|
LEVOTHYROXINE SODIUM 50MCG TAB
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 00904695061
|
| Hospital Charge Code |
3300510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$8.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
LEVOTHYROXINE SODIUM 75MCG TAB
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 51079044101
|
| Hospital Charge Code |
3300511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$4.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
LEVOTHYROXINE SODIUM 75MCG TAB
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 51079044101
|
| Hospital Charge Code |
3300511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Humana ChoiceCare |
$1.82
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.20
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
LEVOTHYROXINE SODIUM 88MCG TAB
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 00074659490
|
| Hospital Charge Code |
3300512
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$9.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Humana ChoiceCare |
$3.12
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.20
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
LEVOTHYROXINE SODIUM 88MCG TAB
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 00074659490
|
| Hospital Charge Code |
3300512
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$8.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
LEVOTHYROXINE SODIUM IV INJ 100MCG
|
Facility
|
OP
|
$355.00
|
|
|
Service Code
|
NDC 42023020101
|
| Hospital Charge Code |
3300505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$88.75 |
| Max. Negotiated Rate |
$337.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$213.00
|
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Cigna Commercial |
$301.75
|
| Rate for Payer: First Health Commercial |
$319.50
|
| Rate for Payer: First Health Workers Compensation |
$137.07
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$319.50
|
| Rate for Payer: GEHA Commercial |
$284.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$319.50
|
| Rate for Payer: Humana ChoiceCare |
$92.30
|
| Rate for Payer: Multiplan All |
$323.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$213.00
|
| Rate for Payer: OMNI Networks Commercial |
$248.50
|
| Rate for Payer: One Health Plan PPO/POS |
$319.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$337.25
|
| Rate for Payer: Three Rivers Provider Network All |
$266.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$312.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$88.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$330.15
|
| Rate for Payer: Zelis Auto |
$142.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$177.50
|
| Rate for Payer: Zelis Worker's Compensation |
$96.92
|
|
|
LEVOTHYROXINE SODIUM IV INJ 100MCG
|
Facility
|
IP
|
$355.00
|
|
|
Service Code
|
NDC 42023020101
|
| Hospital Charge Code |
3300505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.92 |
| Max. Negotiated Rate |
$337.25 |
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Cigna Commercial |
$301.75
|
| Rate for Payer: First Health Commercial |
$319.50
|
| Rate for Payer: First Health Workers Compensation |
$137.07
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$319.50
|
| Rate for Payer: GEHA Commercial |
$248.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$319.50
|
| Rate for Payer: Multiplan All |
$323.05
|
| Rate for Payer: OMNI Networks Commercial |
$248.50
|
| Rate for Payer: One Health Plan PPO/POS |
$319.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$337.25
|
| Rate for Payer: Three Rivers Provider Network All |
$266.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$330.15
|
| Rate for Payer: Zelis Auto |
$142.00
|
| Rate for Payer: Zelis Worker's Compensation |
$96.92
|
|
|
lh (luteinizing hormone) REF004283
|
Facility
|
IP
|
$231.00
|
|
|
Service Code
|
CPT 83002
|
| Hospital Charge Code |
2299121
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$22.86 |
| Max. Negotiated Rate |
$219.45 |
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$196.35
|
| Rate for Payer: First Health Commercial |
$207.90
|
| Rate for Payer: First Health Workers Compensation |
$32.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$207.90
|
| Rate for Payer: GEHA Commercial |
$161.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$207.90
|
| Rate for Payer: Multiplan All |
$210.21
|
| Rate for Payer: OMNI Networks Commercial |
$161.70
|
| Rate for Payer: One Health Plan PPO/POS |
$207.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$219.45
|
| Rate for Payer: Three Rivers Provider Network All |
$173.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$214.83
|
| Rate for Payer: Zelis Auto |
$92.40
|
| Rate for Payer: Zelis Worker's Compensation |
$22.86
|
|
|
lh (luteinizing hormone) REF004283
|
Facility
|
OP
|
$231.00
|
|
|
Service Code
|
CPT 83002
|
| Hospital Charge Code |
