|
ALPRAZolam 0.5 MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 65862067701
|
| Hospital Charge Code |
3300032
|
|
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
|
|
|
ALPRAZolam 0.5 MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 65862067701
|
| Hospital Charge Code |
3300032
|
|
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
|
|
|
ALTEPLASE 100 MG **SEE PROTOCOL**
|
Facility
|
OP
|
$26,219.00
|
|
|
Service Code
|
CPT J2997
|
| Hospital Charge Code |
3300033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.28 |
| Max. Negotiated Rate |
$24,908.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$102.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$15,731.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$102.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$81.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$94.45
|
| Rate for Payer: Cash Price |
$15,731.40
|
| Rate for Payer: Cash Price |
$15,731.40
|
| Rate for Payer: Cigna Commercial |
$22,286.15
|
| Rate for Payer: First Health Commercial |
$23,597.10
|
| Rate for Payer: First Health Workers Compensation |
$10,123.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$23,597.10
|
| Rate for Payer: GEHA Commercial |
$103.89
|
| Rate for Payer: GEHA Medicare |
$94.45
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$23,597.10
|
| Rate for Payer: Humana ChoiceCare |
$103.89
|
| Rate for Payer: Humana Medicare Advantage |
$94.45
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$158.68
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$82.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$94.45
|
| Rate for Payer: Multiplan All |
$23,859.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$160.56
|
| Rate for Payer: OMNI Networks Commercial |
$18,353.30
|
| Rate for Payer: One Health Plan PPO/POS |
$23,597.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$95.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$82.98
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$94.45
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$24,908.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$188.90
|
| Rate for Payer: Three Rivers Provider Network All |
$19,664.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$92.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$82.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$94.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$24,383.67
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$94.45
|
| Rate for Payer: Zelis Auto |
$10,487.60
|
| Rate for Payer: Zelis Medicare |
$80.28
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$113.34
|
| Rate for Payer: Zelis Worker's Compensation |
$7,157.79
|
|
|
ALTEPLASE 100 MG **SEE PROTOCOL**
|
Facility
|
IP
|
$26,219.00
|
|
|
Service Code
|
CPT J2997
|
| Hospital Charge Code |
3300033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,157.79 |
| Max. Negotiated Rate |
$24,908.05 |
| Rate for Payer: Cash Price |
$15,731.40
|
| Rate for Payer: Cigna Commercial |
$22,286.15
|
| Rate for Payer: First Health Commercial |
$23,597.10
|
| Rate for Payer: First Health Workers Compensation |
$10,123.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$23,597.10
|
| Rate for Payer: GEHA Commercial |
$18,353.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$23,597.10
|
| Rate for Payer: Multiplan All |
$23,859.29
|
| Rate for Payer: OMNI Networks Commercial |
$18,353.30
|
| Rate for Payer: One Health Plan PPO/POS |
$23,597.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$24,908.05
|
| Rate for Payer: Three Rivers Provider Network All |
$19,664.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$24,383.67
|
| Rate for Payer: Zelis Auto |
$10,487.60
|
| Rate for Payer: Zelis Worker's Compensation |
$7,157.79
|
|
|
ALTEPLASE 6 MG/NS 50 ML IRRIGATION
|
Facility
|
IP
|
$890.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3303073
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$242.97 |
| Max. Negotiated Rate |
$845.50 |
| Rate for Payer: Cash Price |
$534.00
|
| Rate for Payer: Cigna Commercial |
$756.50
|
| Rate for Payer: First Health Commercial |
$801.00
|
| Rate for Payer: First Health Workers Compensation |
$343.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$801.00
|
| Rate for Payer: GEHA Commercial |
$623.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$801.00
|
| Rate for Payer: Multiplan All |
$809.90
|
| Rate for Payer: OMNI Networks Commercial |
$623.00
|
| Rate for Payer: One Health Plan PPO/POS |
$801.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$845.50
|
| Rate for Payer: Three Rivers Provider Network All |
$667.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$827.70
|
| Rate for Payer: Zelis Auto |
$356.00
|
| Rate for Payer: Zelis Worker's Compensation |
$242.97
|
|
|
ALTEPLASE 6 MG/NS 50 ML IRRIGATION
|
Facility
|
OP
|
$890.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3303073
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$222.50 |
| Max. Negotiated Rate |
$845.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$534.00
|
| Rate for Payer: Cash Price |
$534.00
|
| Rate for Payer: Cigna Commercial |
$756.50
|
| Rate for Payer: First Health Commercial |
$801.00
|
| Rate for Payer: First Health Workers Compensation |
$343.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$801.00
|
| Rate for Payer: GEHA Commercial |
$712.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$801.00
|
| Rate for Payer: Humana ChoiceCare |
$231.40
|
| Rate for Payer: Multiplan All |
$809.90
|
| Rate for Payer: New Mexico Health Connections Medicare |
$534.00
|
| Rate for Payer: OMNI Networks Commercial |
$623.00
|
| Rate for Payer: One Health Plan PPO/POS |
$801.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$845.50
|
| Rate for Payer: Three Rivers Provider Network All |
$667.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$783.20
|
| Rate for Payer: United Healthcare Commercial |
$756.50
|
| Rate for Payer: United Healthcare Managed Medicaid |
$222.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$827.70
