|
KETAMINE 100MG/ML - 5ML VIAL
|
Facility
|
OP
|
$79.00
|
|
|
Service Code
|
NDC 67457010810
|
| Hospital Charge Code |
3301738
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.75 |
| Max. Negotiated Rate |
$75.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$67.15
|
| Rate for Payer: First Health Commercial |
$71.10
|
| Rate for Payer: First Health Workers Compensation |
$30.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$71.10
|
| Rate for Payer: GEHA Commercial |
$63.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$71.10
|
| Rate for Payer: Humana ChoiceCare |
$20.54
|
| Rate for Payer: Multiplan All |
$71.89
|
| Rate for Payer: New Mexico Health Connections Medicare |
$47.40
|
| Rate for Payer: OMNI Networks Commercial |
$55.30
|
| Rate for Payer: One Health Plan PPO/POS |
$71.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$75.05
|
| Rate for Payer: Three Rivers Provider Network All |
$59.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$69.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$19.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$73.47
|
| Rate for Payer: Zelis Auto |
$31.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$39.50
|
| Rate for Payer: Zelis Worker's Compensation |
$21.57
|
|
|
KETAMINE 10MG/ML - 5ML SYRINGE
|
Facility
|
IP
|
$56.00
|
|
| Hospital Charge Code |
3302059
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$53.20 |
| 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 |
$21.62
|
| 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 |
$15.29
|
|
|
KETAMINE 10MG/ML - 5ML SYRINGE
|
Facility
|
OP
|
$56.00
|
|
| Hospital Charge Code |
3302059
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$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 |
$21.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$14.56
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$33.60
|
| 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: TriWest Veterans Administration/VAPC3 |
$49.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$28.00
|
| Rate for Payer: Zelis Worker's Compensation |
$15.29
|
|
|
KETAMINE 200 MG/20 ML INJ MDV
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3303154
|
|
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
|
|
|
KETAMINE 200 MG/20 ML INJ MDV
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3303154
|
|
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
|
|
|
KETAMINE 50 MG/5 ML SYRINGE
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3301755
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$53.20 |
| 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 |
$21.62
|
| 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 |
$15.29
|
|
|
KETAMINE 50 MG/5 ML SYRINGE
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3301755
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$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 |
$21.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$14.56
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$33.60
|
| 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: TriWest Veterans Administration/VAPC3 |
$49.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$28.00
|
| Rate for Payer: Zelis Worker's Compensation |
$15.29
|
|
|
KETAMINE HCL 500MG/10mL
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.37 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$32.30
|
| Rate for Payer: First Health Commercial |
$34.20
|
| Rate for Payer: First Health Workers Compensation |
$14.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$34.20
|
| Rate for Payer: GEHA Commercial |
$26.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$34.20
|
| Rate for Payer: Multiplan All |
$34.58
|
| Rate for Payer: OMNI Networks Commercial |
$26.60
|
| Rate for Payer: One Health Plan PPO/POS |
$34.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$36.10
|
| Rate for Payer: Three Rivers Provider Network All |
$28.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$35.34
|
| Rate for Payer: Zelis Auto |
$15.20
|
| Rate for Payer: Zelis Worker's Compensation |
$10.37
|
|
|
KETAMINE HCL 500MG/10mL
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$32.30
|
| Rate for Payer: First Health Commercial |
$34.20
|
| Rate for Payer: First Health Workers Compensation |
$14.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$34.20
|
| Rate for Payer: GEHA Commercial |
$30.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$34.20
|
| Rate for Payer: Humana ChoiceCare |
$9.88
|
| Rate for Payer: Multiplan All |
$34.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.80
|
| Rate for Payer: OMNI Networks Commercial |
$26.60
|
| Rate for Payer: One Health Plan PPO/POS |
$34.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$36.10
|
| Rate for Payer: Three Rivers Provider Network All |
$28.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$33.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$35.34
|
| Rate for Payer: Zelis Auto |
$15.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$19.00
|
| Rate for Payer: Zelis Worker's Compensation |
$10.37
|
|
|
KETOCONAZOLE CREAM 2%
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
NDC 00168009915
|
| Hospital Charge Code |
3300480
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.39 |
| Max. Negotiated Rate |
$98.80 |
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cigna Commercial |
$88.40
|
| Rate for Payer: First Health Commercial |
$93.60
|