2299121
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.74 |
| Max. Negotiated Rate |
$219.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$33.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$138.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$33.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$26.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$18.52
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$196.35
|
| Rate for Payer: First Health Commercial |
$207.90
|
| Rate for Payer: First Health Workers Compensation |
$32.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$207.90
|
| Rate for Payer: GEHA Commercial |
$184.80
|
| Rate for Payer: GEHA Medicare |
$18.52
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$207.90
|
| Rate for Payer: Humana ChoiceCare |
$20.37
|
| Rate for Payer: Humana Medicare Advantage |
$18.52
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$31.11
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$26.94
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$18.52
|
| Rate for Payer: Multiplan All |
$210.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.48
|
| Rate for Payer: OMNI Networks Commercial |
$161.70
|
| Rate for Payer: One Health Plan PPO/POS |
$207.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$31.11
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$26.94
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$18.52
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$219.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$37.04
|
| Rate for Payer: Three Rivers Provider Network All |
$173.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.15
|
| Rate for Payer: United Healthcare Commercial |
$196.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.52
|
| Rate for Payer: United Payors & United Providers UP&UP |
$214.83
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$18.52
|
| Rate for Payer: Zelis Auto |
$92.40
|
| Rate for Payer: Zelis Medicare |
$15.74
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.22
|
| Rate for Payer: Zelis Worker's Compensation |
$22.86
|
|
|
LIDEX 0.05% 30GM W/LOTION
|
Facility
|
OP
|
$241.00
|
|
| Hospital Charge Code |
3300513
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.25 |
| Max. Negotiated Rate |
$228.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$144.60
|
| Rate for Payer: Cash Price |
$144.60
|
| Rate for Payer: Cigna Commercial |
$204.85
|
| Rate for Payer: First Health Commercial |
$216.90
|
| Rate for Payer: First Health Workers Compensation |
$93.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$216.90
|
| Rate for Payer: GEHA Commercial |
$192.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$216.90
|
| Rate for Payer: Humana ChoiceCare |
$62.66
|
| Rate for Payer: Multiplan All |
$219.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$144.60
|
| Rate for Payer: OMNI Networks Commercial |
$168.70
|
| Rate for Payer: One Health Plan PPO/POS |
$216.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$228.95
|
| Rate for Payer: Three Rivers Provider Network All |
$180.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$212.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$60.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$224.13
|
| Rate for Payer: Zelis Auto |
$96.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$120.50
|
| Rate for Payer: Zelis Worker's Compensation |
$65.79
|
|
|
LIDEX 0.05% 30GM W/LOTION
|
Facility
|
IP
|
$241.00
|
|
| Hospital Charge Code |
3300513
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$65.79 |
| Max. Negotiated Rate |
$228.95 |
| Rate for Payer: Cash Price |
$144.60
|
| Rate for Payer: Cigna Commercial |
$204.85
|
| Rate for Payer: First Health Commercial |
$216.90
|
| Rate for Payer: First Health Workers Compensation |
$93.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$216.90
|
| Rate for Payer: GEHA Commercial |
$168.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$216.90
|
| Rate for Payer: Multiplan All |
$219.31
|
| Rate for Payer: OMNI Networks Commercial |
$168.70
|
| Rate for Payer: One Health Plan PPO/POS |
$216.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$228.95
|
| Rate for Payer: Three Rivers Provider Network All |
$180.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$224.13
|
| Rate for Payer: Zelis Auto |
$96.40
|
| Rate for Payer: Zelis Worker's Compensation |
$65.79
|
|
|
LIDOCAINE 1% 10ML
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3302638
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$20.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$13.20
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$18.70
|
| Rate for Payer: First Health Commercial |
$19.80
|
| Rate for Payer: First Health Workers Compensation |
$8.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$19.80
|
| Rate for Payer: GEHA Commercial |
$17.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$19.80