|
| Rate for Payer: Zelis Auto |
$356.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$445.00
|
| Rate for Payer: Zelis Worker's Compensation |
$242.97
|
|
|
alternaria alternata REF602455
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299145
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.22
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: GEHA Medicare |
$5.22
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.22
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.76
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.59
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.22
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10.44
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.12
|
| Rate for Payer: United Healthcare Commercial |
$47.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.22
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Medicare |
$4.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.26
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
alternaria alternata REF602455
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299145
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
ALTRX +4 10D 28IDX44OD
|
Facility
|
IP
|
$3,550.00
|
|
|
Service Code
|
CPT C1760
|
| Hospital Charge Code |
7005218
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.00 |
| Max. Negotiated Rate |
$3,372.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,840.00
|
| Rate for Payer: Cash Price |
$2,130.00
|
| Rate for Payer: Cash Price |
$2,130.00
|
| Rate for Payer: Cigna Commercial |
$3,017.50
|
| Rate for Payer: First Health Commercial |
$3,195.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,195.00
|
| Rate for Payer: GEHA Commercial |
$2,485.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,195.00
|
| Rate for Payer: Multiplan All |
$3,230.50
|
| Rate for Payer: OMNI Networks Commercial |
$2,485.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,195.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,372.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,662.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,301.50
|
| Rate for Payer: Zelis Auto |
$1,420.00
|
|
|
ALTRX +4 10D 28IDX44OD
|
Facility
|
OP
|
$3,550.00
|
|
|
Service Code
|
CPT C1760
|
| Hospital Charge Code |
7005218
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$887.50 |
| Max. Negotiated Rate |
$3,372.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,130.00
|
| Rate for Payer: Cash Price |
$2,130.00
|
| Rate for Payer: Cash Price |
$2,130.00
|
| Rate for Payer: Cigna Commercial |
$3,017.50
|
| Rate for Payer: First Health Commercial |
$3,195.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,195.00
|
| Rate for Payer: GEHA Commercial |
$2,840.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,195.00
|
| Rate for Payer: Humana ChoiceCare |
$923.00
|
| Rate for Payer: Multiplan All |
$3,230.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,130.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,485.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,195.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,372.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,662.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,124.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$887.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,301.50
|
| Rate for Payer: Zelis Auto |
$1,420.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,775.00
|
|
|
ALUM MAG HYD SIMETH U.D.
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 00121176130
|
| Hospital Charge Code |
3300034
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$8.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Humana ChoiceCare |
$2.60
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.00
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
ALUM MAG HYD SIMETH U.D.
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 00121176130
|
| Hospital Charge Code |
3300034
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$7.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
ALYS BRN NPGT PRGRMG ADDL 15
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT 95984
|
| Hospital Charge Code |
21999312
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$37.40 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$116.45
|
| Rate for Payer: First Health Commercial |
$123.30
|
| Rate for Payer: First Health Workers Compensation |
$52.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$123.30
|
| Rate for Payer: GEHA Commercial |
$95.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$123.30
|
| Rate for Payer: Multiplan All |
$124.67
|
| Rate for Payer: OMNI Networks Commercial |
$95.90
|
| Rate for Payer: One Health Plan PPO/POS |
$123.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$130.15
|
| Rate for Payer: Three Rivers Provider Network All |
$102.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$127.41
|
| Rate for Payer: Zelis Auto |
$54.80
|
| Rate for Payer: Zelis Worker's Compensation |
$37.40
|
|
|
ALYS BRN NPGT PRGRMG ADDL 15
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT 95984
|
| Hospital Charge Code |
21799448
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$37.40 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$116.45
|
| Rate for Payer: First Health Commercial |
$123.30
|
| Rate for Payer: First Health Workers Compensation |
$52.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$123.30
|
| Rate for Payer: GEHA Commercial |
$95.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$123.30
|
| Rate for Payer: Multiplan All |
$124.67
|
| Rate for Payer: OMNI Networks Commercial |
$95.90
|
| Rate for Payer: One Health Plan PPO/POS |
$123.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$130.15
|
| Rate for Payer: Three Rivers Provider Network All |
$102.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$127.41
|
| Rate for Payer: Zelis Auto |
$54.80
|
| Rate for Payer: Zelis Worker's Compensation |
$37.40
|
|
|
ALYS BRN NPGT PRGRMG ADDL 15
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT 95984
|
