|
APP SKN SUB GRFT TAL 100SQCM EA AD 25SC
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
CPT 15272
|
| Hospital Charge Code |
6115272
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$15.02 |
| Max. Negotiated Rate |
$52.25 |
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$46.75
|
| Rate for Payer: First Health Commercial |
$49.50
|
| Rate for Payer: First Health Workers Compensation |
$21.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$49.50
|
| Rate for Payer: GEHA Commercial |
$38.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$49.50
|
| Rate for Payer: Multiplan All |
$50.05
|
| Rate for Payer: OMNI Networks Commercial |
$38.50
|
| Rate for Payer: One Health Plan PPO/POS |
$49.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$52.25
|
| Rate for Payer: Three Rivers Provider Network All |
$41.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$51.15
|
| Rate for Payer: Zelis Auto |
$22.00
|
| Rate for Payer: Zelis Worker's Compensation |
$15.02
|
|
|
APP SKN SUB GRFT TAL 100SQCM EA AD 25SC
|
Facility
|
OP
|
$2,256.00
|
|
|
Service Code
|
CPT 15272
|
| Hospital Charge Code |
1905285
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.59 |
| Max. Negotiated Rate |
$2,143.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$120.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,353.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$120.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$95.59
|
| Rate for Payer: Cash Price |
$1,353.60
|
| Rate for Payer: Cash Price |
$1,353.60
|
| Rate for Payer: Cigna Commercial |
$1,917.60
|
| Rate for Payer: First Health Commercial |
$2,030.40
|
| Rate for Payer: First Health Workers Compensation |
$871.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,030.40
|
| Rate for Payer: GEHA Commercial |
$1,804.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,030.40
|
| Rate for Payer: Humana ChoiceCare |
$586.56
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$97.53
|
| Rate for Payer: Multiplan All |
$2,052.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,353.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,579.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,030.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$112.62
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$97.53
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,143.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,692.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,985.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$97.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,098.08
|
| Rate for Payer: Zelis Auto |
$902.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,128.00
|
| Rate for Payer: Zelis Worker's Compensation |
$615.89
|
|
|
APP SKN SUB GRFT TAL 100SQCM EA AD 25SC
|
Facility
|
IP
|
$2,256.00
|
|
|
Service Code
|
CPT 15272
|
| Hospital Charge Code |
1905285
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$615.89 |
| Max. Negotiated Rate |
$2,143.20 |
| Rate for Payer: Cash Price |
$1,353.60
|
| Rate for Payer: Cigna Commercial |
$1,917.60
|
| Rate for Payer: First Health Commercial |
$2,030.40
|
| Rate for Payer: First Health Workers Compensation |
$871.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,030.40
|
| Rate for Payer: GEHA Commercial |
$1,579.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,030.40
|
| Rate for Payer: Multiplan All |
$2,052.96
|
| Rate for Payer: OMNI Networks Commercial |
$1,579.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,030.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,143.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,692.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,098.08
|
| Rate for Payer: Zelis Auto |
$902.40
|
| Rate for Payer: Zelis Worker's Compensation |
$615.89
|
|
|
APP SKN SUB GRFT TAL 100SQCM EA AD 25SC
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
CPT 15272
|
| Hospital Charge Code |
6115272
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$14.30 |
| Max. Negotiated Rate |
$120.66 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$120.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$120.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$95.59
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$46.75
|
| Rate for Payer: First Health Commercial |
$49.50
|
| Rate for Payer: First Health Workers Compensation |
$21.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$49.50
|
| Rate for Payer: GEHA Commercial |
$44.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$49.50
|
| Rate for Payer: Humana ChoiceCare |
$14.30
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$97.53
|
| Rate for Payer: Multiplan All |
$50.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$33.00
|
| Rate for Payer: OMNI Networks Commercial |
$38.50
|
| Rate for Payer: One Health Plan PPO/POS |
$49.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$112.62
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$97.53
