|
LAC REP MOUTH OVER 2.5CM OR COMPLEX
|
Facility
|
IP
|
$2,679.00
|
|
| Hospital Charge Code |
8140831
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$731.37 |
| Max. Negotiated Rate |
$2,545.05 |
| Rate for Payer: Cash Price |
$1,607.40
|
| Rate for Payer: Cigna Commercial |
$2,277.15
|
| Rate for Payer: First Health Commercial |
$2,411.10
|
| Rate for Payer: First Health Workers Compensation |
$1,034.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,411.10
|
| Rate for Payer: GEHA Commercial |
$1,875.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,411.10
|
| Rate for Payer: Multiplan All |
$2,437.89
|
| Rate for Payer: OMNI Networks Commercial |
$1,875.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,411.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,545.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,009.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,491.47
|
| Rate for Payer: Zelis Auto |
$1,071.60
|
| Rate for Payer: Zelis Worker's Compensation |
$731.37
|
|
|
LAC REP MOUTH UP TO 2.5CM
|
Facility
|
IP
|
$1,462.00
|
|
| Hospital Charge Code |
8140830
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$399.13 |
| Max. Negotiated Rate |
$1,388.90 |
| Rate for Payer: Cash Price |
$877.20
|
| Rate for Payer: Cigna Commercial |
$1,242.70
|
| Rate for Payer: First Health Commercial |
$1,315.80
|
| Rate for Payer: First Health Workers Compensation |
$564.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,315.80
|
| Rate for Payer: GEHA Commercial |
$1,023.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,315.80
|
| Rate for Payer: Multiplan All |
$1,330.42
|
| Rate for Payer: OMNI Networks Commercial |
$1,023.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,315.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,388.90
|
| Rate for Payer: Three Rivers Provider Network All |
$1,096.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,359.66
|
| Rate for Payer: Zelis Auto |
$584.80
|
| Rate for Payer: Zelis Worker's Compensation |
$399.13
|
|
|
LAC REP MOUTH UP TO 2.5CM
|
Facility
|
OP
|
$1,462.00
|
|
| Hospital Charge Code |
8140830
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$365.50 |
| Max. Negotiated Rate |
$1,388.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$877.20
|
| Rate for Payer: Cash Price |
$877.20
|
| Rate for Payer: Cigna Commercial |
$1,242.70
|
| Rate for Payer: First Health Commercial |
$1,315.80
|
| Rate for Payer: First Health Workers Compensation |
$564.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,315.80
|
| Rate for Payer: GEHA Commercial |
$1,169.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,315.80
|
| Rate for Payer: Humana ChoiceCare |
$380.12
|
| Rate for Payer: Multiplan All |
$1,330.42
|
| Rate for Payer: New Mexico Health Connections Medicare |
$877.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,023.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,315.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,388.90
|
| Rate for Payer: Three Rivers Provider Network All |
$1,096.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,286.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$365.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,359.66
|
| Rate for Payer: Zelis Auto |
$584.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$731.00
|
| Rate for Payer: Zelis Worker's Compensation |
$399.13
|
|
|
LAC REP NK/HND/FT GENIT>30CM
|
Facility
|
IP
|
$1,673.00
|
|
| Hospital Charge Code |
8112047
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$456.73 |
| Max. Negotiated Rate |
$1,589.35 |
| Rate for Payer: Cash Price |
$1,003.80
|
| Rate for Payer: Cigna Commercial |
$1,422.05
|
| Rate for Payer: First Health Commercial |
$1,505.70
|
| Rate for Payer: First Health Workers Compensation |
$645.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,505.70
|
| Rate for Payer: GEHA Commercial |
$1,171.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,505.70
|
| Rate for Payer: Multiplan All |
$1,522.43
|
| Rate for Payer: OMNI Networks Commercial |
$1,171.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,505.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,589.35
|
| Rate for Payer: Three Rivers Provider Network All |
$1,254.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,555.89
|
| Rate for Payer: Zelis Auto |
$669.20
|
| Rate for Payer: Zelis Worker's Compensation |
$456.73
|
|
|
LAC REP NK/HND/FT GENIT>30CM
|
Facility
|
OP
|
$1,673.00
|
|
| Hospital Charge Code |
8112047
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$418.25 |
| Max. Negotiated Rate |
$1,589.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,003.80
|
| Rate for Payer: Cash Price |
$1,003.80
|
| Rate for Payer: Cigna Commercial |
$1,422.05
|
| Rate for Payer: First Health Commercial |
$1,505.70
|
| Rate for Payer: First Health Workers Compensation |
$645.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,505.70
|
| Rate for Payer: GEHA Commercial |
$1,338.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,505.70
|
| Rate for Payer: Humana ChoiceCare |
$434.98
|
| Rate for Payer: Multiplan All |
$1,522.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,003.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,171.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,505.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,589.35