| Hospital Charge Code |
21799448
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$34.25 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$82.20
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$116.45
|
| Rate for Payer: First Health Commercial |
$123.30
|
| Rate for Payer: First Health Workers Compensation |
$52.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$123.30
|
| Rate for Payer: GEHA Commercial |
$109.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$123.30
|
| Rate for Payer: Humana ChoiceCare |
$35.62
|
| Rate for Payer: Multiplan All |
$124.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$82.20
|
| Rate for Payer: OMNI Networks Commercial |
$95.90
|
| Rate for Payer: One Health Plan PPO/POS |
$123.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$130.15
|
| Rate for Payer: Three Rivers Provider Network All |
$102.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$120.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$34.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$127.41
|
| Rate for Payer: Zelis Auto |
$54.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$68.50
|
| Rate for Payer: Zelis Worker's Compensation |
$37.40
|
|
|
ALYS BRN NPGT PRGRMG ADDL 15
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT 95984
|
| Hospital Charge Code |
21999312
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$34.25 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$82.20
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$116.45
|
| Rate for Payer: First Health Commercial |
$123.30
|
| Rate for Payer: First Health Workers Compensation |
$52.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$123.30
|
| Rate for Payer: GEHA Commercial |
$109.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$123.30
|
| Rate for Payer: Humana ChoiceCare |
$35.62
|
| Rate for Payer: Multiplan All |
$124.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$82.20
|
| Rate for Payer: OMNI Networks Commercial |
$95.90
|
| Rate for Payer: One Health Plan PPO/POS |
$123.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$130.15
|
| Rate for Payer: Three Rivers Provider Network All |
$102.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$120.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$34.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$127.41
|
| Rate for Payer: Zelis Auto |
$54.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$68.50
|
| Rate for Payer: Zelis Worker's Compensation |
$37.40
|
|
|
ALYS BRN NPGT PRGRMG ADDL 15
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT 95984
|
| Hospital Charge Code |
21900182
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$37.40 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$116.45
|
| Rate for Payer: First Health Commercial |
$123.30
|
| Rate for Payer: First Health Workers Compensation |
$52.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$123.30
|
| Rate for Payer: GEHA Commercial |
$95.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$123.30
|
| Rate for Payer: Multiplan All |
$124.67
|
| Rate for Payer: OMNI Networks Commercial |
$95.90
|
| Rate for Payer: One Health Plan PPO/POS |
$123.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$130.15
|
| Rate for Payer: Three Rivers Provider Network All |
$102.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$127.41
|
| Rate for Payer: Zelis Auto |
$54.80
|
| Rate for Payer: Zelis Worker's Compensation |
$37.40
|
|
|
ALYS BRN NPGT PRGRMG ADDL 15
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT 95984
|
| Hospital Charge Code |
21900182
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$34.25 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$82.20
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$116.45
|
| Rate for Payer: First Health Commercial |
$123.30
|
| Rate for Payer: First Health Workers Compensation |
$52.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$123.30
|
| Rate for Payer: GEHA Commercial |
$109.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$123.30
|
| Rate for Payer: Humana ChoiceCare |
$35.62
|
| Rate for Payer: Multiplan All |
$124.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$82.20
|
| Rate for Payer: OMNI Networks Commercial |
$95.90
|
| Rate for Payer: One Health Plan PPO/POS |
$123.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$130.15
|
| Rate for Payer: Three Rivers Provider Network All |
$102.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$120.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$34.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$127.41
|
| Rate for Payer: Zelis Auto |
$54.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$68.50
|
| Rate for Payer: Zelis Worker's Compensation |
$37.40
|
|
|
AMANTADINE HCL 100 MG CAP
|
Facility
|
IP
|
$8.35
|
|
|
Service Code
|
NDC 00904704206
|
| Hospital Charge Code |
3303193
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$7.93 |
| Rate for Payer: Cash Price |
$5.01
|
| Rate for Payer: Cigna Commercial |
$7.10
|
| Rate for Payer: First Health Commercial |
$7.51
|
| Rate for Payer: First Health Workers Compensation |
$3.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.51
|
| Rate for Payer: GEHA Commercial |
$5.84
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.51
|
| Rate for Payer: Multiplan All |
$7.60
|
| Rate for Payer: OMNI Networks Commercial |
$5.84
|
| Rate for Payer: One Health Plan PPO/POS |
$7.51
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.93
|
| Rate for Payer: Three Rivers Provider Network All |
$6.26
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.77
|
| Rate for Payer: Zelis Auto |
$3.34
|
| Rate for Payer: Zelis Worker's Compensation |
$2.28
|
|
|
AMANTADINE HCL 100 MG CAP
|
Facility
|
OP
|
$8.35
|
|
|
Service Code
|
NDC 00904704206
|
| Hospital Charge Code |
3303193
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$7.93 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5.01
|
| Rate for Payer: Cash Price |
$5.01
|
| Rate for Payer: Cigna Commercial |
$7.10
|
| Rate for Payer: First Health Commercial |
$7.51
|
