|
G0402 WELCOME TO MEDICARE
|
Facility
|
IP
|
$502.00
|
|
|
Service Code
|
CPT G0402
|
| Hospital Charge Code |
21900195
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$137.05 |
| Max. Negotiated Rate |
$476.90 |
| Rate for Payer: Cash Price |
$301.20
|
| Rate for Payer: Cigna Commercial |
$426.70
|
| Rate for Payer: First Health Commercial |
$451.80
|
| Rate for Payer: First Health Workers Compensation |
$193.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$451.80
|
| Rate for Payer: GEHA Commercial |
$351.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$451.80
|
| Rate for Payer: Multiplan All |
$456.82
|
| Rate for Payer: OMNI Networks Commercial |
$351.40
|
| Rate for Payer: One Health Plan PPO/POS |
$451.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$476.90
|
| Rate for Payer: Three Rivers Provider Network All |
$376.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$466.86
|
| Rate for Payer: Zelis Auto |
$200.80
|
| Rate for Payer: Zelis Worker's Compensation |
$137.05
|
|
|
G0402 WELCOME TO MEDICARE PHYSICAL
|
Facility
|
IP
|
$502.00
|
|
|
Service Code
|
CPT G0402
|
| Hospital Charge Code |
21600004
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$137.05 |
| Max. Negotiated Rate |
$476.90 |
| Rate for Payer: Cash Price |
$301.20
|
| Rate for Payer: Cigna Commercial |
$426.70
|
| Rate for Payer: First Health Commercial |
$451.80
|
| Rate for Payer: First Health Workers Compensation |
$193.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$451.80
|
| Rate for Payer: GEHA Commercial |
$351.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$451.80
|
| Rate for Payer: Multiplan All |
$456.82
|
| Rate for Payer: OMNI Networks Commercial |
$351.40
|
| Rate for Payer: One Health Plan PPO/POS |
$451.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$476.90
|
| Rate for Payer: Three Rivers Provider Network All |
$376.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$466.86
|
| Rate for Payer: Zelis Auto |
$200.80
|
| Rate for Payer: Zelis Worker's Compensation |
$137.05
|
|
|
G0402 WELCOME TO MEDICARE PHYSICAL
|
Facility
|
IP
|
$502.00
|
|
|
Service Code
|
CPT G0402
|
| Hospital Charge Code |
25500004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$137.05 |
| Max. Negotiated Rate |
$476.90 |
| Rate for Payer: Cash Price |
$301.20
|
| Rate for Payer: Cigna Commercial |
$426.70
|
| Rate for Payer: First Health Commercial |
$451.80
|
| Rate for Payer: First Health Workers Compensation |
$193.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$451.80
|
| Rate for Payer: GEHA Commercial |
$351.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$451.80
|
| Rate for Payer: Multiplan All |
$456.82
|
| Rate for Payer: OMNI Networks Commercial |
$351.40
|
| Rate for Payer: One Health Plan PPO/POS |
$451.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$476.90
|
| Rate for Payer: Three Rivers Provider Network All |
$376.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$466.86
|
| Rate for Payer: Zelis Auto |
$200.80
|
| Rate for Payer: Zelis Worker's Compensation |
$137.05
|
|
|
G0402 WELCOME TO MEDICARE PHYSICAL
|
Facility
|
OP
|
$502.00
|
|
|
Service Code
|
CPT G0402
|
| Hospital Charge Code |
21500004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$104.01 |
| Max. Negotiated Rate |
$476.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$301.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$122.37
|
| Rate for Payer: Cash Price |
$301.20
|
| Rate for Payer: Cash Price |
$301.20
|
| Rate for Payer: Cigna Commercial |
$426.70
|
| Rate for Payer: First Health Commercial |
$451.80
|
| Rate for Payer: First Health Workers Compensation |
$193.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$451.80
|
| Rate for Payer: GEHA Commercial |
$401.60
|
| Rate for Payer: GEHA Medicare |
$122.37
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$451.80
|
| Rate for Payer: Humana ChoiceCare |
$134.61
|
| Rate for Payer: Humana Medicare Advantage |
$122.37
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$205.58
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$122.37
|
| Rate for Payer: Multiplan All |
$456.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$208.03
|
| Rate for Payer: OMNI Networks Commercial |
$351.40
|
| Rate for Payer: One Health Plan PPO/POS |
$451.80
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$122.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$476.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$244.74
|
| Rate for Payer: Three Rivers Provider Network All |
$376.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$119.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$125.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$466.86
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$122.37
