|
POTASSIUM CHLORIDE 10MEQ TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904721661
|
| Hospital Charge Code |
3300737
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
POTASSIUM CHLORIDE 20MEQ TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300738
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
POTASSIUM CHLORIDE 20MEQ TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300738
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
POTASSIUM CITRATE ER 10 MEQ TAB
|
Facility
|
IP
|
$3.10
|
|
|
Service Code
|
NDC 42543040701
|
| Hospital Charge Code |
3303200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: Cigna Commercial |
$2.63
|
| Rate for Payer: First Health Commercial |
$2.79
|
| Rate for Payer: First Health Workers Compensation |
$1.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.79
|
| Rate for Payer: GEHA Commercial |
$2.17
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.79
|
| Rate for Payer: Multiplan All |
$2.82
|
| Rate for Payer: OMNI Networks Commercial |
$2.17
|
| Rate for Payer: One Health Plan PPO/POS |
$2.79
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.94
|
| Rate for Payer: Three Rivers Provider Network All |
$2.33
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.88
|
| Rate for Payer: Zelis Auto |
$1.24
|
| Rate for Payer: Zelis Worker's Compensation |
$0.85
|
|
|
POTASSIUM CITRATE ER 10 MEQ TAB
|
Facility
|
OP
|
$3.10
|
|
|
Service Code
|
NDC 42543040701
|
| Hospital Charge Code |
3303200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.86
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: Cigna Commercial |
$2.63
|
| Rate for Payer: First Health Commercial |
$2.79
|
| Rate for Payer: First Health Workers Compensation |
$1.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.79
|
| Rate for Payer: GEHA Commercial |
$2.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.79
|
| Rate for Payer: Humana ChoiceCare |
$0.81
|
| Rate for Payer: Multiplan All |
$2.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.86
|
| Rate for Payer: OMNI Networks Commercial |
$2.17
|
| Rate for Payer: One Health Plan PPO/POS |
$2.79
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.94
|
| Rate for Payer: Three Rivers Provider Network All |
$2.33
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.73
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.78
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.88
|
| Rate for Payer: Zelis Auto |
$1.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.55
|
| Rate for Payer: Zelis Worker's Compensation |
$0.85
|
|
|
POTASSIUM CL 10MEQ/100ML RIDER
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
CPT J3480
|
| Hospital Charge Code |
3302500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.55 |
| Max. Negotiated Rate |
$22.80 |
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$20.40
|
| Rate for Payer: First Health Commercial |
$21.60
|
| Rate for Payer: First Health Workers Compensation |
$9.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$21.60
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$21.60
|
| Rate for Payer: Multiplan All |
$21.84
|
| Rate for Payer: OMNI Networks Commercial |
$16.80
|
| Rate for Payer: One Health Plan PPO/POS |
$21.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$22.80
|
| Rate for Payer: Three Rivers Provider Network All |
$18.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$22.32
|
| Rate for Payer: Zelis Auto |
$9.60
|
| Rate for Payer: Zelis Worker's Compensation |
$6.55
|
|
|
POTASSIUM CL 10MEQ/100ML RIDER
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
CPT J3480
|
| Hospital Charge Code |
3302500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$22.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$20.40
|
| Rate for Payer: First Health Commercial |
$21.60
|
| Rate for Payer: First Health Workers Compensation |
$9.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$21.60
|
| Rate for Payer: GEHA Commercial |
$0.12
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$21.60
|
| Rate for Payer: Humana ChoiceCare |
$6.24
|
| Rate for Payer: Multiplan All |
$21.84
|
| Rate for Payer: New Mexico Health Connections Medicare |
$14.40
|
| Rate for Payer: OMNI Networks Commercial |
$16.80
|
| Rate for Payer: One Health Plan PPO/POS |
$21.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$22.80
|
| Rate for Payer: Three Rivers Provider Network All |
$18.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$21.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$22.32
|
| Rate for Payer: Zelis Auto |
$9.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6.55
|
|
|
POTASSIUM CL 20MEQ/100ML RIDER
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
CPT J3480
|
| Hospital Charge Code |
3300735
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$18.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$11.40
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: First Health Commercial |
$17.10
|
| Rate for Payer: First Health Workers Compensation |
$7.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$17.10
|
| Rate for Payer: GEHA Commercial |
$0.12
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17.10
|
| Rate for Payer: Humana ChoiceCare |
$4.94
|
| Rate for Payer: Multiplan All |
$17.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.40
|
| Rate for Payer: OMNI Networks Commercial |
$13.30
|
| Rate for Payer: One Health Plan PPO/POS |
$17.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18.05
|
| Rate for Payer: Three Rivers Provider Network All |
$14.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17.67
|
| Rate for Payer: Zelis Auto |
$7.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$9.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.19
|
|
|
POTASSIUM CL 20MEQ/100ML RIDER
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
CPT J3480
|
| Hospital Charge Code |
3300735
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.19 |
| Max. Negotiated Rate |