| Rate for Payer: First Health Workers Compensation |
$3.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.51
|
| Rate for Payer: GEHA Commercial |
$6.68
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.51
|
| Rate for Payer: Humana ChoiceCare |
$2.17
|
| Rate for Payer: Multiplan All |
$7.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5.01
|
| Rate for Payer: OMNI Networks Commercial |
$5.84
|
| Rate for Payer: One Health Plan PPO/POS |
$7.51
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.93
|
| Rate for Payer: Three Rivers Provider Network All |
$6.26
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.09
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.77
|
| Rate for Payer: Zelis Auto |
$3.34
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.17
|
| Rate for Payer: Zelis Worker's Compensation |
$2.28
|
|
|
AMANTADINE HCL TAB 100MG
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 00832011100
|
| Hospital Charge Code |
3300035
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.75 |
| Max. Negotiated Rate |
$18.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$11.40
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: First Health Commercial |
$17.10
|
| Rate for Payer: First Health Workers Compensation |
$7.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$17.10
|
| Rate for Payer: GEHA Commercial |
$15.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17.10
|
| Rate for Payer: Humana ChoiceCare |
$4.94
|
| Rate for Payer: Multiplan All |
$17.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.40
|
| Rate for Payer: OMNI Networks Commercial |
$13.30
|
| Rate for Payer: One Health Plan PPO/POS |
$17.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18.05
|
| Rate for Payer: Three Rivers Provider Network All |
$14.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17.67
|
| Rate for Payer: Zelis Auto |
$7.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$9.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.19
|
|
|
AMANTADINE HCL TAB 100MG
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 00832011100
|
| Hospital Charge Code |
3300035
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.19 |
| Max. Negotiated Rate |
$18.05 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: First Health Commercial |
$17.10
|
| Rate for Payer: First Health Workers Compensation |
$7.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$17.10
|
| Rate for Payer: GEHA Commercial |
$13.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17.10
|
| Rate for Payer: Multiplan All |
$17.29
|
| Rate for Payer: OMNI Networks Commercial |
$13.30
|
| Rate for Payer: One Health Plan PPO/POS |
$17.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18.05
|
| Rate for Payer: Three Rivers Provider Network All |
$14.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17.67
|
| Rate for Payer: Zelis Auto |
$7.60
|
| Rate for Payer: Zelis Worker's Compensation |
$5.19
|
|
|
AMBULATORY BP ANALYSIS
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
CPT 93788
|
| Hospital Charge Code |
9000017
|
|
Hospital Revenue Code
|
519
|
| 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
|
|
|
AMBULATORY BP ANALYSIS
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
CPT 93788
|
| Hospital Charge Code |
9000017
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$244.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$117.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$117.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$93.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$122.40
|
| Rate for Payer: Cash Price |
$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: GEHA Medicare |
$122.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$13.50
|
| Rate for Payer: Humana ChoiceCare |
$134.64
|
| Rate for Payer: Humana Medicare Advantage |
$122.40
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$205.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$95.11
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$122.40
|
| Rate for Payer: Multiplan All |
$13.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$208.08
|
| Rate for Payer: OMNI Networks Commercial |
$10.50
|
| Rate for Payer: One Health Plan PPO/POS |
$13.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$109.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$95.11
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$122.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$14.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$244.80
|
| Rate for Payer: Three Rivers Provider Network All |
$11.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$119.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$95.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.40
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.95
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$122.40
|
| Rate for Payer: Zelis Auto |
$6.00
|
| Rate for Payer: Zelis Medicare |
$104.04
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$146.88
|
| Rate for Payer: Zelis Worker's Compensation |
$4.09
|
|
|
AMBULATORY BP MONITORING
|
Facility
|
IP
|
$148.00
|
|
|
Service Code
|
CPT 93784
|
| Hospital Charge Code |
9000015
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$40.40 |
| Max. Negotiated Rate |
$140.60 |
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$125.80
|
| Rate for Payer: First Health Commercial |
$133.20
|
| Rate for Payer: First Health Workers Compensation |
$57.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$133.20
|
| Rate for Payer: GEHA Commercial |
$103.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$133.20
|
| Rate for Payer: Multiplan All |
$134.68
|
| Rate for Payer: OMNI Networks Commercial |
$103.60
|
| Rate for Payer: One Health Plan PPO/POS |
$133.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$140.60
|
| Rate for Payer: Three Rivers Provider Network All |
$111.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$137.64
|
| Rate for Payer: Zelis Auto |
$59.20
|
| Rate for Payer: Zelis Worker's Compensation |
$40.40
|
|
