|
BACITRACIN OINT 500 UNIT/GM TUBE
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 45802006003
|
| Hospital Charge Code |
3300084
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.75 |
| Max. Negotiated Rate |
$14.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$12.75
|
| Rate for Payer: First Health Commercial |
$13.50
|
| Rate for Payer: First Health Workers Compensation |
$5.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$13.50
|
| Rate for Payer: GEHA Commercial |
$12.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$13.50
|
| Rate for Payer: Humana ChoiceCare |
$3.90
|
| Rate for Payer: Multiplan All |
$13.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.00
|
| Rate for Payer: OMNI Networks Commercial |
$10.50
|
| Rate for Payer: One Health Plan PPO/POS |
$13.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$14.25
|
| Rate for Payer: Three Rivers Provider Network All |
$11.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.95
|
| Rate for Payer: Zelis Auto |
$6.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.50
|
| Rate for Payer: Zelis Worker's Compensation |
$4.09
|
|
|
BACITRACIN OINT 500 UNIT/GM TUBE
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 45802006003
|
| Hospital Charge Code |
3300084
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$14.25 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$12.75
|
| Rate for Payer: First Health Commercial |
$13.50
|
| Rate for Payer: First Health Workers Compensation |
$5.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$13.50
|
| Rate for Payer: GEHA Commercial |
$10.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$13.50
|
| Rate for Payer: Multiplan All |
$13.65
|
| Rate for Payer: OMNI Networks Commercial |
$10.50
|
| Rate for Payer: One Health Plan PPO/POS |
$13.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$14.25
|
| Rate for Payer: Three Rivers Provider Network All |
$11.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.95
|
| Rate for Payer: Zelis Auto |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.09
|
|
|
BACITRACIN OINT 500 UNIT/GM U.D.
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 45802006070
|
| Hospital Charge Code |
3300085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$4.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Humana ChoiceCare |
$1.30
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.00
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
BACITRACIN OINT 500 UNIT/GM U.D.
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 45802006070
|
| Hospital Charge Code |
3300085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
BACITRACIN ZINC 500 UNIT/GM OINT TUBE
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 00536126328
|
| Hospital Charge Code |
3302996
|
|
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
|
|
|
BACITRACIN ZINC 500 UNIT/GM OINT TUBE
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 00536126328
|
| Hospital Charge Code |
3302996
|
|
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
|
|
|
BACLOFEN 10MG TAB
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 00904647561
|
| Hospital Charge Code |
3300086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$7.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Humana ChoiceCare |
$2.34
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5.40
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.50
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
BACLOFEN 10MG TAB
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 00904647561
|
| Hospital Charge Code |
3300086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$6.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
BACTISURE WOUND LEVAGE WW
|
Facility
|
OP
|
$3,045.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003399
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$761.25 |
| Max. Negotiated Rate |
$2,892.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,827.00
|
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: Cigna Commercial |
$2,588.25
|
| Rate for Payer: First Health Commercial |
$2,740.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,740.50
|
| Rate for Payer: GEHA Commercial |
$2,436.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,740.50
|
| Rate for Payer: Humana ChoiceCare |
$791.70
|
| Rate for Payer: Multiplan All |
$2,770.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,827.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,131.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,740.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,892.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,283.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,679.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$761.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,831.85
|
| Rate for Payer: Zelis Auto |
$1,218.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,522.50
|
|
|
BACTISURE WOUND LEVAGE WW
|
Facility
|
IP
|
