|
OFF/OTHR OP CONS NEW/ESTAB; 55 MINS OR M
|
Facility
|
OP
|
$515.00
|
|
|
Service Code
|
CPT 99245
|
| Hospital Charge Code |
8699245
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$128.75 |
| Max. Negotiated Rate |
$489.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$309.00
|
| Rate for Payer: Cash Price |
$309.00
|
| Rate for Payer: Cigna Commercial |
$437.75
|
| Rate for Payer: First Health Commercial |
$463.50
|
| Rate for Payer: First Health Workers Compensation |
$198.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$463.50
|
| Rate for Payer: GEHA Commercial |
$412.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$463.50
|
| Rate for Payer: Humana ChoiceCare |
$133.90
|
| Rate for Payer: Multiplan All |
$468.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$309.00
|
| Rate for Payer: OMNI Networks Commercial |
$360.50
|
| Rate for Payer: One Health Plan PPO/POS |
$463.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$489.25
|
| Rate for Payer: Three Rivers Provider Network All |
$386.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$453.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$128.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$478.95
|
| Rate for Payer: Zelis Auto |
$206.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$257.50
|
| Rate for Payer: Zelis Worker's Compensation |
$140.59
|
|
|
OFF/OTHR OP CONS NEW/ESTAB; 55 MINS OR M
|
Facility
|
IP
|
$515.00
|
|
|
Service Code
|
CPT 99245
|
| Hospital Charge Code |
8399245
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$140.59 |
| Max. Negotiated Rate |
$489.25 |
| Rate for Payer: Cash Price |
$309.00
|
| Rate for Payer: Cigna Commercial |
$437.75
|
| Rate for Payer: First Health Commercial |
$463.50
|
| Rate for Payer: First Health Workers Compensation |
$198.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$463.50
|
| Rate for Payer: GEHA Commercial |
$360.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$463.50
|
| Rate for Payer: Multiplan All |
$468.65
|
| Rate for Payer: OMNI Networks Commercial |
$360.50
|
| Rate for Payer: One Health Plan PPO/POS |
$463.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$489.25
|
| Rate for Payer: Three Rivers Provider Network All |
$386.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$478.95
|
| Rate for Payer: Zelis Auto |
$206.00
|
| Rate for Payer: Zelis Worker's Compensation |
$140.59
|
|
|
OFF/OTHR OP CONS NEW/ESTAB; 55 MINS OR M
|
Facility
|
OP
|
$515.00
|
|
|
Service Code
|
CPT 99245
|
| Hospital Charge Code |
21600063
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$128.75 |
| Max. Negotiated Rate |
$489.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$309.00
|
| Rate for Payer: Cash Price |
$309.00
|
| Rate for Payer: Cigna Commercial |
$437.75
|
| Rate for Payer: First Health Commercial |
$463.50
|
| Rate for Payer: First Health Workers Compensation |
$198.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$463.50
|
| Rate for Payer: GEHA Commercial |
$412.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$463.50
|
| Rate for Payer: Humana ChoiceCare |
$133.90
|
| Rate for Payer: Multiplan All |
$468.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$309.00
|
| Rate for Payer: OMNI Networks Commercial |
$360.50
|
| Rate for Payer: One Health Plan PPO/POS |
$463.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$489.25
|
| Rate for Payer: Three Rivers Provider Network All |
$386.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$453.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$128.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$478.95
|
| Rate for Payer: Zelis Auto |
$206.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$257.50
|
| Rate for Payer: Zelis Worker's Compensation |
$140.59
|
|
|
OFF/OTHR OP CONS NEW/ESTAB; 55 MINS OR M
|
Facility
|
OP
|
$515.00
|
|
|
Service Code
|
CPT 99245
|
| Hospital Charge Code |
8399245
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$128.75 |
| Max. Negotiated Rate |
$489.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$309.00
|
| Rate for Payer: Cash Price |
$309.00
|
| Rate for Payer: Cigna Commercial |
$437.75
|
| Rate for Payer: First Health Commercial |
$463.50
|
| Rate for Payer: First Health Workers Compensation |
$198.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$463.50
|
| Rate for Payer: GEHA Commercial |
$412.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$463.50
|
| Rate for Payer: Humana ChoiceCare |
$133.90
|
| Rate for Payer: Multiplan All |
$468.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$309.00
|
| Rate for Payer: OMNI Networks Commercial |
$360.50
|
| Rate for Payer: One Health Plan PPO/POS |
$463.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$489.25
|
| Rate for Payer: Three Rivers Provider Network All |
$386.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$453.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$128.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$478.95
|
| Rate for Payer: Zelis Auto |
$206.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$257.50
|
| Rate for Payer: Zelis Worker's Compensation |