| Rate for Payer: First Health Workers Compensation |
$40.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$93.60
|
| Rate for Payer: GEHA Commercial |
$72.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$93.60
|
| Rate for Payer: Multiplan All |
$94.64
|
| Rate for Payer: OMNI Networks Commercial |
$72.80
|
| Rate for Payer: One Health Plan PPO/POS |
$93.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$98.80
|
| Rate for Payer: Three Rivers Provider Network All |
$78.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$96.72
|
| Rate for Payer: Zelis Auto |
$41.60
|
| Rate for Payer: Zelis Worker's Compensation |
$28.39
|
|
|
KETOCONAZOLE CREAM 2%
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
NDC 00168009915
|
| Hospital Charge Code |
3300480
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$98.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$62.40
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cigna Commercial |
$88.40
|
| Rate for Payer: First Health Commercial |
$93.60
|
| Rate for Payer: First Health Workers Compensation |
$40.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$93.60
|
| Rate for Payer: GEHA Commercial |
$83.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$93.60
|
| Rate for Payer: Humana ChoiceCare |
$27.04
|
| Rate for Payer: Multiplan All |
$94.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$62.40
|
| Rate for Payer: OMNI Networks Commercial |
$72.80
|
| Rate for Payer: One Health Plan PPO/POS |
$93.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$98.80
|
| Rate for Payer: Three Rivers Provider Network All |
$78.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$91.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$96.72
|
| Rate for Payer: Zelis Auto |
$41.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$52.00
|
| Rate for Payer: Zelis Worker's Compensation |
$28.39
|
|
|
ketoconazole, level
|
Facility
|
OP
|
$251.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
2200006
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.84 |
| Max. Negotiated Rate |
$238.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$33.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$150.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$33.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$26.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$18.64
|
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cigna Commercial |
$213.35
|
| Rate for Payer: First Health Commercial |
$225.90
|
| Rate for Payer: First Health Workers Compensation |
$31.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$225.90
|
| Rate for Payer: GEHA Commercial |
$200.80
|
| Rate for Payer: GEHA Medicare |
$18.64
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$225.90
|
| Rate for Payer: Humana ChoiceCare |
$20.50
|
| Rate for Payer: Humana Medicare Advantage |
$18.64
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$31.32
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$27.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$18.64
|
| Rate for Payer: Multiplan All |
$228.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.69
|
| Rate for Payer: OMNI Networks Commercial |
$175.70
|
| Rate for Payer: One Health Plan PPO/POS |
$225.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$31.32
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$27.12
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$18.64
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$238.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$37.28
|
| Rate for Payer: Three Rivers Provider Network All |
$188.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.27
|
| Rate for Payer: United Healthcare Commercial |
$213.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$27.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: United Payors & United Providers UP&UP |
$233.43
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$18.64
|
| Rate for Payer: Zelis Auto |
$100.40
|
| Rate for Payer: Zelis Medicare |
$15.84
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.37
|
| Rate for Payer: Zelis Worker's Compensation |
$22.12
|
|
|
ketoconazole, level
|
Facility
|
IP
|
$251.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
2200006
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$22.12 |
| Max. Negotiated Rate |
$238.45 |
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cigna Commercial |
$213.35
|
| Rate for Payer: First Health Commercial |
$225.90
|
| Rate for Payer: First Health Workers Compensation |
$31.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$225.90
|
| Rate for Payer: GEHA Commercial |
$175.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$225.90
|
| Rate for Payer: Multiplan All |
$228.41
|
| Rate for Payer: OMNI Networks Commercial |
$175.70
|
| Rate for Payer: One Health Plan PPO/POS |
$225.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$238.45
|
| Rate for Payer: Three Rivers Provider Network All |
$188.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$233.43
|
| Rate for Payer: Zelis Auto |
$100.40
|
| Rate for Payer: Zelis Worker's Compensation |
$22.12
|
|
|
KETOCONAZOLE SHAMPOO 2%
|
Facility
|
IP
|
$149.00
|
|
|
Service Code
|
NDC 45802046564
|
| Hospital Charge Code |
3300481
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.68 |
| Max. Negotiated Rate |
$141.55 |
| Rate for Payer: Cash Price |
$89.40
|
| Rate for Payer: Cigna Commercial |
$126.65
|
| Rate for Payer: First Health Commercial |
