|
OT WORK HARDENING INITIAL 2 HOURS
|
Facility
|
OP
|
$761.00
|
|
|
Service Code
|
CPT 97545
|
| Hospital Charge Code |
4597545
|
|
Hospital Revenue Code
|
432
|
| Min. Negotiated Rate |
$112.53 |
| Max. Negotiated Rate |
$722.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$456.60
|
| Rate for Payer: Cash Price |
$456.60
|
| Rate for Payer: Cash Price |
$456.60
|
| Rate for Payer: Cigna Commercial |
$646.85
|
| Rate for Payer: First Health Commercial |
$684.90
|
| Rate for Payer: First Health Workers Compensation |
$159.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$684.90
|
| Rate for Payer: GEHA Commercial |
$608.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$684.90
|
| Rate for Payer: Humana ChoiceCare |
$197.86
|
| Rate for Payer: Multiplan All |
$692.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$456.60
|
| Rate for Payer: OMNI Networks Commercial |
$532.70
|
| Rate for Payer: One Health Plan PPO/POS |
$684.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$722.95
|
| Rate for Payer: Three Rivers Provider Network All |
$570.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$669.68
|
| Rate for Payer: United Healthcare Commercial |
$646.85
|
| Rate for Payer: United Healthcare Managed Medicaid |
$190.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$707.73
|
| Rate for Payer: Zelis Auto |
$304.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$380.50
|
| Rate for Payer: Zelis Worker's Compensation |
$112.53
|
|
|
OT WORK HARDENING INITIAL 2 HOURS
|
Facility
|
IP
|
$761.00
|
|
|
Service Code
|
CPT 97545
|
| Hospital Charge Code |
4597545
|
|
Hospital Revenue Code
|
432
|
| Min. Negotiated Rate |
$207.75 |
| Max. Negotiated Rate |
$722.95 |
| Rate for Payer: Cash Price |
$456.60
|
| Rate for Payer: Cigna Commercial |
$646.85
|
| Rate for Payer: First Health Commercial |
$684.90
|
| Rate for Payer: First Health Workers Compensation |
$293.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$684.90
|
| Rate for Payer: GEHA Commercial |
$532.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$684.90
|
| Rate for Payer: Multiplan All |
$692.51
|
| Rate for Payer: OMNI Networks Commercial |
$532.70
|
| Rate for Payer: One Health Plan PPO/POS |
$684.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$722.95
|
| Rate for Payer: Three Rivers Provider Network All |
$570.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$707.73
|
| Rate for Payer: Zelis Auto |
$304.40
|
| Rate for Payer: Zelis Worker's Compensation |
$207.75
|
|
|
ova and parasites examination REF008623
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
2299131
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$7.57 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$16.02
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$84.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$16.02
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$12.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$8.90
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$119.00
|
| Rate for Payer: First Health Commercial |
$126.00
|
| Rate for Payer: First Health Workers Compensation |
$15.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$126.00
|
| Rate for Payer: GEHA Commercial |
$112.00
|
| Rate for Payer: GEHA Medicare |
$8.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$126.00
|
| Rate for Payer: Humana ChoiceCare |
$9.79
|
| Rate for Payer: Humana Medicare Advantage |
$8.90
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$14.95
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$12.95
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$8.90
|
| Rate for Payer: Multiplan All |
$127.40
|
| Rate for Payer: New Mexico Health Connections Medicare |
$15.13
|
| Rate for Payer: OMNI Networks Commercial |
$98.00
|
| Rate for Payer: One Health Plan PPO/POS |
$126.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$14.95
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$12.95
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$8.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$133.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$17.80
|
| Rate for Payer: Three Rivers Provider Network All |
$105.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8.72
|
| Rate for Payer: United Healthcare Commercial |
$119.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.90
|
| Rate for Payer: United Payors & United Providers UP&UP |
$130.20
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$8.90
|
| Rate for Payer: Zelis Auto |
$56.00
|
| Rate for Payer: Zelis Medicare |
$7.57
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.68
|
| Rate for Payer: Zelis Worker's Compensation |
$11.26
|
|
|
ova and parasites examination REF008623
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
2299131
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$11.26 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$119.00
|
| Rate for Payer: First Health Commercial |
$126.00
|
| Rate for Payer: First Health Workers Compensation |
$15.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$126.00
|
| Rate for Payer: GEHA Commercial |
$98.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$126.00
|
| Rate for Payer: Multiplan All |
$127.40
|
| Rate for Payer: OMNI Networks Commercial |
$98.00
|
| Rate for Payer: One Health Plan PPO/POS |
$126.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$133.00
