|
OM- EYE WASH SOLUTION - 120 ML
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
NDC 00536122497
|
| Hospital Charge Code |
3350460
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.19 |
| Max. Negotiated Rate |
$28.50 |
| 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 |
$21.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.00
|
| Rate for Payer: Multiplan All |
$27.30
|
| 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: United Payors & United Providers UP&UP |
$27.90
|
| Rate for Payer: Zelis Auto |
$12.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.19
|
|
|
OM- HYDROCORTISONE NA+ SUCCINATE 100MG
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
CPT J1720
|
| Hospital Charge Code |
3350450
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.92 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$34.00
|
| Rate for Payer: First Health Commercial |
$36.00
|
| Rate for Payer: First Health Workers Compensation |
$15.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.00
|
| Rate for Payer: GEHA Commercial |
$28.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.00
|
| Rate for Payer: Multiplan All |
$36.40
|
| Rate for Payer: OMNI Networks Commercial |
$28.00
|
| Rate for Payer: One Health Plan PPO/POS |
$36.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.00
|
| Rate for Payer: Three Rivers Provider Network All |
$30.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$37.20
|
| Rate for Payer: Zelis Auto |
$16.00
|
| Rate for Payer: Zelis Worker's Compensation |
$10.92
|
|
|
OM- HYDROCORTISONE NA+ SUCCINATE 100MG
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
CPT J1720
|
| Hospital Charge Code |
3350450
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$34.00
|
| Rate for Payer: First Health Commercial |
$36.00
|
| Rate for Payer: First Health Workers Compensation |
$15.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.00
|
| Rate for Payer: GEHA Commercial |
$23.44
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.00
|
| Rate for Payer: Humana ChoiceCare |
$10.40
|
| Rate for Payer: Multiplan All |
$36.40
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.00
|
| Rate for Payer: OMNI Networks Commercial |
$28.00
|
| Rate for Payer: One Health Plan PPO/POS |
$36.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.00
|
| Rate for Payer: Three Rivers Provider Network All |
$30.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$35.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$37.20
|
| Rate for Payer: Zelis Auto |
$16.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.00
|
| Rate for Payer: Zelis Worker's Compensation |
$10.92
|
|
|
OM- IBUPROFEN TAB 200 MG
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350458
|
|
Hospital Revenue Code
|
637
|
| 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- IBUPROFEN TAB 200 MG
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350458
|
|
Hospital Revenue Code
|
637
|
| 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- KETOROLAC IM INJ 60MG/2ML
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
3350452
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$0.29
|
| Rate for Payer: Cash Price |
$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 |
$0.33
|
| Rate for Payer: GEHA Medicare |
$0.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Humana ChoiceCare |
$0.32
|
| Rate for Payer: Humana Medicare Advantage |
$0.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$0.49
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$0.29
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.49
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$0.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$0.58
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$0.29
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Medicare |
$0.25
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.35
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
OM- KETOROLAC IM INJ 60MG/2ML
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
3350452
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$7.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
OM- KETOROLAC INJ 30MG/ML
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
3350451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$0.29
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$11.05
|
| Rate for Payer: First Health Commercial |
$11.70
|
| Rate for Payer: First Health Workers Compensation |
$5.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11.70
|
| Rate for Payer: GEHA Commercial |
$0.33
|
| Rate for Payer: GEHA Medicare |
$0.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11.70
|
| Rate for Payer: Humana ChoiceCare |
$0.32
|
| Rate for Payer: Humana Medicare Advantage |
$0.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$0.49
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$0.29
|
| Rate for Payer: Multiplan All |
$11.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.49
|
| Rate for Payer: OMNI Networks Commercial |
$9.10
|
| Rate for Payer: One Health Plan PPO/POS |
$11.70
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$0.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$0.58
|
| Rate for Payer: Three Rivers Provider Network All |
$9.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12.09
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$0.29
|
| Rate for Payer: Zelis Auto |
$5.20
|
| Rate for Payer: Zelis Medicare |
$0.25
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.35
|
| Rate for Payer: Zelis Worker's Compensation |
$3.55
|
|
|
OM- KETOROLAC INJ 30MG/ML
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
3350451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.55 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$11.05
|
| Rate for Payer: First Health Commercial |
$11.70
|
| Rate for Payer: First Health Workers Compensation |
$5.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11.70
|
| Rate for Payer: GEHA Commercial |
$9.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11.70
|
| Rate for Payer: Multiplan All |
$11.83
|
| Rate for Payer: OMNI Networks Commercial |
$9.10
|
| Rate for Payer: One Health Plan PPO/POS |
$11.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12.35
|
| Rate for Payer: Three Rivers Provider Network All |
$9.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12.09
|
| Rate for Payer: Zelis Auto |
$5.20
|
| Rate for Payer: Zelis Worker's Compensation |
$3.55
|
|
|
OM- LIDOCAINE 1% 2 ML
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350453
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$16.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Humana ChoiceCare |
$5.20
