|
NITROFURANTOIN IR 100 MG CAP
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 50268062415
|
| Hospital Charge Code |
3302964
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$12.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Humana ChoiceCare |
$4.16
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.60
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
NITROFURANTOIN MONO\MACRO 100MG CAP
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 47781030301
|
| Hospital Charge Code |
3300650
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.83 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$21.25
|
| Rate for Payer: First Health Commercial |
$22.50
|
| Rate for Payer: First Health Workers Compensation |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22.50
|
| Rate for Payer: GEHA Commercial |
$17.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22.50
|
| Rate for Payer: Multiplan All |
$22.75
|
| Rate for Payer: OMNI Networks Commercial |
$17.50
|
| Rate for Payer: One Health Plan PPO/POS |
$22.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$23.75
|
| Rate for Payer: Three Rivers Provider Network All |
$18.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23.25
|
| Rate for Payer: Zelis Auto |
$10.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
|
NITROFURANTOIN MONO\MACRO 100MG CAP
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 47781030301
|
| Hospital Charge Code |
3300650
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.25 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$21.25
|
| Rate for Payer: First Health Commercial |
$22.50
|
| Rate for Payer: First Health Workers Compensation |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22.50
|
| Rate for Payer: GEHA Commercial |
$20.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22.50
|
| Rate for Payer: Humana ChoiceCare |
$6.50
|
| Rate for Payer: Multiplan All |
$22.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$15.00
|
| Rate for Payer: OMNI Networks Commercial |
$17.50
|
| Rate for Payer: One Health Plan PPO/POS |
$22.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$23.75
|
| Rate for Payer: Three Rivers Provider Network All |
$18.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$22.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23.25
|
| Rate for Payer: Zelis Auto |
$10.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12.50
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
|
NITROGLYCERIN 0.1 MG/HR PATCH
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 00378910293
|
| Hospital Charge Code |
3303026
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
NITROGLYCERIN 0.1 MG/HR PATCH
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 00378910293
|
| Hospital Charge Code |
3303026
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
NITROGLYCERIN 0.2MG/HR PATCH 24HR
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 00378910493
|
| Hospital Charge Code |
3300654
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
NITROGLYCERIN 0.2MG/HR PATCH 24HR
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 00378910493
|
| Hospital Charge Code |
3300654
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
NITROGLYCERIN 25MG/250ML D5W IV
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 00338104702
|
| Hospital Charge Code |
3300651
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.25 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$36.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Humana ChoiceCare |
$11.70
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.00
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$39.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.50
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
NITROGLYCERIN 25MG/250ML D5W IV
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 00338104702
|
| Hospital Charge Code |
3300651
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: First Health Workers Compensation |
$17.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$31.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.29
|
|
|
NITROGLYCERIN 2% OINTMENT
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 00281032608
|
| Hospital Charge Code |
3300652
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$11.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
NITROGLYCERIN 2% OINTMENT
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 00281032608
|
| Hospital Charge Code |
3300652
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$12.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Humana ChoiceCare |
$4.16
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.60
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
NITROGLYCERIN SUBLINGUAL 0.4MG TAB
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 59762330403
|
| Hospital Charge Code |
3300653
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
NITROGLYCERIN SUBLINGUAL 0.4MG TAB
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 59762330403
|
| Hospital Charge Code |
3300653
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$6.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Humana ChoiceCare |
$2.08
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.80
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
NITROPRUSSIDE 50MG/2ML VIAL
|
Facility
|
IP
|
$251.00
|
|
|
Service Code