|
| Rate for Payer: Zelis Auto |
$200.80
|
| Rate for Payer: Zelis Medicare |
$104.01
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$146.84
|
| Rate for Payer: Zelis Worker's Compensation |
$137.05
|
|
|
G0402 WELCOME TO MEDICARE PHYSICAL
|
Facility
|
IP
|
$502.00
|
|
|
Service Code
|
CPT G0402
|
| Hospital Charge Code |
21500004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$137.05 |
| Max. Negotiated Rate |
$476.90 |
| Rate for Payer: Cash Price |
$301.20
|
| Rate for Payer: Cigna Commercial |
$426.70
|
| Rate for Payer: First Health Commercial |
$451.80
|
| Rate for Payer: First Health Workers Compensation |
$193.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$451.80
|
| Rate for Payer: GEHA Commercial |
$351.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$451.80
|
| Rate for Payer: Multiplan All |
$456.82
|
| Rate for Payer: OMNI Networks Commercial |
$351.40
|
| Rate for Payer: One Health Plan PPO/POS |
$451.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$476.90
|
| Rate for Payer: Three Rivers Provider Network All |
$376.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$466.86
|
| Rate for Payer: Zelis Auto |
$200.80
|
| Rate for Payer: Zelis Worker's Compensation |
$137.05
|
|
|
G0402 WELCOME TO MEDICARE PHYSICAL
|
Facility
|
OP
|
$502.00
|
|
|
Service Code
|
CPT G0402
|
| Hospital Charge Code |
21600004
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$104.01 |
| Max. Negotiated Rate |
$476.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$301.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$122.37
|
| Rate for Payer: Cash Price |
$301.20
|
| Rate for Payer: Cash Price |
$301.20
|
| Rate for Payer: Cigna Commercial |
$426.70
|
| Rate for Payer: First Health Commercial |
$451.80
|
| Rate for Payer: First Health Workers Compensation |
$193.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$451.80
|
| Rate for Payer: GEHA Commercial |
$401.60
|
| Rate for Payer: GEHA Medicare |
$122.37
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$451.80
|
| Rate for Payer: Humana ChoiceCare |
$134.61
|
| Rate for Payer: Humana Medicare Advantage |
$122.37
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$205.58
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$122.37
|
| Rate for Payer: Multiplan All |
$456.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$208.03
|
| Rate for Payer: OMNI Networks Commercial |
$351.40
|
| Rate for Payer: One Health Plan PPO/POS |
$451.80
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$122.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$476.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$244.74
|
| Rate for Payer: Three Rivers Provider Network All |
$376.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$119.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$125.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$466.86
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$122.37
|
| Rate for Payer: Zelis Auto |
$200.80
|
| Rate for Payer: Zelis Medicare |
$104.01
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$146.84
|
| Rate for Payer: Zelis Worker's Compensation |
$137.05
|
|
|
G0402 WELCOME TO MEDICARE PHYSICAL
|
Facility
|
OP
|
$502.00
|
|
|
Service Code
|
CPT G0402
|
| Hospital Charge Code |
25500004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$104.01 |
| Max. Negotiated Rate |
$476.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$301.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$122.37
|
| Rate for Payer: Cash Price |
$301.20
|
| Rate for Payer: Cash Price |
$301.20
|
| Rate for Payer: Cigna Commercial |
$426.70
|
| Rate for Payer: First Health Commercial |
$451.80
|
| Rate for Payer: First Health Workers Compensation |
$193.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$451.80
|
| Rate for Payer: GEHA Commercial |
$401.60
|
| Rate for Payer: GEHA Medicare |
$122.37
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$451.80
|
| Rate for Payer: Humana ChoiceCare |
$134.61
|
| Rate for Payer: Humana Medicare Advantage |
$122.37
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$205.58
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$122.37
|
| Rate for Payer: Multiplan All |
$456.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$208.03
|
| Rate for Payer: OMNI Networks Commercial |
$351.40
|
| Rate for Payer: One Health Plan PPO/POS |
$451.80
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$122.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$476.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$244.74
|
| Rate for Payer: Three Rivers Provider Network All |
$376.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$119.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$125.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$466.86