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.00
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
|
OM- LIDOCAINE 1% 2 ML
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350453
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$14.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
|
OM- METHYLPREDNISOLONE INJ 125MG
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
CPT J2930
|
| Hospital Charge Code |
3350454
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.92 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$34.00
|
| Rate for Payer: First Health Commercial |
$36.00
|
| Rate for Payer: First Health Workers Compensation |
$15.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.00
|
| Rate for Payer: GEHA Commercial |
$28.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.00
|
| Rate for Payer: Multiplan All |
$36.40
|
| Rate for Payer: OMNI Networks Commercial |
$28.00
|
| Rate for Payer: One Health Plan PPO/POS |
$36.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.00
|
| Rate for Payer: Three Rivers Provider Network All |
$30.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$37.20
|
| Rate for Payer: Zelis Auto |
$16.00
|
| Rate for Payer: Zelis Worker's Compensation |
$10.92
|
|
|
OM- METHYLPREDNISOLONE INJ 125MG
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
CPT J2930
|
| Hospital Charge Code |
3350454
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$34.00
|
| Rate for Payer: First Health Commercial |
$36.00
|
| Rate for Payer: First Health Workers Compensation |
$15.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.00
|
| Rate for Payer: GEHA Commercial |
$32.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.00
|
| Rate for Payer: Humana ChoiceCare |
$10.40
|
| Rate for Payer: Multiplan All |
$36.40
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.00
|
| Rate for Payer: OMNI Networks Commercial |
$28.00
|
| Rate for Payer: One Health Plan PPO/POS |
$36.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.00
|
| Rate for Payer: Three Rivers Provider Network All |
$30.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$35.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$37.20
|
| Rate for Payer: Zelis Auto |
$16.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.00
|
| Rate for Payer: Zelis Worker's Compensation |
$10.92
|
|
|
OM- METHYLPREDNISOLONE INJ 40MG/ML
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
CPT J1030
|
| Hospital Charge Code |
3350447
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.65 |
| Max. Negotiated Rate |
$37.05 |
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$33.15
|
| Rate for Payer: First Health Commercial |
$35.10
|
| Rate for Payer: First Health Workers Compensation |
$15.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$35.10
|
| Rate for Payer: GEHA Commercial |
$27.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$35.10
|
| Rate for Payer: Multiplan All |
$35.49
|
| Rate for Payer: OMNI Networks Commercial |
$27.30
|
| Rate for Payer: One Health Plan PPO/POS |
$35.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$37.05
|
| Rate for Payer: Three Rivers Provider Network All |
$29.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$36.27
|
| Rate for Payer: Zelis Auto |
$15.60
|
| Rate for Payer: Zelis Worker's Compensation |
$10.65
|
|
|
OM- METHYLPREDNISOLONE INJ 40MG/ML
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
CPT J1030
|
| Hospital Charge Code |
3350447
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.75 |
| Max. Negotiated Rate |
$37.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$33.15
|
| Rate for Payer: First Health Commercial |
$35.10
|
| Rate for Payer: First Health Workers Compensation |
$15.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$35.10
|
| Rate for Payer: GEHA Commercial |
$31.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$35.10
|
| Rate for Payer: Humana ChoiceCare |
$10.14
|
| Rate for Payer: Multiplan All |
$35.49
|
| Rate for Payer: New Mexico Health Connections Medicare |
$23.40
|
| Rate for Payer: OMNI Networks Commercial |
$27.30
|
| Rate for Payer: One Health Plan PPO/POS |
$35.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$37.05
|
| Rate for Payer: Three Rivers Provider Network All |
$29.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$34.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$36.27
|
| Rate for Payer: Zelis Auto |
$15.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$19.50
|
| Rate for Payer: Zelis Worker's Compensation |
$10.65
|
|
|
OM- WATER FOR INJECTION
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 00409488710
|
| Hospital Charge Code |
3350455
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$9.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Humana ChoiceCare |
$3.12
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.20
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
OM- WATER FOR INJECTION
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 00409488710
|
| Hospital Charge Code |
3350455
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$8.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
OnabotulinumtoxinA 200 UNIT INJ (PT OWN)
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J0585
|
| Hospital Charge Code |
3302970
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$8.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$8.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$6.62
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6.50
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$7.15
|
| Rate for Payer: GEHA Medicare |
$6.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$7.15
|
| Rate for Payer: Humana Medicare Advantage |
$6.50
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$10.92
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$6.75
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6.50
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.05
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$7.80
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$6.75
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$13.00
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.37
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6.50
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Medicare |
$5.53
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.80
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
OnabotulinumtoxinA 200 UNIT INJ (PT OWN)
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J0585
|
| Hospital Charge Code |
3302970
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
ONABOTULINUMTOXINA FOR INJ 100 UNIT
|
Facility
|
OP
|
$2,460.00
|
|
|
Service Code
|