|
NDC 00187430202
|
| Hospital Charge Code |
3300655
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.52 |
| Max. Negotiated Rate |
$238.45 |
| 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 |
$96.91
|
| 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 |
$68.52
|
|
|
NITROPRUSSIDE 50MG/2ML VIAL
|
Facility
|
OP
|
$251.00
|
|
|
Service Code
|
NDC 00187430202
|
| Hospital Charge Code |
3300655
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.75 |
| Max. Negotiated Rate |
$238.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$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 |
$96.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$225.90
|
| Rate for Payer: GEHA Commercial |
$200.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$225.90
|
| Rate for Payer: Humana ChoiceCare |
$65.26
|
| Rate for Payer: Multiplan All |
$228.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$150.60
|
| 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: TriWest Veterans Administration/VAPC3 |
$220.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$62.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$233.43
|
| Rate for Payer: Zelis Auto |
$100.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$125.50
|
| Rate for Payer: Zelis Worker's Compensation |
$68.52
|
|
|
NIX PREMIUM METAL TWO SIDED COMB
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
NDC 63736024793
|
| Hospital Charge Code |
3303127
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.75 |
| Max. Negotiated Rate |
$40.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$25.80
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$36.55
|
| Rate for Payer: First Health Commercial |
$38.70
|
| Rate for Payer: First Health Workers Compensation |
$16.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$38.70
|
| Rate for Payer: GEHA Commercial |
$34.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$38.70
|
| Rate for Payer: Humana ChoiceCare |
$11.18
|
| Rate for Payer: Multiplan All |
$39.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.80
|
| Rate for Payer: OMNI Networks Commercial |
$30.10
|
| Rate for Payer: One Health Plan PPO/POS |
$38.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$40.85
|
| Rate for Payer: Three Rivers Provider Network All |
$32.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$37.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$39.99
|
| Rate for Payer: Zelis Auto |
$17.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.50
|
| Rate for Payer: Zelis Worker's Compensation |
$11.74
|
|
|
NIX PREMIUM METAL TWO SIDED COMB
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
NDC 63736024793
|
| Hospital Charge Code |
3303127
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.74 |
| Max. Negotiated Rate |
$40.85 |
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$36.55
|
| Rate for Payer: First Health Commercial |
$38.70
|
| Rate for Payer: First Health Workers Compensation |
$16.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$38.70
|
| Rate for Payer: GEHA Commercial |
$30.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$38.70
|
| Rate for Payer: Multiplan All |
$39.13
|
| Rate for Payer: OMNI Networks Commercial |
$30.10
|
| Rate for Payer: One Health Plan PPO/POS |
$38.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$40.85
|
| Rate for Payer: Three Rivers Provider Network All |
$32.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$39.99
|
| Rate for Payer: Zelis Auto |
$17.20
|
| Rate for Payer: Zelis Worker's Compensation |
$11.74
|
|
|
NJX ANES&/STEROID PLANTAR COMMON DIG NER
|
Facility
|
IP
|
$978.00
|
|
|
Service Code
|
CPT 64455
|
| Hospital Charge Code |
9664455
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$266.99 |
| Max. Negotiated Rate |
$929.10 |
| Rate for Payer: Cash Price |
$586.80
|
| Rate for Payer: Cigna Commercial |
$831.30
|
| Rate for Payer: First Health Commercial |
$880.20
|
| Rate for Payer: First Health Workers Compensation |
$377.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$880.20
|
| Rate for Payer: GEHA Commercial |
$684.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$880.20
|
| Rate for Payer: Multiplan All |
$889.98
|
| Rate for Payer: OMNI Networks Commercial |
$684.60
|
| Rate for Payer: One Health Plan PPO/POS |
$880.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$929.10
|
| Rate for Payer: Three Rivers Provider Network All |
$733.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$909.54
|
| Rate for Payer: Zelis Auto |
$391.20
|
| Rate for Payer: Zelis Worker's Compensation |
$266.99
|
|
|
NJX ANES&/STEROID PLANTAR COMMON DIG NER
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
CPT 64455
|
| Hospital Charge Code |
6164455
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$30.03 |
| Max. Negotiated Rate |
$560.58 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$66.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$204.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$280.29
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$93.50
|
| Rate for Payer: First Health Commercial |
$99.00
|
| Rate for Payer: First Health Workers Compensation |
$42.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$99.00
|
| Rate for Payer: GEHA Commercial |
$88.00
|
| Rate for Payer: GEHA Medicare |
$280.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$99.00