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$122.37
|
| Rate for Payer: Zelis Auto |
$200.80
|
| Rate for Payer: Zelis Medicare |
$104.01
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$146.84
|
| Rate for Payer: Zelis Worker's Compensation |
$137.05
|
|
|
g6pd (glucose 6-phos dehydro) REF001917
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
CPT 82955
|
| Hospital Charge Code |
2200324
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$114.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$17.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$17.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$13.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$9.70
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cigna Commercial |
$102.85
|
| Rate for Payer: First Health Commercial |
$108.90
|
| Rate for Payer: First Health Workers Compensation |
$18.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.90
|
| Rate for Payer: GEHA Commercial |
$96.80
|
| Rate for Payer: GEHA Medicare |
$9.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.90
|
| Rate for Payer: Humana ChoiceCare |
$10.67
|
| Rate for Payer: Humana Medicare Advantage |
$9.70
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$16.30
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$14.11
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$9.70
|
| Rate for Payer: Multiplan All |
$110.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$16.49
|
| Rate for Payer: OMNI Networks Commercial |
$84.70
|
| Rate for Payer: One Health Plan PPO/POS |
$108.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$16.30
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$14.11
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$9.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.95
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$19.40
|
| Rate for Payer: Three Rivers Provider Network All |
$90.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.51
|
| Rate for Payer: United Healthcare Commercial |
$102.85
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.70
|
| Rate for Payer: United Payors & United Providers UP&UP |
$112.53
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$9.70
|
| Rate for Payer: Zelis Auto |
$48.40
|
| Rate for Payer: Zelis Medicare |
$8.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$11.64
|
| Rate for Payer: Zelis Worker's Compensation |
$12.99
|
|
|
g6pd (glucose 6-phos dehydro) REF001917
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
CPT 82955
|
| Hospital Charge Code |
2200324
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.99 |
| Max. Negotiated Rate |
$114.95 |
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cigna Commercial |
$102.85
|
| Rate for Payer: First Health Commercial |
$108.90
|
| Rate for Payer: First Health Workers Compensation |
$18.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.90
|
| Rate for Payer: GEHA Commercial |
$84.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.90
|
| Rate for Payer: Multiplan All |
$110.11
|
| Rate for Payer: OMNI Networks Commercial |
$84.70
|
| Rate for Payer: One Health Plan PPO/POS |
$108.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.95
|
| Rate for Payer: Three Rivers Provider Network All |
$90.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$112.53
|
| Rate for Payer: Zelis Auto |
$48.40
|
| Rate for Payer: Zelis Worker's Compensation |
$12.99
|
|
|
GA67 GALLIUM PER MCI
|
Facility
|
IP
|
$248.00
|
|
|
Service Code
|
CPT A9556
|
| Hospital Charge Code |
2410065
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$67.70 |
| Max. Negotiated Rate |
$235.60 |
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$210.80
|
| Rate for Payer: First Health Commercial |
$223.20
|
| Rate for Payer: First Health Workers Compensation |
$95.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$223.20
|
| Rate for Payer: GEHA Commercial |
$173.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$223.20
|
| Rate for Payer: Multiplan All |
$225.68
|
| Rate for Payer: OMNI Networks Commercial |
$173.60
|
| Rate for Payer: One Health Plan PPO/POS |
$223.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$235.60
|
| Rate for Payer: Three Rivers Provider Network All |
$186.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$230.64
|
| Rate for Payer: Zelis Auto |
$99.20
|
| Rate for Payer: Zelis Worker's Compensation |
$67.70
|
|
|
GA67 GALLIUM PER MCI
|
Facility
|
OP
|
$248.00
|
|
|
Service Code
|
CPT A9556
|
| Hospital Charge Code |
2410065
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$62.00 |
| Max. Negotiated Rate |
$235.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$148.80