|
| Rate for Payer: Three Rivers Provider Network All |
$105.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$130.20
|
| Rate for Payer: Zelis Auto |
$56.00
|
| Rate for Payer: Zelis Worker's Compensation |
$11.26
|
|
|
oxalate 24hr urine quant REF003970
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
CPT 83945
|
| Hospital Charge Code |
2200435
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.21 |
| Max. Negotiated Rate |
$131.10 |
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$117.30
|
| Rate for Payer: First Health Commercial |
$124.20
|
| Rate for Payer: First Health Workers Compensation |
$24.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$124.20
|
| Rate for Payer: GEHA Commercial |
$96.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$124.20
|
| Rate for Payer: Multiplan All |
$125.58
|
| Rate for Payer: OMNI Networks Commercial |
$96.60
|
| Rate for Payer: One Health Plan PPO/POS |
$124.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$131.10
|
| Rate for Payer: Three Rivers Provider Network All |
$103.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$128.34
|
| Rate for Payer: Zelis Auto |
$55.20
|
| Rate for Payer: Zelis Worker's Compensation |
$17.21
|
|
|
oxalate 24hr urine quant REF003970
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
CPT 83945
|
| Hospital Charge Code |
2200435
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.28 |
| Max. Negotiated Rate |
$131.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$82.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$20.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.45
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$117.30
|
| Rate for Payer: First Health Commercial |
$124.20
|
| Rate for Payer: First Health Workers Compensation |
$24.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$124.20
|
| Rate for Payer: GEHA Commercial |
$110.40
|
| Rate for Payer: GEHA Medicare |
$14.45
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$124.20
|
| Rate for Payer: Humana ChoiceCare |
$15.89
|
| Rate for Payer: Humana Medicare Advantage |
$14.45
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$24.28
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.02
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.45
|
| Rate for Payer: Multiplan All |
$125.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.57
|
| Rate for Payer: OMNI Networks Commercial |
$96.60
|
| Rate for Payer: One Health Plan PPO/POS |
$124.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$24.28
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.02
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.45
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$131.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$28.90
|
| Rate for Payer: Three Rivers Provider Network All |
$103.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.16
|
| Rate for Payer: United Healthcare Commercial |
$117.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$128.34
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.45
|
| Rate for Payer: Zelis Auto |
$55.20
|
| Rate for Payer: Zelis Medicare |
$12.28
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.34
|
| Rate for Payer: Zelis Worker's Compensation |
$17.21
|
|
|
OXcarbazepine 300MG TAB
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 50268068015
|
| Hospital Charge Code |
3301048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Humana ChoiceCare |
$5.46
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.60
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
OXcarbazepine 300MG TAB
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 50268068015
|
| Hospital Charge Code |
3301048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
oxcarbazepine serum/plasma REF716928
|
Facility
|
OP
|
$91.00
|
|
|
Service Code
|
CPT 80183
|
| Hospital Charge Code |
2299295
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.26 |
| Max. Negotiated Rate |
$86.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$23.85
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$54.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$23.85
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$18.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$13.25
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$77.35
|
| Rate for Payer: First Health Commercial |
$81.90
|
| Rate for Payer: First Health Workers Compensation |
$23.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.90
|
| Rate for Payer: GEHA Commercial |
$72.80
|
| Rate for Payer: GEHA Medicare |
$13.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.90
|
| Rate for Payer: Humana ChoiceCare |
$14.57
|
| Rate for Payer: Humana Medicare Advantage |
$13.25
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$22.26
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$19.28
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$13.25
|
| Rate for Payer: Multiplan All |
$82.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.52
|
| Rate for Payer: OMNI Networks Commercial |
$63.70
|
| Rate for Payer: One Health Plan PPO/POS |
$81.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$22.26
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$19.28
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$13.25
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$86.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$26.50