$134.10
|
| Rate for Payer: First Health Workers Compensation |
$57.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$134.10
|
| Rate for Payer: GEHA Commercial |
$104.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$134.10
|
| Rate for Payer: Multiplan All |
$135.59
|
| Rate for Payer: OMNI Networks Commercial |
$104.30
|
| Rate for Payer: One Health Plan PPO/POS |
$134.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$141.55
|
| Rate for Payer: Three Rivers Provider Network All |
$111.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$138.57
|
| Rate for Payer: Zelis Auto |
$59.60
|
| Rate for Payer: Zelis Worker's Compensation |
$40.68
|
|
|
KETOCONAZOLE SHAMPOO 2%
|
Facility
|
OP
|
$149.00
|
|
|
Service Code
|
NDC 45802046564
|
| Hospital Charge Code |
3300481
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.25 |
| Max. Negotiated Rate |
$141.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$89.40
|
| Rate for Payer: Cash Price |
$89.40
|
| Rate for Payer: Cigna Commercial |
$126.65
|
| Rate for Payer: First Health Commercial |
$134.10
|
| Rate for Payer: First Health Workers Compensation |
$57.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$134.10
|
| Rate for Payer: GEHA Commercial |
$119.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$134.10
|
| Rate for Payer: Humana ChoiceCare |
$38.74
|
| Rate for Payer: Multiplan All |
$135.59
|
| Rate for Payer: New Mexico Health Connections Medicare |
$89.40
|
| Rate for Payer: OMNI Networks Commercial |
$104.30
|
| Rate for Payer: One Health Plan PPO/POS |
$134.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$141.55
|
| Rate for Payer: Three Rivers Provider Network All |
$111.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$131.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$37.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$138.57
|
| Rate for Payer: Zelis Auto |
$59.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$74.50
|
| Rate for Payer: Zelis Worker's Compensation |
$40.68
|
|
|
KETOROLAC 30MG/ML INJECTION
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
3300483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
KETOROLAC 30MG/ML INJECTION
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
3300483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$0.29
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$0.33
|
| Rate for Payer: GEHA Medicare |
$0.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Humana ChoiceCare |
$0.32
|
| Rate for Payer: Humana Medicare Advantage |
$0.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$0.49
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$0.29
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.49
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$0.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$0.58
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$0.29
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Medicare |
$0.25
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.35
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
KETOROLAC 60MG/2ML IM X1 ONLY
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
3300482
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$0.29
|
| Rate for Payer: Cash Price |
$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 |
$0.33
|
| Rate for Payer: GEHA Medicare |
$0.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Humana ChoiceCare |
$0.32
|
| Rate for Payer: Humana Medicare Advantage |
$0.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$0.49
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$0.29
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.49
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$0.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$0.58
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$0.29
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Medicare |
$0.25
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.35
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
KETOROLAC 60MG/2ML IM X1 ONLY
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
3300482
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
KETOROLAC TROMETHAMINE 0.5% OPTH. SOL.
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
NDC 60505100301
|
| Hospital Charge Code |
3302827
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.50 |
| Max. Negotiated Rate |
$55.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$34.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$49.30
|
| Rate for Payer: First Health Commercial |
$52.20
|
| Rate for Payer: First Health Workers Compensation |
$22.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$52.20
|
| Rate for Payer: GEHA Commercial |
$46.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$52.20
|
| Rate for Payer: Humana ChoiceCare |
$15.08
|
| Rate for Payer: Multiplan All |
$52.78
|
| Rate for Payer: New Mexico Health Connections Medicare |
$34.80
|
| Rate for Payer: OMNI Networks Commercial |
$40.60
|
| Rate for Payer: One Health Plan PPO/POS |
$52.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$55.10
|
| Rate for Payer: Three Rivers Provider Network All |
$43.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$51.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.94
|
| Rate for Payer: Zelis Auto |
$23.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$29.00
|
| Rate for Payer: Zelis Worker's Compensation |
$15.83
|
|
|
KETOROLAC TROMETHAMINE 0.5% OPTH. SOL.