|
| Rate for Payer: Three Rivers Provider Network All |
$1,254.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,472.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$418.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,555.89
|
| Rate for Payer: Zelis Auto |
$669.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$836.50
|
| Rate for Payer: Zelis Worker's Compensation |
$456.73
|
|
|
LACTATED RINGERS 1000ML
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
CPT J7120
|
| Hospital Charge Code |
3300488
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$14.45
|
| Rate for Payer: First Health Commercial |
$15.30
|
| Rate for Payer: First Health Workers Compensation |
$6.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15.30
|
| Rate for Payer: GEHA Commercial |
$11.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15.30
|
| Rate for Payer: Multiplan All |
$15.47
|
| Rate for Payer: OMNI Networks Commercial |
$11.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16.15
|
| Rate for Payer: Three Rivers Provider Network All |
$12.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15.81
|
| Rate for Payer: Zelis Auto |
$6.80
|
| Rate for Payer: Zelis Worker's Compensation |
$4.64
|
|
|
LACTATED RINGERS 1000ML
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
CPT J7120
|
| Hospital Charge Code |
3300488
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$14.45
|
| Rate for Payer: First Health Commercial |
$15.30
|
| Rate for Payer: First Health Workers Compensation |
$6.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15.30
|
| Rate for Payer: GEHA Commercial |
$2.65
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15.30
|
| Rate for Payer: Humana ChoiceCare |
$4.42
|
| Rate for Payer: Multiplan All |
$15.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10.20
|
| Rate for Payer: OMNI Networks Commercial |
$11.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16.15
|
| Rate for Payer: Three Rivers Provider Network All |
$12.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15.81
|
| Rate for Payer: Zelis Auto |
$6.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.50
|
| Rate for Payer: Zelis Worker's Compensation |
$4.64
|
|
|
LACTIC ACID ARTERIAL
|
Facility
|
IP
|
$217.33
|
|
|
Service Code
|
CPT 83605
|
| Hospital Charge Code |
4099475
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.73 |
| Max. Negotiated Rate |
$206.46 |
| Rate for Payer: Cash Price |
$130.40
|
| Rate for Payer: Cash Price |
$130.40
|
| Rate for Payer: Cigna Commercial |
$184.73
|
| Rate for Payer: First Health Commercial |
$195.60
|
| Rate for Payer: First Health Workers Compensation |
$19.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$195.60
|
| Rate for Payer: GEHA Commercial |
$152.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$195.60
|
| Rate for Payer: Multiplan All |
$197.77
|
| Rate for Payer: OMNI Networks Commercial |
$152.13
|
| Rate for Payer: One Health Plan PPO/POS |
$195.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$206.46
|
| Rate for Payer: Three Rivers Provider Network All |
$163.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.12
|
| Rate for Payer: Zelis Auto |
$86.93
|
| Rate for Payer: Zelis Worker's Compensation |
$13.73
|
|
|
LACTIC ACID ARTERIAL
|
Facility
|
OP
|
$217.33
|
|
|
Service Code
|
CPT 83605
|
| Hospital Charge Code |
4099475
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.83 |
| Max. Negotiated Rate |
$206.46 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$20.82
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$20.82
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$11.57
|
| Rate for Payer: Cash Price |
$130.40
|
| Rate for Payer: Cash Price |
$130.40
|
| Rate for Payer: Cigna Commercial |
$184.73
|
| Rate for Payer: First Health Commercial |
$195.60
|
| Rate for Payer: First Health Workers Compensation |
$19.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$195.60
|
| Rate for Payer: GEHA Commercial |
$173.86
|
| Rate for Payer: GEHA Medicare |
$11.57
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$195.60
|
| Rate for Payer: Humana ChoiceCare |
$12.73
|
| Rate for Payer: Humana Medicare Advantage |
$11.57
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$19.44
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$16.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$11.57
|
| Rate for Payer: Multiplan All |
$197.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$19.67
|
| Rate for Payer: OMNI Networks Commercial |
$152.13
|
| Rate for Payer: One Health Plan PPO/POS |
$195.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$19.43
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$16.83
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$11.57
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$206.46
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$23.14
|
| Rate for Payer: Three Rivers Provider Network All |
$163.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11.34
|
| Rate for Payer: United Healthcare Commercial |
$184.73
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.57
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.12
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$11.57
|
| Rate for Payer: Zelis Auto |