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$210.80
|
| Rate for Payer: First Health Commercial |
$223.20
|
| Rate for Payer: First Health Workers Compensation |
$95.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$223.20
|
| Rate for Payer: GEHA Commercial |
$198.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$223.20
|
| Rate for Payer: Humana ChoiceCare |
$64.48
|
| Rate for Payer: Multiplan All |
$225.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$148.80
|
| Rate for Payer: OMNI Networks Commercial |
$173.60
|
| Rate for Payer: One Health Plan PPO/POS |
$223.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$235.60
|
| Rate for Payer: Three Rivers Provider Network All |
$186.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$218.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$62.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$230.64
|
| Rate for Payer: Zelis Auto |
$99.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$124.00
|
| Rate for Payer: Zelis Worker's Compensation |
$67.70
|
|
|
GABAPENTIN 100MG CAP
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 00904666561
|
| Hospital Charge Code |
3300370
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$7.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Humana ChoiceCare |
$2.34
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5.40
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.50
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
GABAPENTIN 100MG CAP
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 00904666561
|
| Hospital Charge Code |
3300370
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$6.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
GABAPENTIN 300MG CAP
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 00904666661
|
| Hospital Charge Code |
3300371
|
|
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
|
|
|
GABAPENTIN 300MG CAP
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 00904666661
|
| Hospital Charge Code |
3300371
|
|
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
|
|
|
GABAPENTIN 400MG CAP
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 00904666761
|
| Hospital Charge Code |
3300372
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: First Health Commercial |
$12.60
|
| Rate for Payer: First Health Workers Compensation |
$5.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12.60
|
| Rate for Payer: GEHA Commercial |
$9.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12.60
|
| Rate for Payer: Multiplan All |
$12.74
|
| Rate for Payer: OMNI Networks Commercial |
$9.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.02
|
| Rate for Payer: Zelis Auto |
$5.60
|
| Rate for Payer: Zelis Worker's Compensation |
$3.82
|
|
|
GABAPENTIN 400MG CAP
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 00904666761
|
| Hospital Charge Code |
3300372
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: First Health Commercial |
$12.60
|
| Rate for Payer: First Health Workers Compensation |
$5.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12.60
|
| Rate for Payer: GEHA Commercial |
$11.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12.60
|
| Rate for Payer: Humana ChoiceCare |
$3.64
|
| Rate for Payer: Multiplan All |
$12.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.40
|
| Rate for Payer: OMNI Networks Commercial |
$9.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.02
|
| Rate for Payer: Zelis Auto |
$5.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.82
|
|
|
GABAPENTIN ORAL SOLUTION 250MG/5ML
|
Facility
|
OP
|
$13.00
|
|
| Hospital Charge Code |
3302607
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$11.05
|
| Rate for Payer: First Health Commercial |
$11.70
|
| Rate for Payer: First Health Workers Compensation |
$5.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11.70
|
| Rate for Payer: GEHA Commercial |
$10.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11.70
|
| Rate for Payer: Humana ChoiceCare |
$3.38
|
| Rate for Payer: Multiplan All |
$11.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.80
|
| Rate for Payer: OMNI Networks Commercial |
$9.10
|
| Rate for Payer: One Health Plan PPO/POS |
$11.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12.35
|
| Rate for Payer: Three Rivers Provider Network All |
$9.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12.09
|
| Rate for Payer: Zelis Auto |
$5.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.55
|
|
|
GABAPENTIN ORAL SOLUTION 250MG/5ML
|
Facility
|
IP
|
$13.00
|
|
| Hospital Charge Code |
3302607
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.55 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$11.05
|
| Rate for Payer: First Health Commercial |
$11.70
|
