|
oligoclonal bands csf and serumREF019216
|
Facility
|
OP
|
$221.00
|
|
|
Service Code
|
CPT 83916
|
| Hospital Charge Code |
2299795
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.28 |
| Max. Negotiated Rate |
$209.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$49.30
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$132.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$49.30
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$39.06
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$27.39
|
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cigna Commercial |
$187.85
|
| Rate for Payer: First Health Commercial |
$198.90
|
| Rate for Payer: First Health Workers Compensation |
$45.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$198.90
|
| Rate for Payer: GEHA Commercial |
$176.80
|
| Rate for Payer: GEHA Medicare |
$27.39
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$198.90
|
| Rate for Payer: Humana ChoiceCare |
$30.13
|
| Rate for Payer: Humana Medicare Advantage |
$27.39
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$46.02
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$39.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$27.39
|
| Rate for Payer: Multiplan All |
$201.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$46.56
|
| Rate for Payer: OMNI Networks Commercial |
$154.70
|
| Rate for Payer: One Health Plan PPO/POS |
$198.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$46.02
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$39.85
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$27.39
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$209.95
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$54.78
|
| Rate for Payer: Three Rivers Provider Network All |
$165.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$26.84
|
| Rate for Payer: United Healthcare Commercial |
$187.85
|
| Rate for Payer: United Healthcare Managed Medicaid |
$39.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.39
|
| Rate for Payer: United Payors & United Providers UP&UP |
$205.53
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$27.39
|
| Rate for Payer: Zelis Auto |
$88.40
|
| Rate for Payer: Zelis Medicare |
$23.28
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$32.87
|
| Rate for Payer: Zelis Worker's Compensation |
$32.12
|
|
|
oligoclonal bands csf and serumREF019216
|
Facility
|
IP
|
$221.00
|
|
|
Service Code
|
CPT 83916
|
| Hospital Charge Code |
2299795
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$32.12 |
| Max. Negotiated Rate |
$209.95 |
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cigna Commercial |
$187.85
|
| Rate for Payer: First Health Commercial |
$198.90
|
| Rate for Payer: First Health Workers Compensation |
$45.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$198.90
|
| Rate for Payer: GEHA Commercial |
$154.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$198.90
|
| Rate for Payer: Multiplan All |
$201.11
|
| Rate for Payer: OMNI Networks Commercial |
$154.70
|
| Rate for Payer: One Health Plan PPO/POS |
$198.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$209.95
|
| Rate for Payer: Three Rivers Provider Network All |
$165.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$205.53
|
| Rate for Payer: Zelis Auto |
$88.40
|
| Rate for Payer: Zelis Worker's Compensation |
$32.12
|
|
|
olive tree IgE REF602527
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299161
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.22
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: GEHA Medicare |
$5.22
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.22
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.76
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.59
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.22
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10.44
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.12
|
| Rate for Payer: United Healthcare Commercial |
$47.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.22
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Medicare |
$4.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.26
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
olive tree IgE REF602527
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299161
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
OLMESARTAN MEDOXOMIL TAB 20MG
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
NDC 65597010310
|
| Hospital Charge Code |
3300668
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.75 |
| Max. Negotiated Rate |
$29.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$18.60
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$26.35
|
| Rate for Payer: First Health Commercial |
$27.90
|
| Rate for Payer: First Health Workers Compensation |
$11.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.90
|
| Rate for Payer: GEHA Commercial |
$24.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.90
|
| Rate for Payer: Humana ChoiceCare |
$8.06
|
| Rate for Payer: Multiplan All |
$28.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$18.60
|
| Rate for Payer: OMNI Networks Commercial |
$21.70
|
| Rate for Payer: One Health Plan PPO/POS |
$27.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$29.45
|
| Rate for Payer: Three Rivers Provider Network All |
$23.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$27.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$28.83
|
| Rate for Payer: Zelis Auto |
$12.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.50
|
| Rate for Payer: Zelis Worker's Compensation |
$8.46
|
|
|
OLMESARTAN MEDOXOMIL TAB 20MG
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
NDC 65597010310
|
| Hospital Charge Code |
3300668
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$29.45 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$26.35
|
| Rate for Payer: First Health Commercial |
$27.90
|
| Rate for Payer: First Health Workers Compensation |
$11.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.90