|
| Rate for Payer: Three Rivers Provider Network All |
$68.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.98
|
| Rate for Payer: United Healthcare Commercial |
$77.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$19.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$84.63
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$13.25
|
| Rate for Payer: Zelis Auto |
$36.40
|
| Rate for Payer: Zelis Medicare |
$11.26
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.90
|
| Rate for Payer: Zelis Worker's Compensation |
$16.41
|
|
|
oxcarbazepine serum/plasma REF716928
|
Facility
|
IP
|
$91.00
|
|
|
Service Code
|
CPT 80183
|
| Hospital Charge Code |
2299295
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.41 |
| Max. Negotiated Rate |
$86.45 |
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$77.35
|
| Rate for Payer: First Health Commercial |
$81.90
|
| Rate for Payer: First Health Workers Compensation |
$23.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.90
|
| Rate for Payer: GEHA Commercial |
$63.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.90
|
| Rate for Payer: Multiplan All |
$82.81
|
| Rate for Payer: OMNI Networks Commercial |
$63.70
|
| Rate for Payer: One Health Plan PPO/POS |
$81.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$86.45
|
| Rate for Payer: Three Rivers Provider Network All |
$68.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$84.63
|
| Rate for Payer: Zelis Auto |
$36.40
|
| Rate for Payer: Zelis Worker's Compensation |
$16.41
|
|
|
OXcarbazepine TAB 150MG
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 68084084501
|
| Hospital Charge Code |
3300679
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: First Health Commercial |
$12.60
|
| Rate for Payer: First Health Workers Compensation |
$5.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12.60
|
| Rate for Payer: GEHA Commercial |
$11.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12.60
|
| Rate for Payer: Humana ChoiceCare |
$3.64
|
| Rate for Payer: Multiplan All |
$12.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.40
|
| Rate for Payer: OMNI Networks Commercial |
$9.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.02
|
| Rate for Payer: Zelis Auto |
$5.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.82
|
|
|
OXcarbazepine TAB 150MG
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 68084084501
|
| Hospital Charge Code |
3300679
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: First Health Commercial |
$12.60
|
| Rate for Payer: First Health Workers Compensation |
$5.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12.60
|
| Rate for Payer: GEHA Commercial |
$9.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12.60
|
| Rate for Payer: Multiplan All |
$12.74
|
| Rate for Payer: OMNI Networks Commercial |
$9.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.02
|
| Rate for Payer: Zelis Auto |
$5.60
|
| Rate for Payer: Zelis Worker's Compensation |
$3.82
|
|
|
oxidized ldl REF123023
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
CPT 83721
|
| Hospital Charge Code |
2200840
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.68 |
| Max. Negotiated Rate |
$100.70 |
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$90.10
|
| Rate for Payer: First Health Commercial |
$95.40
|
| Rate for Payer: First Health Workers Compensation |
$15.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$95.40
|
| Rate for Payer: GEHA Commercial |
$74.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$95.40
|
| Rate for Payer: Multiplan All |
$96.46
|
| Rate for Payer: OMNI Networks Commercial |
$74.20
|
| Rate for Payer: One Health Plan PPO/POS |
$95.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$100.70
|
| Rate for Payer: Three Rivers Provider Network All |
$79.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$98.58
|
| Rate for Payer: Zelis Auto |
$42.40
|
| Rate for Payer: Zelis Worker's Compensation |
$10.68
|
|
|
oxidized ldl REF123023
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
CPT 83721
|
| Hospital Charge Code |
2200840
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.93 |
| Max. Negotiated Rate |
$100.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$18.90
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$63.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$18.90
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$14.97
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$10.50
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$90.10
|
| Rate for Payer: First Health Commercial |
$95.40
|
| Rate for Payer: First Health Workers Compensation |
$15.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$95.40
|
| Rate for Payer: GEHA Commercial |
$84.80
|
| Rate for Payer: GEHA Medicare |
$10.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$95.40
|
| Rate for Payer: Humana ChoiceCare |
$11.55
|
| Rate for Payer: Humana Medicare Advantage |
$10.50
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$17.64
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$15.28
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$10.50
|
| Rate for Payer: Multiplan All |
$96.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$17.85
|
| Rate for Payer: OMNI Networks Commercial |
$74.20
|
| Rate for Payer: One Health Plan PPO/POS |