$140.59
|
|
|
OFF/OTHR OP CONS NEW/ESTAB; 55 MINS OR M
|
Facility
|
OP
|
$363.90
|
|
|
Service Code
|
CPT 99245
|
| Hospital Charge Code |
7299245
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$90.97 |
| Max. Negotiated Rate |
$345.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$218.34
|
| Rate for Payer: Cash Price |
$218.34
|
| Rate for Payer: Cigna Commercial |
$309.31
|
| Rate for Payer: First Health Commercial |
$327.51
|
| Rate for Payer: First Health Workers Compensation |
$140.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$327.51
|
| Rate for Payer: GEHA Commercial |
$291.12
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$327.51
|
| Rate for Payer: Humana ChoiceCare |
$94.61
|
| Rate for Payer: Multiplan All |
$331.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$218.34
|
| Rate for Payer: OMNI Networks Commercial |
$254.73
|
| Rate for Payer: One Health Plan PPO/POS |
$327.51
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$345.70
|
| Rate for Payer: Three Rivers Provider Network All |
$272.93
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$320.23
|
| Rate for Payer: United Healthcare Managed Medicaid |
$90.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$338.43
|
| Rate for Payer: Zelis Auto |
$145.56
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$181.95
|
| Rate for Payer: Zelis Worker's Compensation |
$99.34
|
|
|
OFF VIS NEW PT STRFWD MDM AT LEAST 15 MI
|
Facility
|
IP
|
$209.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
9699202
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$57.06 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$177.65
|
| Rate for Payer: First Health Commercial |
$188.10
|
| Rate for Payer: First Health Workers Compensation |
$80.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$188.10
|
| Rate for Payer: GEHA Commercial |
$146.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$188.10
|
| Rate for Payer: Multiplan All |
$190.19
|
| Rate for Payer: OMNI Networks Commercial |
$146.30
|
| Rate for Payer: One Health Plan PPO/POS |
$188.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$198.55
|
| Rate for Payer: Three Rivers Provider Network All |
$156.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$194.37
|
| Rate for Payer: Zelis Auto |
$83.60
|
| Rate for Payer: Zelis Worker's Compensation |
$57.06
|
|
|
OFF VIS NEW PT STRFWD MDM AT LEAST 15 MI
|
Facility
|
IP
|
$209.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
20399202
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$57.06 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$177.65
|
| Rate for Payer: First Health Commercial |
$188.10
|
| Rate for Payer: First Health Workers Compensation |
$80.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$188.10
|
| Rate for Payer: GEHA Commercial |
$146.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$188.10
|
| Rate for Payer: Multiplan All |
$190.19
|
| Rate for Payer: OMNI Networks Commercial |
$146.30
|
| Rate for Payer: One Health Plan PPO/POS |
$188.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$198.55
|
| Rate for Payer: Three Rivers Provider Network All |
$156.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$194.37
|
| Rate for Payer: Zelis Auto |
$83.60
|
| Rate for Payer: Zelis Worker's Compensation |
$57.06
|
|
|
OFF VIS NEW PT STRFWD MDM AT LEAST 15 MI
|
Facility
|
OP
|
$209.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
20399202
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$52.25 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$125.40
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$177.65
|
| Rate for Payer: First Health Commercial |
$188.10
|
| Rate for Payer: First Health Workers Compensation |
$80.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$188.10
|
| Rate for Payer: GEHA Commercial |
$167.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$188.10
|
| Rate for Payer: Humana ChoiceCare |
$54.34
|
| Rate for Payer: Multiplan All |
$190.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$125.40
|
| Rate for Payer: OMNI Networks Commercial |
$146.30
|
| Rate for Payer: One Health Plan PPO/POS |
$188.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$198.55
|
| Rate for Payer: Three Rivers Provider Network All |
$156.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$183.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$52.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$194.37
|
| Rate for Payer: Zelis Auto |
$83.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$104.50
|
| Rate for Payer: Zelis Worker's Compensation |
$57.06
|
|
|
OFF VIS NEW PT STRFWD MDM AT LEAST 15 MI
|
Facility
|
OP
|
$209.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
9699202
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$52.25 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$125.40
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$177.65
|
| Rate for Payer: First Health Commercial |
$188.10
|
| Rate for Payer: First Health Workers Compensation |
$80.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$188.10
|
| Rate for Payer: GEHA Commercial |
