worker's Compensation |
$12.01
|
|
|
FOMEPIZOLE INJ 1GM/ML
|
Facility
|
IP
|
$44.00
|
|
|
Service Code
|
CPT J1451
|
| Hospital Charge Code |
3300361
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.01 |
| Max. Negotiated Rate |
$41.80 |
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$37.40
|
| Rate for Payer: First Health Commercial |
$39.60
|
| Rate for Payer: First Health Workers Compensation |
$16.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$39.60
|
| Rate for Payer: GEHA Commercial |
$30.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$39.60
|
| Rate for Payer: Multiplan All |
$40.04
|
| Rate for Payer: OMNI Networks Commercial |
$30.80
|
| Rate for Payer: One Health Plan PPO/POS |
$39.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$41.80
|
| Rate for Payer: Three Rivers Provider Network All |
$33.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$40.92
|
| Rate for Payer: Zelis Auto |
$17.60
|
| Rate for Payer: Zelis Worker's Compensation |
$12.01
|
|
|
FONDAPARINUX 7.5 MG/0.6 ML INJ
|
Facility
|
OP
|
$237.00
|
|
|
Service Code
|
CPT J1652
|
| Hospital Charge Code |
3302896
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$225.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$142.20
|
| 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 |
$91.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$213.30
|
| Rate for Payer: GEHA Commercial |
$0.79
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$213.30
|
| Rate for Payer: Humana ChoiceCare |
$61.62
|
| Rate for Payer: Multiplan All |
$215.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$142.20
|
| 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: TriWest Veterans Administration/VAPC3 |
$208.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$59.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$220.41
|
| Rate for Payer: Zelis Auto |
$94.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$118.50
|
| Rate for Payer: Zelis Worker's Compensation |
$64.70
|
|
|
FONDAPARINUX 7.5 MG/0.6 ML INJ
|
Facility
|
IP
|
$237.00
|
|
|
Service Code
|
CPT J1652
|
| Hospital Charge Code |
3302896
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.70 |
| Max. Negotiated Rate |
$225.15 |
| 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 |
$91.51
|
| 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 |
$64.70
|
|
|
FONDAPARINUX INJ 2.5MG/0.5ML
|
Facility
|
IP
|
$243.00
|
|
|
Service Code
|
CPT J1652
|
| Hospital Charge Code |
3300362
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.34 |
| Max. Negotiated Rate |
$230.85 |
| Rate for Payer: Cash Price |
$145.80
|
| Rate for Payer: Cigna Commercial |
$206.55
|
| Rate for Payer: First Health Commercial |
$218.70
|
| Rate for Payer: First Health Workers Compensation |
$93.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$218.70
|
| Rate for Payer: GEHA Commercial |
$170.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$218.70
|
| Rate for Payer: Multiplan All |
$221.13
|
| Rate for Payer: OMNI Networks Commercial |
$170.10
|
| Rate for Payer: One Health Plan PPO/POS |
$218.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$230.85
|
| Rate for Payer: Three Rivers Provider Network All |
$182.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$225.99
|
| Rate for Payer: Zelis Auto |
$97.20
|
| Rate for Payer: Zelis Worker's Compensation |
$66.34
|
|
|
FONDAPARINUX INJ 2.5MG/0.5ML
|
Facility
|
OP
|
$243.00
|
|
|
Service Code
|
CPT J1652
|
| Hospital Charge Code |
3300362
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$230.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$145.80
|
| Rate for Payer: Cash Price |
$145.80
|
| Rate for Payer: Cash Price |
$145.80
|
| Rate for Payer: Cigna Commercial |
$206.55
|
| Rate for Payer: First Health Commercial |
$218.70
|
| Rate for Payer: First Health Workers Compensation |
$93.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$218.70
|
| Rate for Payer: GEHA Commercial |
$0.79
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$218.70
|
| Rate for Payer: Humana ChoiceCare |
$63.18
|
| Rate for Payer: Multiplan All |
$221.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$145.80
|
| Rate for Payer: OMNI Networks Commercial |
$170.10
|
| Rate for Payer: One Health Plan PPO/POS |
$218.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$230.85
|
| Rate for Payer: Three Rivers Provider Network All |
$182.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$213.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$60.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$225.99
|
| Rate for Payer: Zelis Auto |
$97.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$121.50
|
| Rate for Payer: Zelis Worker's Compensation |
$66.34
|
|
|
FO PIP DIP JNT/SPRNG PRE OTS
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
CPT L3925
|
| Hospital Charge Code |
8503925
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$88.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$88.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$28.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$88.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$70.39
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$40.80
|
| Rate for Payer: First Health Commercial |
$43.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$43.20
|
| Rate for Payer: GEHA Commercial |
$38.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$43.20
|
| Rate for Payer: Humana ChoiceCare |
$12.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$71.83
|
| Rate for Payer: Multiplan All |
$43.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$28.80
|
| Rate for Payer: OMNI Networks Commercial |
$33.60
|
| Rate for Payer: One Health Plan PPO/POS |