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$52.25
|
| Rate for Payer: Three Rivers Provider Network All |
$41.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$48.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$97.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$51.15
|
| Rate for Payer: Zelis Auto |
$22.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$27.50
|
| Rate for Payer: Zelis Worker's Compensation |
$15.02
|
|
|
APP SKN SUB GRFT TAL 100SQCM EA AD 25SC
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
CPT 15272
|
| Hospital Charge Code |
20300120
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.11 |
| Max. Negotiated Rate |
$76.95 |
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$68.85
|
| Rate for Payer: First Health Commercial |
$72.90
|
| Rate for Payer: First Health Workers Compensation |
$31.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.90
|
| Rate for Payer: GEHA Commercial |
$56.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.90
|
| Rate for Payer: Multiplan All |
$73.71
|
| Rate for Payer: OMNI Networks Commercial |
$56.70
|
| Rate for Payer: One Health Plan PPO/POS |
$72.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.95
|
| Rate for Payer: Three Rivers Provider Network All |
$60.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$75.33
|
| Rate for Payer: Zelis Auto |
$32.40
|
| Rate for Payer: Zelis Worker's Compensation |
$22.11
|
|
|
APP SKN SUB GRFT TAL 100SQCM EA AD 25SC
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
CPT 15272
|
| Hospital Charge Code |
20300120
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$21.06 |
| Max. Negotiated Rate |
$120.66 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$120.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$48.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$120.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$95.59
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$68.85
|
| Rate for Payer: First Health Commercial |
$72.90
|
| Rate for Payer: First Health Workers Compensation |
$31.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.90
|
| Rate for Payer: GEHA Commercial |
$64.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.90
|
| Rate for Payer: Humana ChoiceCare |
$21.06
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$97.53
|
| Rate for Payer: Multiplan All |
$73.71
|
| Rate for Payer: New Mexico Health Connections Medicare |
$48.60
|
| Rate for Payer: OMNI Networks Commercial |
$56.70
|
| Rate for Payer: One Health Plan PPO/POS |
$72.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$112.62
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$97.53
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.95
|
| Rate for Payer: Three Rivers Provider Network All |
$60.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$71.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$97.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$75.33
|
| Rate for Payer: Zelis Auto |
$32.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$40.50
|
| Rate for Payer: Zelis Worker's Compensation |
$22.11
|
|
|
APRODINE 2.5-60MG TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904025024
|
| Hospital Charge Code |
3300926
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
APRODINE 2.5-60MG TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904025024
|
| Hospital Charge Code |
3300926
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
APTT
|
Facility
|
OP
|
$149.00
|
|
|
Service Code
|
CPT 85730
|
| Hospital Charge Code |
2205730
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$5.11 |
| Max. Negotiated Rate |
$141.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$10.81
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$89.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$10.81
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$8.57
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6.01
|
| Rate for Payer: Cash Price |
$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 |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$134.10
|
| Rate for Payer: GEHA Commercial |
$119.20
|
| Rate for Payer: GEHA Medicare |
$6.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$134.10
|
| Rate for Payer: Humana ChoiceCare |
$6.61
|
| Rate for Payer: Humana Medicare Advantage |
$6.01
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$10.10
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$8.74
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6.01
|
| Rate for Payer: Multiplan All |
$135.59
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10.22
|
| Rate for Payer: OMNI Networks Commercial |
$104.30
|
| Rate for Payer: One Health Plan PPO/POS |
$134.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$10.09
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$8.74
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$141.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$12.02
|
| Rate for Payer: Three Rivers Provider Network All |