|
| Rate for Payer: GEHA Commercial |
$21.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.90
|
| Rate for Payer: Multiplan All |
$28.21
|
| Rate for Payer: OMNI Networks Commercial |
$21.70
|
| Rate for Payer: One Health Plan PPO/POS |
$27.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$29.45
|
| Rate for Payer: Three Rivers Provider Network All |
$23.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$28.83
|
| Rate for Payer: Zelis Auto |
$12.40
|
| Rate for Payer: Zelis Worker's Compensation |
$8.46
|
|
|
OM- ACETAMINOPHEN TAB 325MG
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
OM- ACETAMINOPHEN TAB 325MG
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
OMALIZUMAB 150 MG INJ
|
Facility
|
IP
|
$4,197.00
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
3303174
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,145.78 |
| Max. Negotiated Rate |
$3,987.15 |
| Rate for Payer: Cash Price |
$2,518.20
|
| Rate for Payer: Cigna Commercial |
$3,567.45
|
| Rate for Payer: First Health Commercial |
$3,777.30
|
| Rate for Payer: First Health Workers Compensation |
$1,620.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,777.30
|
| Rate for Payer: GEHA Commercial |
$2,937.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,777.30
|
| Rate for Payer: Multiplan All |
$3,819.27
|
| Rate for Payer: OMNI Networks Commercial |
$2,937.90
|
| Rate for Payer: One Health Plan PPO/POS |
$3,777.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,987.15
|
| Rate for Payer: Three Rivers Provider Network All |
$3,147.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,903.21
|
| Rate for Payer: Zelis Auto |
$1,678.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1,145.78
|
|
|
OMALIZUMAB 150 MG INJ
|
Facility
|
OP
|
$4,197.00
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
3303174
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.21 |
| Max. Negotiated Rate |
$3,987.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$43.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,518.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$43.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$34.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$44.60
|
| Rate for Payer: Cash Price |
$2,518.20
|
| Rate for Payer: Cash Price |
$2,518.20
|
| Rate for Payer: Cigna Commercial |
$3,567.45
|
| Rate for Payer: First Health Commercial |
$3,777.30
|
| Rate for Payer: First Health Workers Compensation |
$1,620.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,777.30
|
| Rate for Payer: GEHA Commercial |
$49.06
|
| Rate for Payer: GEHA Medicare |
$44.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,777.30
|
| Rate for Payer: Humana ChoiceCare |
$49.06
|
| Rate for Payer: Humana Medicare Advantage |
$44.60
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$74.93
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$34.91
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$44.60
|
| Rate for Payer: Multiplan All |
$3,819.27
|
| Rate for Payer: New Mexico Health Connections Medicare |
$75.82
|
| Rate for Payer: OMNI Networks Commercial |
$2,937.90
|
| Rate for Payer: One Health Plan PPO/POS |
$3,777.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$40.31
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$34.91
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$44.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,987.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$89.20
|
| Rate for Payer: Three Rivers Provider Network All |
$3,147.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$43.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$34.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.60
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,903.21
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$44.60
|
| Rate for Payer: Zelis Auto |
$1,678.80
|
| Rate for Payer: Zelis Medicare |
$37.91
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$53.52
|
| Rate for Payer: Zelis Worker's Compensation |
$1,145.78
|
|
|
OM- ASPIRIN CHEW TAB 81MG
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 63739043401
|
| Hospital Charge Code |
3350457
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
OM- ASPIRIN CHEW TAB 81MG
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 63739043401
|
| Hospital Charge Code |
3350457
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
OM- CEFTRIAXONE INJ 1000 MG
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
3350446
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.47 |
| 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: 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 |
$0.47
|
| 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
|
|
|
OM- CEFTRIAXONE INJ 1000 MG
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
3350446
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
OM- CIPROFLOXACIN HCL 0.3% EYE DROPS
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 69315030802
|
| Hospital Charge Code |
3350459
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
OM- CIPROFLOXACIN HCL 0.3% EYE DROPS
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 69315030802
|
| Hospital Charge Code |
3350459
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
OM- DIPHENHYDRAMINE HCL INJ 50MG/ML
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
CPT J1200
|
| Hospital Charge Code |
3350448
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.84 |
| 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: 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 |
$0.84
|
| 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
|
|
|
OM- DIPHENHYDRAMINE HCL INJ 50MG/ML
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
CPT J1200
|
| Hospital Charge Code |
3350448
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
OMEGA-3 1000MG CAP
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 77333030810
|
| Hospital Charge Code |
3300670
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
OMEGA-3 1000MG CAP