| Rate for Payer: First Health Workers Compensation |
$5.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11.70
|
| Rate for Payer: GEHA Commercial |
$9.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11.70
|
| Rate for Payer: Multiplan All |
$11.83
|
| Rate for Payer: OMNI Networks Commercial |
$9.10
|
| Rate for Payer: One Health Plan PPO/POS |
$11.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12.35
|
| Rate for Payer: Three Rivers Provider Network All |
$9.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12.09
|
| Rate for Payer: Zelis Auto |
$5.20
|
| Rate for Payer: Zelis Worker's Compensation |
$3.55
|
|
|
gabapentin, serum/plasma REF716811
|
Facility
|
IP
|
$187.00
|
|
|
Service Code
|
CPT 80171
|
| Hospital Charge Code |
2200676
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.76 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cigna Commercial |
$158.95
|
| Rate for Payer: First Health Commercial |
$168.30
|
| Rate for Payer: First Health Workers Compensation |
$26.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$168.30
|
| Rate for Payer: GEHA Commercial |
$130.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$168.30
|
| Rate for Payer: Multiplan All |
$170.17
|
| Rate for Payer: OMNI Networks Commercial |
$130.90
|
| Rate for Payer: One Health Plan PPO/POS |
$168.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$177.65
|
| Rate for Payer: Three Rivers Provider Network All |
$140.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$173.91
|
| Rate for Payer: Zelis Auto |
$74.80
|
| Rate for Payer: Zelis Worker's Compensation |
$18.76
|
|
|
gabapentin, serum/plasma REF716811
|
Facility
|
OP
|
$187.00
|
|
|
Service Code
|
CPT 80171
|
| Hospital Charge Code |
2200676
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.42 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$39.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$112.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$39.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$30.90
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$21.67
|
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cigna Commercial |
$158.95
|
| Rate for Payer: First Health Commercial |
$168.30
|
| Rate for Payer: First Health Workers Compensation |
$26.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$168.30
|
| Rate for Payer: GEHA Commercial |
$149.60
|
| Rate for Payer: GEHA Medicare |
$21.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$168.30
|
| Rate for Payer: Humana ChoiceCare |
$23.84
|
| Rate for Payer: Humana Medicare Advantage |
$21.67
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$36.41
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$31.52
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$21.67
|
| Rate for Payer: Multiplan All |
$170.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$36.84
|
| Rate for Payer: OMNI Networks Commercial |
$130.90
|
| Rate for Payer: One Health Plan PPO/POS |
$168.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$36.40
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$31.52
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$21.67
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$177.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$43.34
|
| Rate for Payer: Three Rivers Provider Network All |
$140.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$21.24
|
| Rate for Payer: United Healthcare Commercial |
$158.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.67
|
| Rate for Payer: United Payors & United Providers UP&UP |
$173.91
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$21.67
|
| Rate for Payer: Zelis Auto |
$74.80
|
| Rate for Payer: Zelis Medicare |
$18.42
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$26.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.76
|
|
|
gad-65 autoantibody REF143008
|
Facility
|
IP
|
$274.00
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
2200168
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$22.04 |
| Max. Negotiated Rate |
$260.30 |
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cigna Commercial |
$232.90
|
| Rate for Payer: First Health Commercial |
$246.60
|
| Rate for Payer: First Health Workers Compensation |
$31.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$246.60
|
| Rate for Payer: GEHA Commercial |
$191.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$246.60
|
| Rate for Payer: Multiplan All |
$249.34
|
| Rate for Payer: OMNI Networks Commercial |
$191.80
|
| Rate for Payer: One Health Plan PPO/POS |
$246.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$260.30
|
| Rate for Payer: Three Rivers Provider Network All |
$205.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$254.82
|
| Rate for Payer: Zelis Auto |