$18.05 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: First Health Commercial |
$17.10
|
| Rate for Payer: First Health Workers Compensation |
$7.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$17.10
|
| Rate for Payer: GEHA Commercial |
$13.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17.10
|
| Rate for Payer: Multiplan All |
$17.29
|
| Rate for Payer: OMNI Networks Commercial |
$13.30
|
| Rate for Payer: One Health Plan PPO/POS |
$17.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18.05
|
| Rate for Payer: Three Rivers Provider Network All |
$14.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17.67
|
| Rate for Payer: Zelis Auto |
$7.60
|
| Rate for Payer: Zelis Worker's Compensation |
$5.19
|
|
|
POTASSIUM CL ORAL 20MEQ/15ML
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 00121146515
|
| Hospital Charge Code |
3300739
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
POTASSIUM CL ORAL 20MEQ/15ML
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 00121146515
|
| Hospital Charge Code |
3300739
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$6.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Humana ChoiceCare |
$2.08
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.80
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
POTASSIUM CL POWDER PACKET 20MEQ
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
NDC 00603155416
|
| Hospital Charge Code |
3302900
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
POTASSIUM CL POWDER PACKET 20MEQ
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
NDC 00603155416
|
| Hospital Charge Code |
3302900
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
POTASSIUM PHOSPHATE 3 MMOL/ML
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
NDC 63323008605
|
| Hospital Charge Code |
3300741
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.68 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$136.00
|
| Rate for Payer: First Health Commercial |
$144.00
|
| Rate for Payer: First Health Workers Compensation |
$61.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$144.00
|
| Rate for Payer: GEHA Commercial |
$112.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$144.00
|
| Rate for Payer: Multiplan All |
$145.60
|
| Rate for Payer: OMNI Networks Commercial |
$112.00
|
| Rate for Payer: One Health Plan PPO/POS |
$144.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$152.00
|
| Rate for Payer: Three Rivers Provider Network All |
$120.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$148.80
|
| Rate for Payer: Zelis Auto |
$64.00
|
| Rate for Payer: Zelis Worker's Compensation |
$43.68
|
|
|
POTASSIUM PHOSPHATE 3 MMOL/ML
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
NDC 63323008605
|
| Hospital Charge Code |
3300741
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.00 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$96.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$136.00
|
| Rate for Payer: First Health Commercial |
$144.00
|
| Rate for Payer: First Health Workers Compensation |
$61.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$144.00
|
| Rate for Payer: GEHA Commercial |
$128.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$144.00
|
| Rate for Payer: Humana ChoiceCare |
$41.60
|
| Rate for Payer: Multiplan All |
$145.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$96.00
|
| Rate for Payer: OMNI Networks Commercial |
$112.00
|
| Rate for Payer: One Health Plan PPO/POS |
$144.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$152.00
|
| Rate for Payer: Three Rivers Provider Network All |
$120.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$140.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$40.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$148.80
|
| Rate for Payer: Zelis Auto |
$64.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$80.00
|
| Rate for Payer: Zelis Worker's Compensation |
$43.68
|
|
|
POTASSIUM PHOSPHATE 500MG TAB
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 00486111101
|
| Hospital Charge Code |
3300742
|
|
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
|
|
|
POTASSIUM PHOSPHATE 500MG TAB
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00486111101
|
| Hospital Charge Code |
3300742
|
|
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
|
|
|
POTASSIUM RBC REF
|
Facility
|
OP
|
$310.00
|
|
|
Service Code
|
CPT 87015
|
| Hospital Charge Code |
2200453
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.68 |
| Max. Negotiated Rate |
$294.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$12.03
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$186.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$12.03
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$9.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6.68
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$263.50
|
| Rate for Payer: First Health Commercial |
$279.00
|
| Rate for Payer: First Health Workers Compensation |
$12.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$279.00
|
| Rate for Payer: GEHA Commercial |
$248.00
|
| Rate for Payer: GEHA Medicare |
$6.68
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$279.00
|
| Rate for Payer: Humana ChoiceCare |
$7.35
|
| Rate for Payer: Humana Medicare Advantage |
$6.68
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$11.22
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$9.72
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6.68
|
| Rate for Payer: Multiplan All |
$282.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.36
|
| Rate for Payer: OMNI Networks Commercial |
$217.00
|
| Rate for Payer: One Health Plan PPO/POS |
$279.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$11.23
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$9.72
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6.68
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$294.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$13.36
|
| Rate for Payer: Three Rivers Provider Network All |