|
| Rate for Payer: Humana ChoiceCare |
$5.72
|
| Rate for Payer: Multiplan All |
$20.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$13.20
|
| Rate for Payer: OMNI Networks Commercial |
$15.40
|
| Rate for Payer: One Health Plan PPO/POS |
$19.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$20.90
|
| Rate for Payer: Three Rivers Provider Network All |
$16.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$19.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$20.46
|
| Rate for Payer: Zelis Auto |
$8.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$11.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6.01
|
|
|
LIDOCAINE 1% 10ML
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3302638
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.01 |
| Max. Negotiated Rate |
$20.90 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$18.70
|
| Rate for Payer: First Health Commercial |
$19.80
|
| Rate for Payer: First Health Workers Compensation |
$8.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$19.80
|
| Rate for Payer: GEHA Commercial |
$15.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$19.80
|
| Rate for Payer: Multiplan All |
$20.02
|
| Rate for Payer: OMNI Networks Commercial |
$15.40
|
| Rate for Payer: One Health Plan PPO/POS |
$19.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$20.90
|
| Rate for Payer: Three Rivers Provider Network All |
$16.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$20.46
|
| Rate for Payer: Zelis Auto |
$8.80
|
| Rate for Payer: Zelis Worker's Compensation |
$6.01
|
|
|
LIDOCAINE 1% 20mL
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300520
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: First Health Commercial |
$12.60
|
| Rate for Payer: First Health Workers Compensation |
$5.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12.60
|
| Rate for Payer: GEHA Commercial |
$9.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12.60
|
| Rate for Payer: Multiplan All |
$12.74
|
| Rate for Payer: OMNI Networks Commercial |
$9.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.02
|
| Rate for Payer: Zelis Auto |
$5.60
|
| Rate for Payer: Zelis Worker's Compensation |
$3.82
|
|
|
LIDOCAINE 1% 20mL
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300520
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: First Health Commercial |
$12.60
|
| Rate for Payer: First Health Workers Compensation |
$5.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12.60
|
| Rate for Payer: GEHA Commercial |
$11.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12.60
|
| Rate for Payer: Humana ChoiceCare |
$3.64
|
| Rate for Payer: Multiplan All |
$12.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.40
|
| Rate for Payer: OMNI Networks Commercial |
$9.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.02
|
| Rate for Payer: Zelis Auto |
$5.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.82
|
|
|
LIDOCAINE 1% 30mL
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3302639
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$26.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$23.80
|
| Rate for Payer: First Health Commercial |
$25.20
|
| Rate for Payer: First Health Workers Compensation |
$10.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$25.20
|
| Rate for Payer: GEHA Commercial |
$22.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$25.20
|
| Rate for Payer: Humana ChoiceCare |
$7.28
|
| Rate for Payer: Multiplan All |
$25.48
|
| Rate for Payer: New Mexico Health Connections Medicare |
$16.80
|
| Rate for Payer: OMNI Networks Commercial |
$19.60
|
| Rate for Payer: One Health Plan PPO/POS |
$25.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$26.60
|
| Rate for Payer: Three Rivers Provider Network All |
$21.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$24.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$26.04
|
| Rate for Payer: Zelis Auto |
$11.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$14.00
|
| Rate for Payer: Zelis Worker's Compensation |
$7.64
|
|
|
LIDOCAINE 1% 30mL
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3302639
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.64 |
| Max. Negotiated Rate |
$26.60 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$23.80
|
| Rate for Payer: First Health Commercial |
$25.20
|
| Rate for Payer: First Health Workers Compensation |
$10.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$25.20
|
| Rate for Payer: GEHA Commercial |
$19.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$25.20
|
| Rate for Payer: Multiplan All |
$25.48
|
| Rate for Payer: OMNI Networks Commercial |
$19.60
|
| Rate for Payer: One Health Plan PPO/POS |
$25.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$26.60
|
| Rate for Payer: Three Rivers Provider Network All |
$21.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$26.04