$3,045.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003399
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.00 |
| Max. Negotiated Rate |
$2,892.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,436.00
|
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: Cigna Commercial |
$2,588.25
|
| Rate for Payer: First Health Commercial |
$2,740.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,740.50
|
| Rate for Payer: GEHA Commercial |
$2,131.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,740.50
|
| Rate for Payer: Multiplan All |
$2,770.95
|
| Rate for Payer: OMNI Networks Commercial |
$2,131.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,740.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,892.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,283.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,831.85
|
| Rate for Payer: Zelis Auto |
$1,218.00
|
|
|
BACTRIM IV SOLN 400-80MG/5ML
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
CPT S0039
|
| Hospital Charge Code |
3300866
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.25 |
| Max. Negotiated Rate |
$76.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$68.85
|
| Rate for Payer: First Health Commercial |
$72.90
|
| Rate for Payer: First Health Workers Compensation |
$31.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.90
|
| Rate for Payer: GEHA Commercial |
$64.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.90
|
| Rate for Payer: Humana ChoiceCare |
$21.06
|
| Rate for Payer: Multiplan All |
$73.71
|
| Rate for Payer: New Mexico Health Connections Medicare |
$48.60
|
| Rate for Payer: OMNI Networks Commercial |
$56.70
|
| Rate for Payer: One Health Plan PPO/POS |
$72.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.95
|
| Rate for Payer: Three Rivers Provider Network All |
$60.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$71.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$20.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$75.33
|
| Rate for Payer: Zelis Auto |
$32.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$40.50
|
| Rate for Payer: Zelis Worker's Compensation |
$22.11
|
|
|
BACTRIM IV SOLN 400-80MG/5ML
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
CPT S0039
|
| Hospital Charge Code |
3300866
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.11 |
| Max. Negotiated Rate |
$76.95 |
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$68.85
|
| Rate for Payer: First Health Commercial |
$72.90
|
| Rate for Payer: First Health Workers Compensation |
$31.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.90
|
| Rate for Payer: GEHA Commercial |
$56.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.90
|
| Rate for Payer: Multiplan All |
$73.71
|
| Rate for Payer: OMNI Networks Commercial |
$56.70
|
| Rate for Payer: One Health Plan PPO/POS |
$72.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.95
|
| Rate for Payer: Three Rivers Provider Network All |
$60.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$75.33
|
| Rate for Payer: Zelis Auto |
$32.40
|
| Rate for Payer: Zelis Worker's Compensation |
$22.11
|
|
|
BAG ISOLATION 5XL40
|
Facility
|
IP
|
$32.00
|
|
| Hospital Charge Code |
90002796
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$30.40 |
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$27.20
|
| Rate for Payer: First Health Commercial |
$28.80
|
| Rate for Payer: First Health Workers Compensation |
$12.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$28.80
|
| Rate for Payer: GEHA Commercial |
$22.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$28.80
|
| Rate for Payer: Multiplan All |
$29.12
|
| Rate for Payer: OMNI Networks Commercial |
$22.40
|
| Rate for Payer: One Health Plan PPO/POS |
$28.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$30.40
|
| Rate for Payer: Three Rivers Provider Network All |
$24.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$29.76
|
| Rate for Payer: Zelis Auto |
$12.80
|
| Rate for Payer: Zelis Worker's Compensation |
$8.74
|
|
|
BAG ISOLATION 5XL40
|
Facility
|
OP
|
$32.00
|
|
| Hospital Charge Code |
90002796
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.00 |
| Max. Negotiated Rate |
$30.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$27.20
|
| Rate for Payer: First Health Commercial |
$28.80
|
| Rate for Payer: First Health Workers Compensation |
$12.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$28.80
|
| Rate for Payer: GEHA Commercial |
$25.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$28.80
|
| Rate for Payer: Humana ChoiceCare |
$8.32
|
| Rate for Payer: Multiplan All |
$29.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$19.20
|
| Rate for Payer: OMNI Networks Commercial |
$22.40
|
| Rate for Payer: One Health Plan PPO/POS |
$28.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$30.40
|
| Rate for Payer: Three Rivers Provider Network All |
$24.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$28.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$29.76