$86.93
|
| Rate for Payer: Zelis Medicare |
$9.83
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$13.88
|
| Rate for Payer: Zelis Worker's Compensation |
$13.73
|
|
|
LACTIC ACID VENOUS (Vitros)
|
Facility
|
IP
|
$201.00
|
|
|
Service Code
|
CPT 83605
|
| Hospital Charge Code |
2232269
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.73 |
| Max. Negotiated Rate |
$190.95 |
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cigna Commercial |
$170.85
|
| Rate for Payer: First Health Commercial |
$180.90
|
| Rate for Payer: First Health Workers Compensation |
$19.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$180.90
|
| Rate for Payer: GEHA Commercial |
$140.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$180.90
|
| Rate for Payer: Multiplan All |
$182.91
|
| Rate for Payer: OMNI Networks Commercial |
$140.70
|
| Rate for Payer: One Health Plan PPO/POS |
$180.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$190.95
|
| Rate for Payer: Three Rivers Provider Network All |
$150.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$186.93
|
| Rate for Payer: Zelis Auto |
$80.40
|
| Rate for Payer: Zelis Worker's Compensation |
$13.73
|
|
|
LACTIC ACID VENOUS (Vitros)
|
Facility
|
OP
|
$201.00
|
|
|
Service Code
|
CPT 83605
|
| Hospital Charge Code |
2232269
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.83 |
| Max. Negotiated Rate |
$190.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$20.82
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$120.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$20.82
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$11.57
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cigna Commercial |
$170.85
|
| Rate for Payer: First Health Commercial |
$180.90
|
| Rate for Payer: First Health Workers Compensation |
$19.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$180.90
|
| Rate for Payer: GEHA Commercial |
$160.80
|
| Rate for Payer: GEHA Medicare |
$11.57
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$180.90
|
| Rate for Payer: Humana ChoiceCare |
$12.73
|
| Rate for Payer: Humana Medicare Advantage |
$11.57
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$19.44
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$16.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$11.57
|
| Rate for Payer: Multiplan All |
$182.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$19.67
|
| Rate for Payer: OMNI Networks Commercial |
$140.70
|
| Rate for Payer: One Health Plan PPO/POS |
$180.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$19.43
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$16.83
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$11.57
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$190.95
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$23.14
|
| Rate for Payer: Three Rivers Provider Network All |
$150.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11.34
|
| Rate for Payer: United Healthcare Commercial |
$170.85
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.57
|
| Rate for Payer: United Payors & United Providers UP&UP |
$186.93
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$11.57
|
| Rate for Payer: Zelis Auto |
$80.40
|
| Rate for Payer: Zelis Medicare |
$9.83
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$13.88
|
| Rate for Payer: Zelis Worker's Compensation |
$13.73
|
|
|
lactose tolerance test REF046300
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
CPT 82951
|
| Hospital Charge Code |
2299540
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.83 |
| Max. Negotiated Rate |
$189.05 |
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$169.15
|
| Rate for Payer: First Health Commercial |
$179.10
|
| Rate for Payer: First Health Workers Compensation |
$20.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$179.10
|
| Rate for Payer: GEHA Commercial |
$139.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$179.10
|
| Rate for Payer: Multiplan All |
$181.09
|
| Rate for Payer: OMNI Networks Commercial |
$139.30
|
| Rate for Payer: One Health Plan PPO/POS |
$179.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$189.05
|
| Rate for Payer: Three Rivers Provider Network All |
$149.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$185.07
|
| Rate for Payer: Zelis Auto |
$79.60
|
| Rate for Payer: Zelis Worker's Compensation |
$14.83
|
|
|
lactose tolerance test REF046300
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
CPT 82951
|
| Hospital Charge Code |
2299540
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.94 |
| Max. Negotiated Rate |
$189.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$23.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$119.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$23.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$18.35
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$12.87
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$169.15
|
| Rate for Payer: First Health Commercial |
$179.10
|
| Rate for Payer: First Health Workers Compensation |
$20.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$179.10
|
| Rate for Payer: GEHA Commercial |
$159.20
|
| Rate for Payer: GEHA Medicare |
$12.87
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$179.10
|