$167.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$188.10
|
| Rate for Payer: Humana ChoiceCare |
$54.34
|
| Rate for Payer: Multiplan All |
$190.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$125.40
|
| Rate for Payer: OMNI Networks Commercial |
$146.30
|
| Rate for Payer: One Health Plan PPO/POS |
$188.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$198.55
|
| Rate for Payer: Three Rivers Provider Network All |
$156.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$183.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$52.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$194.37
|
| Rate for Payer: Zelis Auto |
$83.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$104.50
|
| Rate for Payer: Zelis Worker's Compensation |
$57.06
|
|
|
OFLOXACIN OPTH SOLN 0.3%
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
NDC 11980077905
|
| Hospital Charge Code |
3300662
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.28 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cigna Commercial |
$28.90
|
| Rate for Payer: First Health Commercial |
$30.60
|
| Rate for Payer: First Health Workers Compensation |
$13.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$30.60
|
| Rate for Payer: GEHA Commercial |
$23.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$30.60
|
| Rate for Payer: Multiplan All |
$30.94
|
| Rate for Payer: OMNI Networks Commercial |
$23.80
|
| Rate for Payer: One Health Plan PPO/POS |
$30.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$32.30
|
| Rate for Payer: Three Rivers Provider Network All |
$25.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$31.62
|
| Rate for Payer: Zelis Auto |
$13.60
|
| Rate for Payer: Zelis Worker's Compensation |
$9.28
|
|
|
OFLOXACIN OPTH SOLN 0.3%
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
NDC 11980077905
|
| Hospital Charge Code |
3300662
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$20.40
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cigna Commercial |
$28.90
|
| Rate for Payer: First Health Commercial |
$30.60
|
| Rate for Payer: First Health Workers Compensation |
$13.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$30.60
|
| Rate for Payer: GEHA Commercial |
$27.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$30.60
|
| Rate for Payer: Humana ChoiceCare |
$8.84
|
| Rate for Payer: Multiplan All |
$30.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$20.40
|
| Rate for Payer: OMNI Networks Commercial |
$23.80
|
| Rate for Payer: One Health Plan PPO/POS |
$30.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$32.30
|
| Rate for Payer: Three Rivers Provider Network All |
$25.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$29.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$31.62
|
| Rate for Payer: Zelis Auto |
$13.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.28
|
|
|
OFLOXACIN OTIC SOLN 0.3%
|
Facility
|
OP
|
$302.00
|
|
|
Service Code
|
NDC 60505036301
|
| Hospital Charge Code |
3300663
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.50 |
| Max. Negotiated Rate |
$286.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$181.20
|
| Rate for Payer: Cash Price |
$181.20
|
| Rate for Payer: Cigna Commercial |
$256.70
|
| Rate for Payer: First Health Commercial |
$271.80
|
| Rate for Payer: First Health Workers Compensation |
$116.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$271.80
|
| Rate for Payer: GEHA Commercial |
$241.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$271.80
|
| Rate for Payer: Humana ChoiceCare |
$78.52
|
| Rate for Payer: Multiplan All |
$274.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$181.20
|
| Rate for Payer: OMNI Networks Commercial |
$211.40
|
| Rate for Payer: One Health Plan PPO/POS |
$271.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$286.90
|
| Rate for Payer: Three Rivers Provider Network All |
$226.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$265.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$75.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$280.86
|
| Rate for Payer: Zelis Auto |
$120.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$151.00
|
| Rate for Payer: Zelis Worker's Compensation |
$82.45
|
|
|
OFLOXACIN OTIC SOLN 0.3%
|
Facility
|
OP
|
$301.00
|
|
|
Service Code
|
NDC 61314001505
|
| Hospital Charge Code |
3300664
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.25 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$180.60
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$240.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Humana ChoiceCare |
$78.26
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$180.60
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$264.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$75.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$150.50
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
OFLOXACIN OTIC SOLN 0.3%
|
Facility
|
IP
|
$301.00
|
|
|
Service Code
|
NDC 61314001505
|
| Hospital Charge Code |
3300664
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.17 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$210.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