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 77333030810
|
| Hospital Charge Code |
3300670
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
OMENTAL FLAP, INTRA-ABDOM
|
Facility
|
IP
|
$936.00
|
|
|
Service Code
|
CPT 49905
|
| Hospital Charge Code |
6149905
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$255.53 |
| Max. Negotiated Rate |
$889.20 |
| Rate for Payer: Cash Price |
$561.60
|
| Rate for Payer: Cigna Commercial |
$795.60
|
| Rate for Payer: First Health Commercial |
$842.40
|
| Rate for Payer: First Health Workers Compensation |
$361.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$842.40
|
| Rate for Payer: GEHA Commercial |
$655.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$842.40
|
| Rate for Payer: Multiplan All |
$851.76
|
| Rate for Payer: OMNI Networks Commercial |
$655.20
|
| Rate for Payer: One Health Plan PPO/POS |
$842.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$889.20
|
| Rate for Payer: Three Rivers Provider Network All |
$702.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$870.48
|
| Rate for Payer: Zelis Auto |
$374.40
|
| Rate for Payer: Zelis Worker's Compensation |
$255.53
|
|
|
OMENTAL FLAP, INTRA-ABDOM
|
Facility
|
OP
|
$936.00
|
|
|
Service Code
|
CPT 49905
|
| Hospital Charge Code |
6149905
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$234.00 |
| Max. Negotiated Rate |
$889.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$561.60
|
| Rate for Payer: Cash Price |
$561.60
|
| Rate for Payer: Cigna Commercial |
$795.60
|
| Rate for Payer: First Health Commercial |
$842.40
|
| Rate for Payer: First Health Workers Compensation |
$361.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$842.40
|
| Rate for Payer: GEHA Commercial |
$748.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$842.40
|
| Rate for Payer: Humana ChoiceCare |
$243.36
|
| Rate for Payer: Multiplan All |
$851.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$561.60
|
| Rate for Payer: OMNI Networks Commercial |
$655.20
|
| Rate for Payer: One Health Plan PPO/POS |
$842.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$889.20
|
| Rate for Payer: Three Rivers Provider Network All |
$702.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$823.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$234.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$870.48
|
| Rate for Payer: Zelis Auto |
$374.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$468.00
|
| Rate for Payer: Zelis Worker's Compensation |
$255.53
|
|
|
OM- EPINEPHRINE AUTO-INJECTOR 0.3MG
|
Facility
|
IP
|
$914.00
|
|
|
Service Code
|
CPT J0171
|
| Hospital Charge Code |
3350449
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$249.52 |
| Max. Negotiated Rate |
$868.30 |
| Rate for Payer: Cash Price |
$548.40
|
| Rate for Payer: Cigna Commercial |
$776.90
|
| Rate for Payer: First Health Commercial |
$822.60
|
| Rate for Payer: First Health Workers Compensation |
$352.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$822.60
|
| Rate for Payer: GEHA Commercial |
$639.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$822.60
|
| Rate for Payer: Multiplan All |
$831.74
|
| Rate for Payer: OMNI Networks Commercial |
$639.80
|
| Rate for Payer: One Health Plan PPO/POS |
$822.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$868.30
|
| Rate for Payer: Three Rivers Provider Network All |
$685.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$850.02
|
| Rate for Payer: Zelis Auto |
$365.60
|
| Rate for Payer: Zelis Worker's Compensation |
$249.52
|
|
|
OM- EPINEPHRINE AUTO-INJECTOR 0.3MG
|
Facility
|
OP
|
$914.00
|
|
|
Service Code
|
CPT J0171
|
| Hospital Charge Code |
3350449
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$228.50 |
| Max. Negotiated Rate |
$868.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$548.40
|
| Rate for Payer: Cash Price |
$548.40
|
| Rate for Payer: Cigna Commercial |
$776.90
|
| Rate for Payer: First Health Commercial |
$822.60
|
| Rate for Payer: First Health Workers Compensation |
$352.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$822.60
|
| Rate for Payer: GEHA Commercial |
$731.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$822.60
|
| Rate for Payer: Humana ChoiceCare |
$237.64
|
| Rate for Payer: Multiplan All |
$831.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$548.40
|
| Rate for Payer: OMNI Networks Commercial |
$639.80
|
| Rate for Payer: One Health Plan PPO/POS |
$822.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$868.30
|
| Rate for Payer: Three Rivers Provider Network All |
$685.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$804.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$228.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$850.02
|
| Rate for Payer: Zelis Auto |
$365.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$457.00
|
| Rate for Payer: Zelis Worker's Compensation |
$249.52
|
|
|
OM- EYE WASH SOLUTION - 120 ML
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
NDC 00536122497
|
| Hospital Charge Code |
3350460
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$28.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$25.50
|
| Rate for Payer: First Health Commercial |
$27.00
|
| Rate for Payer: First Health Workers Compensation |
$11.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.00
|
| Rate for Payer: GEHA Commercial |
$24.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.00
|
| Rate for Payer: Humana ChoiceCare |
$7.80
|
| Rate for Payer: Multiplan All |
$27.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$18.00
|
| Rate for Payer: OMNI Networks Commercial |
$21.00
|
| Rate for Payer: One Health Plan PPO/POS |
$27.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$28.50
|
| Rate for Payer: Three Rivers Provider Network All |
$22.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$26.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$27.90
|
| Rate for Payer: Zelis Auto |
$12.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.19
|
|