$95.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$17.64
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$15.28
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$10.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$100.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$21.00
|
| Rate for Payer: Three Rivers Provider Network All |
$79.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.29
|
| Rate for Payer: United Healthcare Commercial |
$90.10
|
| Rate for Payer: United Healthcare Managed Medicaid |
$15.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$98.58
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$10.50
|
| Rate for Payer: Zelis Auto |
$42.40
|
| Rate for Payer: Zelis Medicare |
$8.93
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12.60
|
| Rate for Payer: Zelis Worker's Compensation |
$10.68
|
|
|
OXYBUTYNIN ER 5 MG TAB
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
NDC 00904657006
|
| Hospital Charge Code |
3300681
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.50 |
| Max. Negotiated Rate |
$24.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$22.10
|
| Rate for Payer: First Health Commercial |
$23.40
|
| Rate for Payer: First Health Workers Compensation |
$10.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$23.40
|
| Rate for Payer: GEHA Commercial |
$20.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$23.40
|
| Rate for Payer: Humana ChoiceCare |
$6.76
|
| Rate for Payer: Multiplan All |
$23.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$15.60
|
| Rate for Payer: OMNI Networks Commercial |
$18.20
|
| Rate for Payer: One Health Plan PPO/POS |
$23.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$24.70
|
| Rate for Payer: Three Rivers Provider Network All |
$19.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$22.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$24.18
|
| Rate for Payer: Zelis Auto |
$10.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$13.00
|
| Rate for Payer: Zelis Worker's Compensation |
$7.10
|
|
|
OXYBUTYNIN ER 5 MG TAB
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
NDC 00904657006
|
| Hospital Charge Code |
3300681
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.10 |
| Max. Negotiated Rate |
$24.70 |
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$22.10
|
| Rate for Payer: First Health Commercial |
$23.40
|
| Rate for Payer: First Health Workers Compensation |
$10.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$23.40
|
| Rate for Payer: GEHA Commercial |
$18.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$23.40
|
| Rate for Payer: Multiplan All |
$23.66
|
| Rate for Payer: OMNI Networks Commercial |
$18.20
|
| Rate for Payer: One Health Plan PPO/POS |
$23.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$24.70
|
| Rate for Payer: Three Rivers Provider Network All |
$19.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$24.18
|
| Rate for Payer: Zelis Auto |
$10.40
|
| Rate for Payer: Zelis Worker's Compensation |
$7.10
|
|
|
OxyCODONE ER (OXYCONTIN) 10MG TAB
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 59011041020
|
| Hospital Charge Code |
3300684
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
OxyCODONE ER (OXYCONTIN) 10MG TAB
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 59011041020
|
| Hospital Charge Code |
3300684
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Humana ChoiceCare |
$5.46
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.60
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
OxyCODONE HCL CONC 20MG/ML
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 43386092060
|
| Hospital Charge Code |
3300682
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$8.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Humana ChoiceCare |
$2.86
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.60
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
OxyCODONE HCL CONC 20MG/ML
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 43386092060
|
| Hospital Charge Code |
3300682
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$7.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
OxyCODONE IR 5 MG TAB
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300683
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$4.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
OxyCODONE IR 5 MG TAB
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300683
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Humana ChoiceCare |
$1.82
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.20
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
OxyCODONE W/ACETAMINOPHEN 10-325MG TAB
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 50268064615
|
| Hospital Charge Code |
3302543
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Humana ChoiceCare |
$1.82
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.20
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
OxyCODONE W/ACETAMINOPHEN 10-325MG TAB
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 50268064615
|
| Hospital Charge Code |
3302543
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$4.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
OxyCODONE W/ACETAMINOPHEN 5-325MG TAB
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 68084035501
|
| Hospital Charge Code |
3300685
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