$109.60
|
| Rate for Payer: Zelis Worker's Compensation |
$22.04
|
|
|
gad-65 autoantibody REF143008
|
Facility
|
OP
|
$274.00
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
2200168
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.03 |
| Max. Negotiated Rate |
$260.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$42.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$164.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$42.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$33.62
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$23.57
|
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cigna Commercial |
$232.90
|
| Rate for Payer: First Health Commercial |
$246.60
|
| Rate for Payer: First Health Workers Compensation |
$31.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$246.60
|
| Rate for Payer: GEHA Commercial |
$219.20
|
| Rate for Payer: GEHA Medicare |
$23.57
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$246.60
|
| Rate for Payer: Humana ChoiceCare |
$25.93
|
| Rate for Payer: Humana Medicare Advantage |
$23.57
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$39.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$34.30
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$23.57
|
| Rate for Payer: Multiplan All |
$249.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$40.07
|
| Rate for Payer: OMNI Networks Commercial |
$191.80
|
| Rate for Payer: One Health Plan PPO/POS |
$246.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$39.61
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$34.30
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$23.57
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$260.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$47.14
|
| Rate for Payer: Three Rivers Provider Network All |
$205.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$23.10
|
| Rate for Payer: United Healthcare Commercial |
$232.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$34.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.57
|
| Rate for Payer: United Payors & United Providers UP&UP |
$254.82
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$23.57
|
| Rate for Payer: Zelis Auto |
$109.60
|
| Rate for Payer: Zelis Medicare |
$20.03
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$28.28
|
| Rate for Payer: Zelis Worker's Compensation |
$22.04
|
|
|
GADAVIST 10ML SYRINGE
|
Facility
|
IP
|
$581.00
|
|
|
Service Code
|
CPT A9585
|
| Hospital Charge Code |
3301401
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.61 |
| Max. Negotiated Rate |
$551.95 |
| Rate for Payer: Cash Price |
$348.60
|
| Rate for Payer: Cigna Commercial |
$493.85
|
| Rate for Payer: First Health Commercial |
$522.90
|
| Rate for Payer: First Health Workers Compensation |
$224.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$522.90
|
| Rate for Payer: GEHA Commercial |
$406.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$522.90
|
| Rate for Payer: Multiplan All |
$528.71
|
| Rate for Payer: OMNI Networks Commercial |
$406.70
|
| Rate for Payer: One Health Plan PPO/POS |
$522.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$551.95
|
| Rate for Payer: Three Rivers Provider Network All |
$435.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$540.33
|
| Rate for Payer: Zelis Auto |
$232.40
|
| Rate for Payer: Zelis Worker's Compensation |
$158.61
|
|
|
GADAVIST 10ML SYRINGE
|
Facility
|
OP
|
$581.00
|
|
|
Service Code
|
CPT A9585
|
| Hospital Charge Code |
3301401
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$551.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$348.60
|
| Rate for Payer: Cash Price |
$348.60
|
| Rate for Payer: Cash Price |
$348.60
|
| Rate for Payer: Cigna Commercial |
$493.85
|
| Rate for Payer: First Health Commercial |
$522.90
|
| Rate for Payer: First Health Workers Compensation |
$224.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$522.90
|
| Rate for Payer: GEHA Commercial |
$0.31
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$522.90
|
| Rate for Payer: Humana ChoiceCare |
$151.06
|
| Rate for Payer: Multiplan All |
$528.71
|
| Rate for Payer: New Mexico Health Connections Medicare |
$348.60
|
| Rate for Payer: OMNI Networks Commercial |
$406.70
|
| Rate for Payer: One Health Plan PPO/POS |
$522.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$551.95
|
| Rate for Payer: Three Rivers Provider Network All |
$435.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$511.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$145.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$540.33
|
| Rate for Payer: Zelis Auto |
$232.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$290.50
|
| Rate for Payer: Zelis Worker's Compensation |
$158.61
|
|