|
| Rate for Payer: Zelis Auto |
$12.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$16.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.74
|
|
|
BALLOON SIZING BARRX 360
|
Facility
|
OP
|
$2,182.00
|
|
|
Service Code
|
CPT C1726
|
| Hospital Charge Code |
7006565
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$545.50 |
| Max. Negotiated Rate |
$2,072.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,309.20
|
| Rate for Payer: Cash Price |
$1,309.20
|
| Rate for Payer: Cash Price |
$1,309.20
|
| Rate for Payer: Cigna Commercial |
$1,854.70
|
| Rate for Payer: First Health Commercial |
$1,963.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,963.80
|
| Rate for Payer: GEHA Commercial |
$1,745.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,963.80
|
| Rate for Payer: Humana ChoiceCare |
$567.32
|
| Rate for Payer: Multiplan All |
$1,985.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,309.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,527.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,963.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,072.90
|
| Rate for Payer: Three Rivers Provider Network All |
$1,636.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,920.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$545.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,029.26
|
| Rate for Payer: Zelis Auto |
$872.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,091.00
|
|
|
BALLOON SIZING BARRX 360
|
Facility
|
IP
|
$2,182.00
|
|
|
Service Code
|
CPT C1726
|
| Hospital Charge Code |
7006565
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$872.80 |
| Max. Negotiated Rate |
$2,072.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,745.60
|
| Rate for Payer: Cash Price |
$1,309.20
|
| Rate for Payer: Cash Price |
$1,309.20
|
| Rate for Payer: Cigna Commercial |
$1,854.70
|
| Rate for Payer: First Health Commercial |
$1,963.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,963.80
|
| Rate for Payer: GEHA Commercial |
$1,527.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,963.80
|
| Rate for Payer: Multiplan All |
$1,985.62
|
| Rate for Payer: OMNI Networks Commercial |
$1,527.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,963.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,072.90
|
| Rate for Payer: Three Rivers Provider Network All |
$1,636.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,029.26
|
| Rate for Payer: Zelis Auto |
$872.80
|
|
|
BAMLANIVIMAB 700 MG/20 ML INJ
|
Facility
|
IP
|
$943.00
|
|
|
Service Code
|
CPT M0245
|
| Hospital Charge Code |
3303149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$257.44 |
| Max. Negotiated Rate |
$895.85 |
| Rate for Payer: Cash Price |
$565.80
|
| Rate for Payer: Cigna Commercial |
$801.55
|
| Rate for Payer: First Health Commercial |
$848.70
|
| Rate for Payer: First Health Workers Compensation |
$364.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$848.70
|
| Rate for Payer: GEHA Commercial |
$660.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$848.70
|
| Rate for Payer: Multiplan All |
$858.13
|
| Rate for Payer: OMNI Networks Commercial |
$660.10
|
| Rate for Payer: One Health Plan PPO/POS |
$848.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$895.85
|
| Rate for Payer: Three Rivers Provider Network All |
$707.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$876.99
|
| Rate for Payer: Zelis Auto |
$377.20
|
| Rate for Payer: Zelis Worker's Compensation |
$257.44
|
|
|
BAMLANIVIMAB 700 MG/20 ML INJ
|
Facility
|
OP
|
$943.00
|
|
|
Service Code
|
CPT M0245
|
| Hospital Charge Code |
3303149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$245.18 |
| Max. Negotiated Rate |
$895.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$715.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$565.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$715.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$566.82
|
| Rate for Payer: Cash Price |
$565.80
|
| Rate for Payer: Cash Price |
$565.80
|
| Rate for Payer: Cigna Commercial |
$801.55
|
| Rate for Payer: First Health Commercial |
$848.70
|
| Rate for Payer: First Health Workers Compensation |
$364.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$848.70
|
| Rate for Payer: GEHA Commercial |
$754.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$848.70
|
| Rate for Payer: Humana ChoiceCare |
$245.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$578.36
|
| Rate for Payer: Multiplan All |
$858.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$565.80
|
| Rate for Payer: OMNI Networks Commercial |
$660.10
|
| Rate for Payer: One Health Plan PPO/POS |
$848.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$667.80
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$578.36
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$895.85
|
| Rate for Payer: Three Rivers Provider Network All |