$111.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.89
|
| Rate for Payer: United Healthcare Commercial |
$126.65
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$138.57
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6.01
|
| Rate for Payer: Zelis Auto |
$59.60
|
| Rate for Payer: Zelis Medicare |
$5.11
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.21
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
|
APTT
|
Facility
|
IP
|
$149.00
|
|
|
Service Code
|
CPT 85730
|
| Hospital Charge Code |
2205730
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$6.83 |
| Max. Negotiated Rate |
$141.55 |
| Rate for Payer: Cash Price |
$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 |
$9.65
|
| 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 |
$6.83
|
|
|
ARGININE HCL 30 GM/300 ML
|
Facility
|
OP
|
$286.00
|
|
|
Service Code
|
NDC 00009043601
|
| Hospital Charge Code |
3302898
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$71.50 |
| Max. Negotiated Rate |
$271.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$171.60
|
| Rate for Payer: Cash Price |
$171.60
|
| Rate for Payer: Cigna Commercial |
$243.10
|
| Rate for Payer: First Health Commercial |
$257.40
|
| Rate for Payer: First Health Workers Compensation |
$110.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$257.40
|
| Rate for Payer: GEHA Commercial |
$228.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$257.40
|
| Rate for Payer: Humana ChoiceCare |
$74.36
|
| Rate for Payer: Multiplan All |
$260.26
|
| Rate for Payer: New Mexico Health Connections Medicare |
$171.60
|
| Rate for Payer: OMNI Networks Commercial |
$200.20
|
| Rate for Payer: One Health Plan PPO/POS |
$257.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$271.70
|
| Rate for Payer: Three Rivers Provider Network All |
$214.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$251.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$71.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$265.98
|
| Rate for Payer: Zelis Auto |
$114.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$143.00
|
| Rate for Payer: Zelis Worker's Compensation |
$78.08
|
|
|
ARGININE HCL 30 GM/300 ML
|
Facility
|
IP
|
$286.00
|
|
|
Service Code
|
NDC 00009043601
|
| Hospital Charge Code |
3302898
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$78.08 |
| Max. Negotiated Rate |
$271.70 |
| Rate for Payer: Cash Price |
$171.60
|
| Rate for Payer: Cigna Commercial |
$243.10
|
| Rate for Payer: First Health Commercial |
$257.40
|
| Rate for Payer: First Health Workers Compensation |
$110.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$257.40
|
| Rate for Payer: GEHA Commercial |
$200.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$257.40
|
| Rate for Payer: Multiplan All |
$260.26
|
| Rate for Payer: OMNI Networks Commercial |
$200.20
|
| Rate for Payer: One Health Plan PPO/POS |
$257.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$271.70
|
| Rate for Payer: Three Rivers Provider Network All |
$214.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$265.98
|
| Rate for Payer: Zelis Auto |
$114.40
|
| Rate for Payer: Zelis Worker's Compensation |
$78.08
|
|
|
ARIPiprazole 10MG ODT
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
NDC 62332010330
|
| Hospital Charge Code |
3300064
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.00 |
| Max. Negotiated Rate |
$155.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$98.40
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cigna Commercial |
$139.40
|
| Rate for Payer: First Health Commercial |
$147.60
|
| Rate for Payer: First Health Workers Compensation |
$63.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$147.60
|
| Rate for Payer: GEHA Commercial |
$131.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$147.60
|
| Rate for Payer: Humana ChoiceCare |
$42.64
|
| Rate for Payer: Multiplan All |
$149.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$98.40
|
| Rate for Payer: OMNI Networks Commercial |
$114.80
|
| Rate for Payer: One Health Plan PPO/POS |
$147.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$155.80
|
| Rate for Payer: Three Rivers Provider Network All |
$123.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$144.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$41.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$152.52
|
| Rate for Payer: Zelis Auto |
$65.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$82.00
|
| Rate for Payer: Zelis Worker's Compensation |
$44.77
|
|
|
ARIPiprazole 10MG ODT
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
NDC 62332010330
|
| Hospital Charge Code |
3300064
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.77 |
| Max. Negotiated Rate |
$155.80 |
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cigna Commercial |
$139.40
|
| Rate for Payer: First Health Commercial |
$147.60
|
| Rate for Payer: First Health Workers Compensation |
$63.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$147.60
|