| Rate for Payer: Humana ChoiceCare |
$14.16
|
| Rate for Payer: Humana Medicare Advantage |
$12.87
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$21.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$18.72
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$12.87
|
| Rate for Payer: Multiplan All |
$181.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$21.88
|
| Rate for Payer: OMNI Networks Commercial |
$139.30
|
| Rate for Payer: One Health Plan PPO/POS |
$179.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$21.62
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$18.72
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$12.87
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$189.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$25.74
|
| Rate for Payer: Three Rivers Provider Network All |
$149.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.61
|
| Rate for Payer: United Healthcare Commercial |
$169.15
|
| Rate for Payer: United Healthcare Managed Medicaid |
$18.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.87
|
| Rate for Payer: United Payors & United Providers UP&UP |
$185.07
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$12.87
|
| Rate for Payer: Zelis Auto |
$79.60
|
| Rate for Payer: Zelis Medicare |
$10.94
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.44
|
| Rate for Payer: Zelis Worker's Compensation |
$14.83
|
|
|
Lactulose Enema
|
Facility
|
IP
|
$91.00
|
|
|
Service Code
|
NDC 00121115430
|
| Hospital Charge Code |
3302842
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.84 |
| Max. Negotiated Rate |
$86.45 |
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$77.35
|
| Rate for Payer: First Health Commercial |
$81.90
|
| Rate for Payer: First Health Workers Compensation |
$35.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.90
|
| Rate for Payer: GEHA Commercial |
$63.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.90
|
| Rate for Payer: Multiplan All |
$82.81
|
| Rate for Payer: OMNI Networks Commercial |
$63.70
|
| Rate for Payer: One Health Plan PPO/POS |
$81.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$86.45
|
| Rate for Payer: Three Rivers Provider Network All |
$68.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$84.63
|
| Rate for Payer: Zelis Auto |
$36.40
|
| Rate for Payer: Zelis Worker's Compensation |
$24.84
|
|
|
Lactulose Enema
|
Facility
|
OP
|
$91.00
|
|
|
Service Code
|
NDC 00121115430
|
| Hospital Charge Code |
3302842
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$86.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$77.35
|
| Rate for Payer: First Health Commercial |
$81.90
|
| Rate for Payer: First Health Workers Compensation |
$35.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.90
|
| Rate for Payer: GEHA Commercial |
$72.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.90
|
| Rate for Payer: Humana ChoiceCare |
$23.66
|
| Rate for Payer: Multiplan All |
$82.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$54.60
|
| Rate for Payer: OMNI Networks Commercial |
$63.70
|
| Rate for Payer: One Health Plan PPO/POS |
$81.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$86.45
|
| Rate for Payer: Three Rivers Provider Network All |
$68.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$80.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$22.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$84.63
|
| Rate for Payer: Zelis Auto |
$36.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$45.50
|
| Rate for Payer: Zelis Worker's Compensation |
$24.84
|
|
|
LACTULOSE SOLUTION 10GM/15ML UD
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 00121457715
|
| Hospital Charge Code |
3300489
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$8.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Humana ChoiceCare |
$2.86
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.60
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
LACTULOSE SOLUTION 10GM/15ML UD
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 00121457715
|
| Hospital Charge Code |
3300489
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$7.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
LACTULOSE SOLUTION 20GM/30ML UD
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 00121115430
|
| Hospital Charge Code |
3302840
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$4.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Humana ChoiceCare |
$1.30
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.00
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
LACTULOSE SOLUTION 20GM/30ML UD
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 00121115430
|
| Hospital Charge Code |
3302840
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
LAMBDA LIGHT CHANGE FREE SERUM
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
CPT 83883
|
| Hospital Charge Code |
2246248
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.56 |
| Max. Negotiated Rate |
$147.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$24.48
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$93.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$24.48
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$13.60
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$131.75
|
| Rate for Payer: First Health Commercial |