|
| Rate for Payer: Humana ChoiceCare |
$308.32
|
| Rate for Payer: Humana Medicare Advantage |
$280.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$470.89
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$208.89
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$280.29
|
| Rate for Payer: Multiplan All |
$100.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$476.49
|
| Rate for Payer: OMNI Networks Commercial |
$77.00
|
| Rate for Payer: One Health Plan PPO/POS |
$99.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$241.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$208.89
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$280.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$104.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$560.58
|
| Rate for Payer: Three Rivers Provider Network All |
$82.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$274.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$280.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$102.30
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$280.29
|
| Rate for Payer: Zelis Auto |
$44.00
|
| Rate for Payer: Zelis Medicare |
$238.25
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$336.35
|
| Rate for Payer: Zelis Worker's Compensation |
$30.03
|
|
|
NJX ANES&/STEROID PLANTAR COMMON DIG NER
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
CPT 64455
|
| Hospital Charge Code |
6164455
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$30.03 |
| Max. Negotiated Rate |
$104.50 |
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$93.50
|
| Rate for Payer: First Health Commercial |
$99.00
|
| Rate for Payer: First Health Workers Compensation |
$42.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$99.00
|
| Rate for Payer: GEHA Commercial |
$77.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$99.00
|
| Rate for Payer: Multiplan All |
$100.10
|
| Rate for Payer: OMNI Networks Commercial |
$77.00
|
| Rate for Payer: One Health Plan PPO/POS |
$99.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$104.50
|
| Rate for Payer: Three Rivers Provider Network All |
$82.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$102.30
|
| Rate for Payer: Zelis Auto |
$44.00
|
| Rate for Payer: Zelis Worker's Compensation |
$30.03
|
|
|
NJX ANES&/STEROID PLANTAR COMMON DIG NER
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
CPT 64455
|
| Hospital Charge Code |
8300053
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$39.86 |
| Max. Negotiated Rate |
$138.70 |
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cigna Commercial |
$124.10
|
| Rate for Payer: First Health Commercial |
$131.40
|
| Rate for Payer: First Health Workers Compensation |
$56.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$131.40
|
| Rate for Payer: GEHA Commercial |
$102.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$131.40
|
| Rate for Payer: Multiplan All |
$132.86
|
| Rate for Payer: OMNI Networks Commercial |
$102.20
|
| Rate for Payer: One Health Plan PPO/POS |
$131.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$138.70
|
| Rate for Payer: Three Rivers Provider Network All |
$109.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$135.78
|
| Rate for Payer: Zelis Auto |
$58.40
|
| Rate for Payer: Zelis Worker's Compensation |
$39.86
|
|
|
NJX ANES&/STEROID PLANTAR COMMON DIG NER
|
Facility
|
OP
|
$978.00
|
|
|
Service Code
|
CPT 64455
|
| Hospital Charge Code |
9664455
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$204.72 |
| Max. Negotiated Rate |
$929.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$586.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$204.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$280.29
|
| Rate for Payer: Cash Price |
$586.80
|
| Rate for Payer: Cash Price |
$586.80
|
| Rate for Payer: Cigna Commercial |
$831.30
|
| Rate for Payer: First Health Commercial |
$880.20
|
| Rate for Payer: First Health Workers Compensation |
$377.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$880.20
|
| Rate for Payer: GEHA Commercial |
$782.40
|
| Rate for Payer: GEHA Medicare |
$280.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$880.20
|
| Rate for Payer: Humana ChoiceCare |
$308.32
|
| Rate for Payer: Humana Medicare Advantage |
$280.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$470.89
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$208.89
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$280.29
|
| Rate for Payer: Multiplan All |
$889.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$476.49
|
| Rate for Payer: OMNI Networks Commercial |
$684.60
|
| Rate for Payer: One Health Plan PPO/POS |
$880.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$241.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$208.89
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$280.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$929.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$560.58
|
| Rate for Payer: Three Rivers Provider Network All |
$733.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$274.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$280.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$909.54
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$280.29
|
| Rate for Payer: Zelis Auto |
$391.20
|
| Rate for Payer: Zelis Medicare |
$238.25