OFLOXACIN OTIC SOLN 0.3%
|
Facility
|
IP
|
$302.00
|
|
|
Service Code
|
NDC 60505036301
|
| Hospital Charge Code |
3300663
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.45 |
| Max. Negotiated Rate |
$286.90 |
| Rate for Payer: Cash Price |
$181.20
|
| Rate for Payer: Cigna Commercial |
$256.70
|
| Rate for Payer: First Health Commercial |
$271.80
|
| Rate for Payer: First Health Workers Compensation |
$116.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$271.80
|
| Rate for Payer: GEHA Commercial |
$211.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$271.80
|
| Rate for Payer: Multiplan All |
$274.82
|
| Rate for Payer: OMNI Networks Commercial |
$211.40
|
| Rate for Payer: One Health Plan PPO/POS |
$271.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$286.90
|
| Rate for Payer: Three Rivers Provider Network All |
$226.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$280.86
|
| Rate for Payer: Zelis Auto |
$120.80
|
| Rate for Payer: Zelis Worker's Compensation |
$82.45
|
|
|
OGCT 50G GLUCOSE (Vitros)
|
Facility
|
IP
|
$213.00
|
|
|
Service Code
|
CPT 82951
|
| Hospital Charge Code |
2232270
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.83 |
| Max. Negotiated Rate |
$202.35 |
| Rate for Payer: Cash Price |
$127.80
|
| Rate for Payer: Cash Price |
$127.80
|
| Rate for Payer: Cigna Commercial |
$181.05
|
| Rate for Payer: First Health Commercial |
$191.70
|
| Rate for Payer: First Health Workers Compensation |
$20.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$191.70
|
| Rate for Payer: GEHA Commercial |
$149.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$191.70
|
| Rate for Payer: Multiplan All |
$193.83
|
| Rate for Payer: OMNI Networks Commercial |
$149.10
|
| Rate for Payer: One Health Plan PPO/POS |
$191.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$202.35
|
| Rate for Payer: Three Rivers Provider Network All |
$159.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$198.09
|
| Rate for Payer: Zelis Auto |
$85.20
|
| Rate for Payer: Zelis Worker's Compensation |
$14.83
|
|
|
OGCT 50G GLUCOSE (Vitros)
|
Facility
|
OP
|
$213.00
|
|
|
Service Code
|
CPT 82951
|
| Hospital Charge Code |
2232270
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.94 |
| Max. Negotiated Rate |
$202.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$23.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$127.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$23.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$18.35
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$12.87
|
| Rate for Payer: Cash Price |
$127.80
|
| Rate for Payer: Cash Price |
$127.80
|
| Rate for Payer: Cigna Commercial |
$181.05
|
| Rate for Payer: First Health Commercial |
$191.70
|
| Rate for Payer: First Health Workers Compensation |
$20.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$191.70
|
| Rate for Payer: GEHA Commercial |
$170.40
|
| Rate for Payer: GEHA Medicare |
$12.87
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$191.70
|
| Rate for Payer: Humana ChoiceCare |
$14.16
|
| Rate for Payer: Humana Medicare Advantage |
$12.87
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$21.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$18.72
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$12.87
|
| Rate for Payer: Multiplan All |
$193.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$21.88
|
| Rate for Payer: OMNI Networks Commercial |
$149.10
|
| Rate for Payer: One Health Plan PPO/POS |
$191.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$21.62
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$18.72
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$12.87
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$202.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$25.74
|
| Rate for Payer: Three Rivers Provider Network All |
$159.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.61
|
| Rate for Payer: United Healthcare Commercial |
$181.05
|
| Rate for Payer: United Healthcare Managed Medicaid |
$18.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.87
|
| Rate for Payer: United Payors & United Providers UP&UP |
$198.09
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$12.87
|
| Rate for Payer: Zelis Auto |
$85.20
|
| Rate for Payer: Zelis Medicare |
$10.94
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.44
|
| Rate for Payer: Zelis Worker's Compensation |
$14.83
|
|
|
OLANZapine 10MG IM ONLY INJECTION
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT J2358
|
| Hospital Charge Code |
3300665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$4.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$4.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$2.92
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$42.50
|
| Rate for Payer: First Health Commercial |
$45.00
|
| Rate for Payer: First Health Workers Compensation |
$19.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.00
|
| Rate for Payer: GEHA Commercial |
$3.21
|
| Rate for Payer: GEHA Medicare |
$2.92
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Humana ChoiceCare |