$707.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$829.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$578.36
|
| Rate for Payer: United Payors & United Providers UP&UP |
$876.99
|
| Rate for Payer: Zelis Auto |
$377.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$471.50
|
| Rate for Payer: Zelis Worker's Compensation |
$257.44
|
|
|
BAMLANIVIMAB 700 MG/20 ML INJ
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT Q0245
|
| Hospital Charge Code |
3302994
|
|
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
|
|
|
BAMLANIVIMAB 700 MG/20 ML INJ
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT Q0245
|
| Hospital Charge Code |
3302994
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$0.02
|
| 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 |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$0.01
|
| 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 |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$0.01
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.01
|
| 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 |
$0.01
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$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: TriWest Veterans Administration/VAPC3 |
$0.01
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.01
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
banana, IgE REF602742
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2200709
|
|
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
|
|
|
banana, IgE REF602742
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2200709
|
|
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
|
|
|
BARICITINIB 2 MG TAB
|
Facility
|
IP
|
$459.00
|
|
|
Service Code
|
NDC 00002418230
|
| Hospital Charge Code |
3303000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$125.31 |
| Max. Negotiated Rate |
$436.05 |
| Rate for Payer: Cash Price |
$275.40
|
| Rate for Payer: Cigna Commercial |
$390.15
|
| Rate for Payer: First Health Commercial |
$413.10
|
| Rate for Payer: First Health Workers Compensation |
$177.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$413.10
|
| Rate for Payer: GEHA Commercial |
$321.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$413.10
|
| Rate for Payer: Multiplan All |
$417.69
|
| Rate for Payer: OMNI Networks Commercial |
$321.30
|
| Rate for Payer: One Health Plan PPO/POS |
$413.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$436.05
|
| Rate for Payer: Three Rivers Provider Network All |
$344.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$426.87
|
| Rate for Payer: Zelis Auto |
$183.60
|
| Rate for Payer: Zelis Worker's Compensation |
$125.31
|
|
|
BARICITINIB 2 MG TAB
|
Facility
|
OP
|
$459.00
|
|
|
Service Code
|
NDC 00002418230
|
| Hospital Charge Code |
3303000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$114.75 |
| Max. Negotiated Rate |
$436.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$275.40
|
| Rate for Payer: Cash Price |
$275.40
|
| Rate for Payer: Cigna Commercial |
$390.15
|
| Rate for Payer: First Health Commercial |
$413.10
|
| Rate for Payer: First Health Workers Compensation |
$177.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$413.10
|
| Rate for Payer: GEHA Commercial |
$367.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$413.10
|
| Rate for Payer: Humana ChoiceCare |
$119.34
|
| Rate for Payer: Multiplan All |
$417.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$275.40
|
| Rate for Payer: OMNI Networks Commercial |
$321.30
|
| Rate for Payer: One Health Plan PPO/POS |
$413.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$436.05
|
| Rate for Payer: Three Rivers Provider Network All |
$344.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$403.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$114.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$426.87
|
| Rate for Payer: Zelis Auto |
$183.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$229.50
|
| Rate for Payer: Zelis Worker's Compensation |
$125.31
|
|
|
BARIUM SULFATE FOR SUSP 98%
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
NDC 32909076401
|
| Hospital Charge Code |
3300087
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.83 |
| Max. Negotiated Rate |
$44.65 |
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$39.95
|
| Rate for Payer: First Health Commercial |
$42.30
|
| Rate for Payer: First Health Workers Compensation |
$18.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$42.30
|
| Rate for Payer: GEHA Commercial |
$32.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$42.30
|
| Rate for Payer: Multiplan All |
$42.77
|
| Rate for Payer: OMNI Networks Commercial |
$32.90
|
| Rate for Payer: One Health Plan PPO/POS |
$42.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$44.65
|
| Rate for Payer: Three Rivers Provider Network All |
$35.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$43.71
|
| Rate for Payer: Zelis Auto |
$18.80
|
| Rate for Payer: Zelis Worker's Compensation |
$12.83
|
|