|
| Rate for Payer: Zelis Auto |
$11.20
|
| Rate for Payer: Zelis Worker's Compensation |
$7.64
|
|
|
LIDOCAINE 1% W/EPI (1:100,000)
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300526
|
|
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
|
|
|
LIDOCAINE 1% W/EPI (1:100,000)
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300526
|
|
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
|
|
|
LIDOCAINE 1% W/EPI (1:200,000)
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3302484
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$26.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$23.80
|
| Rate for Payer: First Health Commercial |
$25.20
|
| Rate for Payer: First Health Workers Compensation |
$10.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$25.20
|
| Rate for Payer: GEHA Commercial |
$22.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$25.20
|
| Rate for Payer: Humana ChoiceCare |
$7.28
|
| Rate for Payer: Multiplan All |
$25.48
|
| Rate for Payer: New Mexico Health Connections Medicare |
$16.80
|
| Rate for Payer: OMNI Networks Commercial |
$19.60
|
| Rate for Payer: One Health Plan PPO/POS |
$25.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$26.60
|
| Rate for Payer: Three Rivers Provider Network All |
$21.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$24.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$26.04
|
| Rate for Payer: Zelis Auto |
$11.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$14.00
|
| Rate for Payer: Zelis Worker's Compensation |
$7.64
|
|
|
LIDOCAINE 1% W/EPI (1:200,000)
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3302484
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.64 |
| Max. Negotiated Rate |
$26.60 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$23.80
|
| Rate for Payer: First Health Commercial |
$25.20
|
| Rate for Payer: First Health Workers Compensation |
$10.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$25.20
|
| Rate for Payer: GEHA Commercial |
$19.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$25.20
|
| Rate for Payer: Multiplan All |
$25.48
|
| Rate for Payer: OMNI Networks Commercial |
$19.60
|
| Rate for Payer: One Health Plan PPO/POS |
$25.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$26.60
|
| Rate for Payer: Three Rivers Provider Network All |
$21.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$26.04
|
| Rate for Payer: Zelis Auto |
$11.20
|
| Rate for Payer: Zelis Worker's Compensation |
$7.64
|
|
|
LIDOCAINE 2% - 10mL
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3302767
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$22.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$20.40
|
| Rate for Payer: First Health Commercial |
$21.60
|
| Rate for Payer: First Health Workers Compensation |
$9.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$21.60
|
| Rate for Payer: GEHA Commercial |
$19.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$21.60
|
| Rate for Payer: Humana ChoiceCare |
$6.24
|
| Rate for Payer: Multiplan All |
$21.84
|
| Rate for Payer: New Mexico Health Connections Medicare |
$14.40
|
| Rate for Payer: OMNI Networks Commercial |
$16.80
|
| Rate for Payer: One Health Plan PPO/POS |
$21.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$22.80
|
| Rate for Payer: Three Rivers Provider Network All |
$18.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$21.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$22.32
|
| Rate for Payer: Zelis Auto |
$9.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6.55
|
|
|
LIDOCAINE 2% - 10mL
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3302767
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.55 |
| Max. Negotiated Rate |
$22.80 |
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$20.40
|
| Rate for Payer: First Health Commercial |
$21.60
|
| Rate for Payer: First Health Workers Compensation |
$9.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$21.60
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$21.60
|
| Rate for Payer: Multiplan All |
$21.84
|
| Rate for Payer: OMNI Networks Commercial |
$16.80
|
| Rate for Payer: One Health Plan PPO/POS |
$21.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$22.80
|
| Rate for Payer: Three Rivers Provider Network All |
$18.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$22.32
|
| Rate for Payer: Zelis Auto |
$9.60
|
| Rate for Payer: Zelis Worker's Compensation |
$6.55
|
|
|
LIDOCAINE 2% 20ML
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300521
|
|
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
|
|
|
LIDOCAINE 2% 20ML
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300521
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$8.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Humana ChoiceCare |
$2.60
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.00
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