$139.50
|
| Rate for Payer: First Health Workers Compensation |
$17.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$139.50
|
| Rate for Payer: GEHA Commercial |
$124.00
|
| Rate for Payer: GEHA Medicare |
$13.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$139.50
|
| Rate for Payer: Humana ChoiceCare |
$14.96
|
| Rate for Payer: Humana Medicare Advantage |
$13.60
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$22.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$19.79
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$13.60
|
| Rate for Payer: Multiplan All |
$141.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$23.12
|
| Rate for Payer: OMNI Networks Commercial |
$108.50
|
| Rate for Payer: One Health Plan PPO/POS |
$139.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$22.85
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$19.79
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$13.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$147.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$27.20
|
| Rate for Payer: Three Rivers Provider Network All |
$116.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.33
|
| Rate for Payer: United Healthcare Commercial |
$131.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$19.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.60
|
| Rate for Payer: United Payors & United Providers UP&UP |
$144.15
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$13.60
|
| Rate for Payer: Zelis Auto |
$62.00
|
| Rate for Payer: Zelis Medicare |
$11.56
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$16.32
|
| Rate for Payer: Zelis Worker's Compensation |
$12.19
|
|
|
LAMBDA LIGHT CHANGE FREE SERUM
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
CPT 83883
|
| Hospital Charge Code |
2246248
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.19 |
| Max. Negotiated Rate |
$147.25 |
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$131.75
|
| Rate for Payer: First Health Commercial |
$139.50
|
| Rate for Payer: First Health Workers Compensation |
$17.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$139.50
|
| Rate for Payer: GEHA Commercial |
$108.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$139.50
|
| Rate for Payer: Multiplan All |
$141.05
|
| Rate for Payer: OMNI Networks Commercial |
$108.50
|
| Rate for Payer: One Health Plan PPO/POS |
$139.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$147.25
|
| Rate for Payer: Three Rivers Provider Network All |
$116.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$144.15
|
| Rate for Payer: Zelis Auto |
$62.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.19
|
|
|
lamotrigine REF716944
|
Facility
|
IP
|
$251.00
|
|
|
Service Code
|
CPT 80175
|
| Hospital Charge Code |
2247249
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.41 |
| 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 |
$23.22
|
| 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 |
$16.41
|
|
|
lamotrigine REF716944
|
Facility
|
OP
|
$251.00
|
|
|
Service Code
|
CPT 80175
|
| Hospital Charge Code |
2247249
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.26 |
| Max. Negotiated Rate |
$238.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$23.85
|
| 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 |
$23.85
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$18.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$13.25
|
| 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 |
$23.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$225.90
|
| Rate for Payer: GEHA Commercial |
$200.80
|
| Rate for Payer: GEHA Medicare |
$13.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$225.90
|
| Rate for Payer: Humana ChoiceCare |
$14.57
|
| Rate for Payer: Humana Medicare Advantage |
$13.25
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$22.26
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$19.28
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$13.25
|
| Rate for Payer: Multiplan All |
$228.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.52
|
| 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 |
$22.26
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$19.28
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$13.25
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$238.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$26.50
|
| Rate for Payer: Three Rivers Provider Network All |
$188.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.98
|
| Rate for Payer: United Healthcare Commercial |
$213.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$19.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$233.43
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$13.25
|
| Rate for Payer: Zelis Auto |
$100.40
|
| Rate for Payer: Zelis Medicare |
$11.26
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.90
|
| Rate for Payer: Zelis Worker's Compensation |
$16.41
|
|
|
LamoTRIgine TAB 100MG
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084031911
|
| Hospital Charge Code |
3300490
|
|
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
|
|
|
LamoTRIgine TAB 100MG
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084031911
|
| Hospital Charge Code |
3300490
|
|
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
|
|