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$336.35
|
| Rate for Payer: Zelis Worker's Compensation |
$266.99
|
|
|
NJX ANES&/STEROID PLANTAR COMMON DIG NER
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
CPT 64455
|
| Hospital Charge Code |
8764455
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$39.86 |
| Max. Negotiated Rate |
$138.70 |
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cigna Commercial |
$124.10
|
| Rate for Payer: First Health Commercial |
$131.40
|
| Rate for Payer: First Health Workers Compensation |
$56.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$131.40
|
| Rate for Payer: GEHA Commercial |
$102.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$131.40
|
| Rate for Payer: Multiplan All |
$132.86
|
| Rate for Payer: OMNI Networks Commercial |
$102.20
|
| Rate for Payer: One Health Plan PPO/POS |
$131.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$138.70
|
| Rate for Payer: Three Rivers Provider Network All |
$109.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$135.78
|
| Rate for Payer: Zelis Auto |
$58.40
|
| Rate for Payer: Zelis Worker's Compensation |
$39.86
|
|
|
NJX ANES&/STEROID PLANTAR COMMON DIG NER
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
CPT 64455
|
| Hospital Charge Code |
8764455
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$39.86 |
| Max. Negotiated Rate |
$560.58 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$87.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$204.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$280.29
|
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cigna Commercial |
$124.10
|
| Rate for Payer: First Health Commercial |
$131.40
|
| Rate for Payer: First Health Workers Compensation |
$56.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$131.40
|
| Rate for Payer: GEHA Commercial |
$116.80
|
| Rate for Payer: GEHA Medicare |
$280.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$131.40
|
| Rate for Payer: Humana ChoiceCare |
$308.32
|
| Rate for Payer: Humana Medicare Advantage |
$280.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$470.89
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$208.89
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$280.29
|
| Rate for Payer: Multiplan All |
$132.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$476.49
|
| Rate for Payer: OMNI Networks Commercial |
$102.20
|
| Rate for Payer: One Health Plan PPO/POS |
$131.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$241.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$208.89
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$280.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$138.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$560.58
|
| Rate for Payer: Three Rivers Provider Network All |
$109.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$274.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$280.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$135.78
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$280.29
|
| Rate for Payer: Zelis Auto |
$58.40
|
| Rate for Payer: Zelis Medicare |
$238.25
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$336.35
|
| Rate for Payer: Zelis Worker's Compensation |
$39.86
|
|
|
NJX ANES&/STEROID PLANTAR COMMON DIG NER
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
CPT 64455
|
| Hospital Charge Code |
8300053
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$39.86 |
| Max. Negotiated Rate |
$560.58 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$87.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$204.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$280.29
|
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cigna Commercial |
$124.10
|
| Rate for Payer: First Health Commercial |
$131.40
|
| Rate for Payer: First Health Workers Compensation |
$56.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$131.40
|
| Rate for Payer: GEHA Commercial |
$116.80
|
| Rate for Payer: GEHA Medicare |
$280.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$131.40
|
| Rate for Payer: Humana ChoiceCare |
$308.32
|
| Rate for Payer: Humana Medicare Advantage |
$280.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$470.89
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$208.89
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$280.29
|
| Rate for Payer: Multiplan All |
$132.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$476.49
|
| Rate for Payer: OMNI Networks Commercial |
$102.20
|
| Rate for Payer: One Health Plan PPO/POS |
$131.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$241.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$208.89
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$280.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$138.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$560.58
|
| Rate for Payer: Three Rivers Provider Network All |
$109.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$274.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$280.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$135.78
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$280.29
|
| Rate for Payer: Zelis Auto |
$58.40
|
| Rate for Payer: Zelis Medicare |
$238.25
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$336.35
|
| Rate for Payer: Zelis Worker's Compensation |
$39.86
|
|