| Rate for Payer: GEHA Commercial |
$114.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$147.60
|
| Rate for Payer: Multiplan All |
$149.24
|
| Rate for Payer: OMNI Networks Commercial |
$114.80
|
| Rate for Payer: One Health Plan PPO/POS |
$147.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$155.80
|
| Rate for Payer: Three Rivers Provider Network All |
$123.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$152.52
|
| Rate for Payer: Zelis Auto |
$65.60
|
| Rate for Payer: Zelis Worker's Compensation |
$44.77
|
|
|
ARIPiprazole 2MG TAB
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
NDC 65162089603
|
| Hospital Charge Code |
3300065
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.56 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: First Health Commercial |
$51.30
|
| Rate for Payer: First Health Workers Compensation |
$22.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$51.30
|
| Rate for Payer: GEHA Commercial |
$39.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$51.30
|
| Rate for Payer: Multiplan All |
$51.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.90
|
| Rate for Payer: One Health Plan PPO/POS |
$51.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$54.15
|
| Rate for Payer: Three Rivers Provider Network All |
$42.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.01
|
| Rate for Payer: Zelis Auto |
$22.80
|
| Rate for Payer: Zelis Worker's Compensation |
$15.56
|
|
|
ARIPiprazole 2MG TAB
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
NDC 65162089603
|
| Hospital Charge Code |
3300065
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.25 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$34.20
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: First Health Commercial |
$51.30
|
| Rate for Payer: First Health Workers Compensation |
$22.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$51.30
|
| Rate for Payer: GEHA Commercial |
$45.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$51.30
|
| Rate for Payer: Humana ChoiceCare |
$14.82
|
| Rate for Payer: Multiplan All |
$51.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$34.20
|
| Rate for Payer: OMNI Networks Commercial |
$39.90
|
| Rate for Payer: One Health Plan PPO/POS |
$51.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$54.15
|
| Rate for Payer: Three Rivers Provider Network All |
$42.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$50.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.01
|
| Rate for Payer: Zelis Auto |
$22.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$28.50
|
| Rate for Payer: Zelis Worker's Compensation |
$15.56
|
|
|
ARIPiprazole 5MG TAB
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
NDC 65162089709
|
| Hospital Charge Code |
3300066
|
|
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
|
|
|
ARIPiprazole 5MG TAB
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
NDC 65162089709
|
| Hospital Charge Code |
3300066
|
|
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
|
|
|
aripiprazole quant REF809671
|
Facility
|
IP
|
$251.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
229970
|
|
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
|
|
|
aripiprazole quant REF809671
|
Facility
|
OP
|
$251.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
229970
|
|
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
|
|
|
ARM TENDON LENGTHENING
|
Facility
|
OP
|
$1,173.00
|
|
|
Service Code
|
CPT 24305
|
| Hospital Charge Code |
6124305
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$320.23 |
| Max. Negotiated Rate |
$6,161.78 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$3,212.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$703.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$3,212.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2,544.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,080.89
|
| Rate for Payer: Cash Price |
$703.80
|
| Rate for Payer: Cash Price |
$703.80
|
| Rate for Payer: Cigna Commercial |
$997.05
|
| Rate for Payer: First Health Commercial |
$1,055.70
|
| Rate for Payer: First Health Workers Compensation |
$452.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,055.70
|
| Rate for Payer: GEHA Commercial |
$938.40
|
| Rate for Payer: GEHA Medicare |
$3,080.89
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,055.70
|
| Rate for Payer: Humana ChoiceCare |
$3,388.98
|
| Rate for Payer: Humana Medicare Advantage |
$3,080.89
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,175.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,596.69
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,080.89
|
| Rate for Payer: Multiplan All |
$1,067.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,237.51
|
| Rate for Payer: OMNI Networks Commercial |
$821.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,055.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,998.24
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,596.69