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
NDC 60505100301
|
| Hospital Charge Code |
3302827
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.83 |
| Max. Negotiated Rate |
$55.10 |
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$49.30
|
| Rate for Payer: First Health Commercial |
$52.20
|
| Rate for Payer: First Health Workers Compensation |
$22.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$52.20
|
| Rate for Payer: GEHA Commercial |
$40.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$52.20
|
| Rate for Payer: Multiplan All |
$52.78
|
| Rate for Payer: OMNI Networks Commercial |
$40.60
|
| Rate for Payer: One Health Plan PPO/POS |
$52.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$55.10
|
| Rate for Payer: Three Rivers Provider Network All |
$43.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.94
|
| Rate for Payer: Zelis Auto |
$23.20
|
| Rate for Payer: Zelis Worker's Compensation |
$15.83
|
|
|
KETOROLAC TROMETHAMINE 10MG TAB
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 00093031401
|
| Hospital Charge Code |
3300484
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$6.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Humana ChoiceCare |
$2.08
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.80
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
KETOROLAC TROMETHAMINE 10MG TAB
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 00093031401
|
| Hospital Charge Code |
3300484
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
KIDNEY ENDOSCOPY
|
Facility
|
IP
|
$1,022.00
|
|
|
Service Code
|
CPT 50570
|
| Hospital Charge Code |
6150570
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$279.01 |
| Max. Negotiated Rate |
$970.90 |
| Rate for Payer: Cash Price |
$613.20
|
| Rate for Payer: Cigna Commercial |
$868.70
|
| Rate for Payer: First Health Commercial |
$919.80
|
| Rate for Payer: First Health Workers Compensation |
$394.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$919.80
|
| Rate for Payer: GEHA Commercial |
$715.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$919.80
|
| Rate for Payer: Multiplan All |
$930.02
|
| Rate for Payer: OMNI Networks Commercial |
$715.40
|
| Rate for Payer: One Health Plan PPO/POS |
$919.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$970.90
|
| Rate for Payer: Three Rivers Provider Network All |
$766.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$950.46
|
| Rate for Payer: Zelis Auto |
$408.80
|
| Rate for Payer: Zelis Worker's Compensation |
$279.01
|
|
|
KIDNEY ENDOSCOPY
|
Facility
|
OP
|
$764.00
|
|
|
Service Code
|
CPT 50551
|
| Hospital Charge Code |
6150551
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$208.57 |
| Max. Negotiated Rate |
$9,654.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$721.34
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$458.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$721.34
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$571.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$4,827.10
|
| Rate for Payer: Cash Price |
$458.40
|
| Rate for Payer: Cash Price |
$458.40
|
| Rate for Payer: Cigna Commercial |
$649.40
|
| Rate for Payer: First Health Commercial |
$687.60
|
| Rate for Payer: First Health Workers Compensation |
$294.98
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$687.60
|
| Rate for Payer: GEHA Commercial |
$611.20
|
| Rate for Payer: GEHA Medicare |
$4,827.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$687.60
|
| Rate for Payer: Humana ChoiceCare |
$5,309.81
|
| Rate for Payer: Humana Medicare Advantage |
$4,827.10
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8,109.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$583.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$4,827.10
|
| Rate for Payer: Multiplan All |
$695.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8,206.07
|
| Rate for Payer: OMNI Networks Commercial |
$534.80
|
| Rate for Payer: One Health Plan PPO/POS |
$687.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$673.25
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$583.08
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$4,827.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$725.80
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$9,654.20
|
| Rate for Payer: Three Rivers Provider Network All |
$573.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,730.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$583.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,827.10
|
| Rate for Payer: United Payors & United Providers UP&UP |
$710.52
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$4,827.10
|
| Rate for Payer: Zelis Auto |
$305.60
|
| Rate for Payer: Zelis Medicare |
$4,103.03
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,792.52
|
| Rate for Payer: Zelis Worker's Compensation |
$208.57
|
|