$43.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$82.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$71.83
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$45.60
|
| Rate for Payer: Three Rivers Provider Network All |
$36.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$42.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$71.83
|
| Rate for Payer: United Payors & United Providers UP&UP |
$44.64
|
| Rate for Payer: Zelis Auto |
$19.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$24.00
|
|
|
FO PIP DIP JNT/SPRNG PRE OTS
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
CPT L3925
|
| Hospital Charge Code |
8503925
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$19.20 |
| Max. Negotiated Rate |
$45.60 |
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$40.80
|
| Rate for Payer: First Health Commercial |
$43.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$43.20
|
| Rate for Payer: GEHA Commercial |
$33.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$43.20
|
| Rate for Payer: Multiplan All |
$43.68
|
| Rate for Payer: OMNI Networks Commercial |
$33.60
|
| Rate for Payer: One Health Plan PPO/POS |
$43.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$45.60
|
| Rate for Payer: Three Rivers Provider Network All |
$36.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$44.64
|
| Rate for Payer: Zelis Auto |
$19.20
|
|
|
FORCEP ADULT RADIAL JA
|
Facility
|
OP
|
$144.00
|
|
| Hospital Charge Code |
90000587
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$136.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$122.40
|
| Rate for Payer: First Health Commercial |
$129.60
|
| Rate for Payer: First Health Workers Compensation |
$55.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$129.60
|
| Rate for Payer: GEHA Commercial |
$115.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$129.60
|
| Rate for Payer: Humana ChoiceCare |
$37.44
|
| Rate for Payer: Multiplan All |
$131.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$86.40
|
| Rate for Payer: OMNI Networks Commercial |
$100.80
|
| Rate for Payer: One Health Plan PPO/POS |
$129.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$136.80
|
| Rate for Payer: Three Rivers Provider Network All |
$108.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$126.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$36.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$133.92
|
| Rate for Payer: Zelis Auto |
$57.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$72.00
|
| Rate for Payer: Zelis Worker's Compensation |
$39.31
|
|
|
FORCEP ADULT RADIAL JA
|
Facility
|
IP
|
$144.00
|
|
| Hospital Charge Code |
90000587
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$39.31 |
| Max. Negotiated Rate |
$136.80 |
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$122.40
|
| Rate for Payer: First Health Commercial |
$129.60
|
| Rate for Payer: First Health Workers Compensation |
$55.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$129.60
|
| Rate for Payer: GEHA Commercial |
$100.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$129.60
|
| Rate for Payer: Multiplan All |
$131.04
|
| Rate for Payer: OMNI Networks Commercial |
$100.80
|
| Rate for Payer: One Health Plan PPO/POS |
$129.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$136.80
|
| Rate for Payer: Three Rivers Provider Network All |
$108.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$133.92
|
| Rate for Payer: Zelis Auto |
$57.60
|
| Rate for Payer: Zelis Worker's Compensation |
$39.31
|
|
|
FORCEPS TISSUE STRAIGHT W/2X3TEETH
|
Facility
|
IP
|
$380.00
|
|
| Hospital Charge Code |
90030837
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$103.74 |
| Max. Negotiated Rate |
$361.00 |
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Cigna Commercial |
$323.00
|
| Rate for Payer: First Health Commercial |
$342.00
|
| Rate for Payer: First Health Workers Compensation |
$146.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$342.00
|
| Rate for Payer: GEHA Commercial |
$266.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$342.00
|
| Rate for Payer: Multiplan All |
$345.80
|
| Rate for Payer: OMNI Networks Commercial |
$266.00
|
| Rate for Payer: One Health Plan PPO/POS |
$342.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$361.00
|
| Rate for Payer: Three Rivers Provider Network All |
$285.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$353.40
|
| Rate for Payer: Zelis Auto |
$152.00
|
| Rate for Payer: Zelis Worker's Compensation |
$103.74
|
|
|
FORCEPS TISSUE STRAIGHT W/2X3TEETH
|
Facility
|
OP
|
$380.00
|
|
| Hospital Charge Code |
90030837
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$95.00 |
| Max. Negotiated Rate |
$361.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$228.00
|
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Cigna Commercial |
$323.00
|
| Rate for Payer: First Health Commercial |
$342.00
|
| Rate for Payer: First Health Workers Compensation |
$146.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$342.00
|
| Rate for Payer: GEHA Commercial |
$304.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$342.00
|
| Rate for Payer: Humana ChoiceCare |
$98.80
|
| Rate for Payer: Multiplan All |
$345.80
|
| Rate for Payer: New Mexico Health Connections Medicare |
$228.00
|
| Rate for Payer: OMNI Networks Commercial |
$266.00
|
| Rate for Payer: One Health Plan PPO/POS |
$342.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$361.00
|
| Rate for Payer: Three Rivers Provider Network All |
$285.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$334.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$95.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$353.40
|
| Rate for Payer: Zelis Auto |
$152.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$190.00