$3.21
|
| Rate for Payer: Humana Medicare Advantage |
$2.92
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$4.91
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3.54
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$2.92
|
| Rate for Payer: Multiplan All |
$45.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.96
|
| Rate for Payer: OMNI Networks Commercial |
$35.00
|
| Rate for Payer: One Health Plan PPO/POS |
$45.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$4.09
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3.54
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$2.92
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$5.84
|
| Rate for Payer: Three Rivers Provider Network All |
$37.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.86
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.92
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46.50
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$2.92
|
| Rate for Payer: Zelis Auto |
$20.00
|
| Rate for Payer: Zelis Medicare |
$2.48
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.50
|
| Rate for Payer: Zelis Worker's Compensation |
$13.65
|
|
|
OLANZapine 10MG IM ONLY INJECTION
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT J2358
|
| Hospital Charge Code |
3300665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.65 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$42.50
|
| Rate for Payer: First Health Commercial |
$45.00
|
| Rate for Payer: First Health Workers Compensation |
$19.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.00
|
| Rate for Payer: GEHA Commercial |
$35.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Multiplan All |
$45.50
|
| Rate for Payer: OMNI Networks Commercial |
$35.00
|
| Rate for Payer: One Health Plan PPO/POS |
$45.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47.50
|
| Rate for Payer: Three Rivers Provider Network All |
$37.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46.50
|
| Rate for Payer: Zelis Auto |
$20.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.65
|
|
|
OLANZapine 5MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084072301
|
| Hospital Charge Code |
3300667
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
OLANZapine 5MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084072301
|
| Hospital Charge Code |
3300667
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
OLANZapine ODT 5MG TAB
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 60505327500
|
| Hospital Charge Code |
3300666
|
|
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
|
|
|
OLANZapine ODT 5MG TAB
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 60505327500
|
| Hospital Charge Code |
3300666
|
|
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
|
|
|
olanzapine REF811513
|
Facility
|
OP
|
$274.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
2299327
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$260.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$164.40
|
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cigna Commercial |
$232.90
|
| Rate for Payer: First Health Commercial |
$246.60
|
| Rate for Payer: First Health Workers Compensation |
$27.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$246.60
|
| Rate for Payer: GEHA Commercial |
$219.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$246.60
|
| Rate for Payer: Humana ChoiceCare |
$71.24
|
| Rate for Payer: Multiplan All |
$249.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$164.40
|
| Rate for Payer: OMNI Networks Commercial |
$191.80
|
| Rate for Payer: One Health Plan PPO/POS |
$246.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$260.30
|
| Rate for Payer: Three Rivers Provider Network All |
$205.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$241.12
|
| Rate for Payer: United Healthcare Commercial |
$232.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$68.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$254.82
|
| Rate for Payer: Zelis Auto |
$109.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$137.00
|
| Rate for Payer: Zelis Worker's Compensation |
$19.29
|
|
|
olanzapine REF811513
|
Facility
|
IP
|
$274.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
2299327
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$260.30 |
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cigna Commercial |
$232.90
|
| Rate for Payer: First Health Commercial |
$246.60
|
| Rate for Payer: First Health Workers Compensation |
$27.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$246.60
|
| Rate for Payer: GEHA Commercial |
$191.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$246.60
|
| Rate for Payer: Multiplan All |
$249.34
|
| Rate for Payer: OMNI Networks Commercial |
$191.80
|
| Rate for Payer: One Health Plan PPO/POS |
$246.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$260.30
|
| Rate for Payer: Three Rivers Provider Network All |
$205.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$254.82
|
| Rate for Payer: Zelis Auto |
$109.60
|
| Rate for Payer: Zelis Worker's Compensation |
$19.29
|
|