CPT J0585
|
| Hospital Charge Code |
3300672
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.53 |
| Max. Negotiated Rate |
$2,337.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$8.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,476.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$8.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$6.62
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6.50
|
| Rate for Payer: Cash Price |
$1,476.00
|
| Rate for Payer: Cash Price |
$1,476.00
|
| Rate for Payer: Cigna Commercial |
$2,091.00
|
| Rate for Payer: First Health Commercial |
$2,214.00
|
| Rate for Payer: First Health Workers Compensation |
$949.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,214.00
|
| Rate for Payer: GEHA Commercial |
$7.15
|
| Rate for Payer: GEHA Medicare |
$6.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,214.00
|
| Rate for Payer: Humana ChoiceCare |
$7.15
|
| Rate for Payer: Humana Medicare Advantage |
$6.50
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$10.92
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$6.75
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6.50
|
| Rate for Payer: Multiplan All |
$2,238.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.05
|
| Rate for Payer: OMNI Networks Commercial |
$1,722.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,214.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$7.80
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$6.75
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,337.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$13.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,845.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.37
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,287.80
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6.50
|
| Rate for Payer: Zelis Auto |
$984.00
|
| Rate for Payer: Zelis Medicare |
$5.53
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.80
|
| Rate for Payer: Zelis Worker's Compensation |
$671.58
|
|
|
ONABOTULINUMTOXINA FOR INJ 100 UNIT
|
Facility
|
IP
|
$2,460.00
|
|
|
Service Code
|
CPT J0585
|
| Hospital Charge Code |
3300672
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$671.58 |
| Max. Negotiated Rate |
$2,337.00 |
| Rate for Payer: Cash Price |
$1,476.00
|
| Rate for Payer: Cigna Commercial |
$2,091.00
|
| Rate for Payer: First Health Commercial |
$2,214.00
|
| Rate for Payer: First Health Workers Compensation |
$949.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,214.00
|
| Rate for Payer: GEHA Commercial |
$1,722.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,214.00
|
| Rate for Payer: Multiplan All |
$2,238.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,722.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,214.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,337.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,845.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,287.80
|
| Rate for Payer: Zelis Auto |
$984.00
|
| Rate for Payer: Zelis Worker's Compensation |
$671.58
|
|
|
ONABOTULINUMTOXINA FOR INJ 200 UNIT
|
Facility
|
OP
|
$5,227.00
|
|
|
Service Code
|
CPT J0585
|
| Hospital Charge Code |
3300673
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.53 |
| Max. Negotiated Rate |
$4,965.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$8.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,136.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$8.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$6.62
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6.50
|
| Rate for Payer: Cash Price |
$3,136.20
|
| Rate for Payer: Cash Price |
$3,136.20
|
| Rate for Payer: Cigna Commercial |
$4,442.95
|
| Rate for Payer: First Health Commercial |
$4,704.30
|
| Rate for Payer: First Health Workers Compensation |
$2,018.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,704.30
|
| Rate for Payer: GEHA Commercial |
$7.15
|
| Rate for Payer: GEHA Medicare |
$6.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,704.30
|
| Rate for Payer: Humana ChoiceCare |
$7.15
|
| Rate for Payer: Humana Medicare Advantage |
$6.50
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$10.92
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$6.75
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6.50
|
| Rate for Payer: Multiplan All |
$4,756.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.05
|
| Rate for Payer: OMNI Networks Commercial |
$3,658.90
|
| Rate for Payer: One Health Plan PPO/POS |
$4,704.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$7.80
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$6.75
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,965.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$13.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,920.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.37
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,861.11
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6.50
|
| Rate for Payer: Zelis Auto |
$2,090.80
|
| Rate for Payer: Zelis Medicare |
$5.53
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1,426.97
|
|
|
ONABOTULINUMTOXINA FOR INJ 200 UNIT
|
Facility
|
IP
|
$5,227.00
|
|
|
Service Code
|
CPT J0585
|
| Hospital Charge Code |
3300673
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,426.97 |
| Max. Negotiated Rate |
$4,965.65 |
| Rate for Payer: Cash Price |
$3,136.20
|
| Rate for Payer: Cigna Commercial |
$4,442.95
|
| Rate for Payer: First Health Commercial |
$4,704.30
|
| Rate for Payer: First Health Workers Compensation |
$2,018.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,704.30
|
| Rate for Payer: GEHA Commercial |
$3,658.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,704.30
|
| Rate for Payer: Multiplan All |
$4,756.57
|
| Rate for Payer: OMNI Networks Commercial |
$3,658.90
|
| Rate for Payer: One Health Plan PPO/POS |
$4,704.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,965.65
|
| Rate for Payer: Three Rivers Provider Network All |
$3,920.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,861.11
|
| Rate for Payer: Zelis Auto |
$2,090.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1,426.97
|
|
|
ONDANSETRON HCL 4 MG/2 ML INJ
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
CPT J2405
|
| Hospital Charge Code |
3300674
|
|
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
|
|
|
ONDANSETRON HCL 4 MG/2 ML INJ
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
CPT J2405
|
| Hospital Charge Code |
3300674
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| 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 |
$0.10
|
| 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
|
|