|
| Rate for Payer: Zelis Worker's Compensation |
$103.74
|
|
|
FOREHEAD FLAP W/VASC PEDICLE
|
Facility
|
OP
|
$2,061.00
|
|
|
Service Code
|
CPT 15731
|
| Hospital Charge Code |
6115731
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$562.65 |
| Max. Negotiated Rate |
$6,952.48 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,419.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,236.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,419.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,916.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,476.24
|
| Rate for Payer: Cash Price |
$1,236.60
|
| Rate for Payer: Cash Price |
$1,236.60
|
| Rate for Payer: Cigna Commercial |
$1,751.85
|
| Rate for Payer: First Health Commercial |
$1,854.90
|
| Rate for Payer: First Health Workers Compensation |
$795.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,854.90
|
| Rate for Payer: GEHA Commercial |
$1,648.80
|
| Rate for Payer: GEHA Medicare |
$3,476.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,854.90
|
| Rate for Payer: Humana ChoiceCare |
$3,823.86
|
| Rate for Payer: Humana Medicare Advantage |
$3,476.24
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,840.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,955.93
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,476.24
|
| Rate for Payer: Multiplan All |
$1,875.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,909.61
|
| Rate for Payer: OMNI Networks Commercial |
$1,442.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,854.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,258.40
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,955.93
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,476.24
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,957.95
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,952.48
|
| Rate for Payer: Three Rivers Provider Network All |
$1,545.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,406.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,955.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,476.24
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,916.73
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,476.24
|
| Rate for Payer: Zelis Auto |
$824.40
|
| Rate for Payer: Zelis Medicare |
$2,954.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,171.49
|
| Rate for Payer: Zelis Worker's Compensation |
$562.65
|
|
|
FOREHEAD FLAP W/VASC PEDICLE
|
Facility
|
IP
|
$2,061.00
|
|
|
Service Code
|
CPT 15731
|
| Hospital Charge Code |
6115731
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$562.65 |
| Max. Negotiated Rate |
$1,957.95 |
| Rate for Payer: Cash Price |
$1,236.60
|
| Rate for Payer: Cigna Commercial |
$1,751.85
|
| Rate for Payer: First Health Commercial |
$1,854.90
|
| Rate for Payer: First Health Workers Compensation |
$795.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,854.90
|
| Rate for Payer: GEHA Commercial |
$1,442.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,854.90
|
| Rate for Payer: Multiplan All |
$1,875.51
|
| Rate for Payer: OMNI Networks Commercial |
$1,442.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,854.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,957.95
|
| Rate for Payer: Three Rivers Provider Network All |
$1,545.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,916.73
|
| Rate for Payer: Zelis Auto |
$824.40
|
| Rate for Payer: Zelis Worker's Compensation |
$562.65
|
|
|
FORESKN MANJ W/LSS PREPUTIAL ADS&STRETCH
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
CPT 54450
|
| Hospital Charge Code |
6154450
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$49.14 |
| Max. Negotiated Rate |
$461.88 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$305.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$108.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$305.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$242.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$230.94
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$153.00
|
| Rate for Payer: First Health Commercial |
$162.00
|
| Rate for Payer: First Health Workers Compensation |
$69.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$162.00
|
| Rate for Payer: GEHA Commercial |
$144.00
|
| Rate for Payer: GEHA Medicare |
$230.94
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$162.00
|
| Rate for Payer: Humana ChoiceCare |
$254.03
|
| Rate for Payer: Humana Medicare Advantage |
$230.94
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$387.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$246.94
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$230.94
|
| Rate for Payer: Multiplan All |
$163.80
|
| Rate for Payer: New Mexico Health Connections Medicare |
$392.60
|
| Rate for Payer: OMNI Networks Commercial |
$126.00
|
| Rate for Payer: One Health Plan PPO/POS |
$162.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$285.12
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$246.94
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$230.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$171.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$461.88
|
| Rate for Payer: Three Rivers Provider Network All |
$135.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$226.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$246.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$230.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$167.40
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$230.94
|
| Rate for Payer: Zelis Auto |
$72.00
|
| Rate for Payer: Zelis Medicare |
$196.30
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$277.13
|
| Rate for Payer: Zelis Worker's Compensation |
$49.14
|
|