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,080.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,114.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,161.78
|
| Rate for Payer: Three Rivers Provider Network All |
$879.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,019.27
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,596.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,080.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,090.89
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,080.89
|
| Rate for Payer: Zelis Auto |
$469.20
|
| Rate for Payer: Zelis Medicare |
$2,618.76
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,697.07
|
| Rate for Payer: Zelis Worker's Compensation |
$320.23
|
|
|
ARM TENDON LENGTHENING
|
Facility
|
IP
|
$1,173.00
|
|
|
Service Code
|
CPT 24305
|
| Hospital Charge Code |
6124305
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$320.23 |
| Max. Negotiated Rate |
$1,114.35 |
| Rate for Payer: Cash Price |
$703.80
|
| Rate for Payer: Cigna Commercial |
$997.05
|
| Rate for Payer: First Health Commercial |
$1,055.70
|
| Rate for Payer: First Health Workers Compensation |
$452.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,055.70
|
| Rate for Payer: GEHA Commercial |
$821.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,055.70
|
| Rate for Payer: Multiplan All |
$1,067.43
|
| Rate for Payer: OMNI Networks Commercial |
$821.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,055.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,114.35
|
| Rate for Payer: Three Rivers Provider Network All |
$879.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,090.89
|
| Rate for Payer: Zelis Auto |
$469.20
|
| Rate for Payer: Zelis Worker's Compensation |
$320.23
|
|
|
ARROW MEDLINE 1L 4.5FR X 15CM/CDC 41541
|
Facility
|
OP
|
$888.00
|
|
|
Service Code
|
CPT C1751
|
| Hospital Charge Code |
7003025
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$843.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$532.80
|
| Rate for Payer: Cash Price |
$532.80
|
| Rate for Payer: Cash Price |
$532.80
|
| Rate for Payer: Cigna Commercial |
$754.80
|
| Rate for Payer: First Health Commercial |
$799.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$799.20
|
| Rate for Payer: GEHA Commercial |
$710.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$799.20
|
| Rate for Payer: Humana ChoiceCare |
$230.88
|
| Rate for Payer: Multiplan All |
$808.08
|
| Rate for Payer: New Mexico Health Connections Medicare |
$532.80
|
| Rate for Payer: OMNI Networks Commercial |
$621.60
|
| Rate for Payer: One Health Plan PPO/POS |
$799.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$843.60
|
| Rate for Payer: Three Rivers Provider Network All |
$666.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$781.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$222.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$825.84
|
| Rate for Payer: Zelis Auto |
$355.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$444.00
|
|
|
ARROW MEDLINE 1L 4.5FR X 15CM/CDC 41541
|
Facility
|
IP
|
$888.00
|
|
|
Service Code
|
CPT C1751
|
| Hospital Charge Code |
7003025
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$355.20 |
| Max. Negotiated Rate |
$843.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$710.40
|
| Rate for Payer: Cash Price |
$532.80
|
| Rate for Payer: Cash Price |
$532.80
|
| Rate for Payer: Cigna Commercial |
$754.80
|
| Rate for Payer: First Health Commercial |
$799.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$799.20
|
| Rate for Payer: GEHA Commercial |
$621.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$799.20
|
| Rate for Payer: Multiplan All |
$808.08
|
| Rate for Payer: OMNI Networks Commercial |
$621.60
|
| Rate for Payer: One Health Plan PPO/POS |
$799.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$843.60
|
| Rate for Payer: Three Rivers Provider Network All |
$666.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$825.84
|
| Rate for Payer: Zelis Auto |
$355.20
|
|
|
ARROW MIDLINE 2L 5.5FR X 15CM/CDC 41552
|
Facility
|
IP
|
$883.00
|
|
|
Service Code
|
CPT C1751
|
| Hospital Charge Code |
7003026
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$353.20 |
| Max. Negotiated Rate |
$838.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$706.40
|
| Rate for Payer: Cash Price |
$529.80
|
| Rate for Payer: Cash Price |
$529.80
|
| Rate for Payer: Cigna Commercial |
$750.55
|
| Rate for Payer: First Health Commercial |
$794.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$794.70
|
| Rate for Payer: GEHA Commercial |
$618.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$794.70
|
| Rate for Payer: Multiplan All |
$803.53
|
| Rate for Payer: OMNI Networks Commercial |
$618.10
|
| Rate for Payer: One Health Plan PPO/POS |
$794.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$838.85
|
| Rate for Payer: Three Rivers Provider Network All |
$662.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$821.19
|
| Rate for Payer: Zelis Auto |
$353.20
|
|