$232.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.55
|
| Rate for Payer: United Healthcare Commercial |
$263.50
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.68
|
| Rate for Payer: United Payors & United Providers UP&UP |
$288.30
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6.68
|
| Rate for Payer: Zelis Auto |
$124.00
|
| Rate for Payer: Zelis Medicare |
$5.68
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.02
|
| Rate for Payer: Zelis Worker's Compensation |
$8.72
|
|
|
POTASSIUM RBC REF
|
Facility
|
IP
|
$310.00
|
|
|
Service Code
|
CPT 87015
|
| Hospital Charge Code |
2200453
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.72 |
| Max. Negotiated Rate |
$294.50 |
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$263.50
|
| Rate for Payer: First Health Commercial |
$279.00
|
| Rate for Payer: First Health Workers Compensation |
$12.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$279.00
|
| Rate for Payer: GEHA Commercial |
$217.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$279.00
|
| Rate for Payer: Multiplan All |
$282.10
|
| Rate for Payer: OMNI Networks Commercial |
$217.00
|
| Rate for Payer: One Health Plan PPO/POS |
$279.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$294.50
|
| Rate for Payer: Three Rivers Provider Network All |
$232.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$288.30
|
| Rate for Payer: Zelis Auto |
$124.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.72
|
|
|
POTASSIUM UA POP
|
Facility
|
IP
|
$85.00
|
|
|
Service Code
|
CPT 84133
|
| Hospital Charge Code |
2299384
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.80 |
| Max. Negotiated Rate |
$80.75 |
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$72.25
|
| Rate for Payer: First Health Commercial |
$76.50
|
| Rate for Payer: First Health Workers Compensation |
$8.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$76.50
|
| Rate for Payer: GEHA Commercial |
$59.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$76.50
|
| Rate for Payer: Multiplan All |
$77.35
|
| Rate for Payer: OMNI Networks Commercial |
$59.50
|
| Rate for Payer: One Health Plan PPO/POS |
$76.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$80.75
|
| Rate for Payer: Three Rivers Provider Network All |
$63.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$79.05
|
| Rate for Payer: Zelis Auto |
$34.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.80
|
|
|
POTASSIUM UA POP
|
Facility
|
OP
|
$85.00
|
|
|
Service Code
|
CPT 84133
|
| Hospital Charge Code |
2299384
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.02 |
| Max. Negotiated Rate |
$80.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$8.52
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$51.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$8.52
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$6.75
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$4.73
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$72.25
|
| Rate for Payer: First Health Commercial |
$76.50
|
| Rate for Payer: First Health Workers Compensation |
$8.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$76.50
|
| Rate for Payer: GEHA Commercial |
$68.00
|
| Rate for Payer: GEHA Medicare |
$4.73
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$76.50
|
| Rate for Payer: Humana ChoiceCare |
$5.20
|
| Rate for Payer: Humana Medicare Advantage |
$4.73
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$7.95
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$6.89
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$4.73
|
| Rate for Payer: Multiplan All |
$77.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.04
|
| Rate for Payer: OMNI Networks Commercial |
$59.50
|
| Rate for Payer: One Health Plan PPO/POS |
$76.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$7.95
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$6.89
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$4.73
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$80.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$9.46
|
| Rate for Payer: Three Rivers Provider Network All |
$63.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.64
|
| Rate for Payer: United Healthcare Commercial |
$72.25
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.73
|
| Rate for Payer: United Payors & United Providers UP&UP |
$79.05
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$4.73
|
| Rate for Payer: Zelis Auto |
$34.00
|
| Rate for Payer: Zelis Medicare |
$4.02
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.68
|
| Rate for Payer: Zelis Worker's Compensation |
$5.80
|
|
|
POTASSIUM (Vitros)
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
CPT 84132
|
| Hospital Charge Code |
2232196
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.05 |
| Max. Negotiated Rate |
$50.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$8.56
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$31.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$8.56
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$6.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$4.76
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$45.05
|
| Rate for Payer: First Health Commercial |
$47.70
|
| Rate for Payer: First Health Workers Compensation |
$8.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$47.70
|
| Rate for Payer: GEHA Commercial |
$42.40
|
| Rate for Payer: GEHA Medicare |
$4.76
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$47.70
|
| Rate for Payer: Humana ChoiceCare |
$5.24
|
| Rate for Payer: Humana Medicare Advantage |
$4.76
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$6.92
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$4.76
|
| Rate for Payer: Multiplan All |
$48.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.09
|
| Rate for Payer: OMNI Networks Commercial |
$37.10
|
| Rate for Payer: One Health Plan PPO/POS |
$47.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$7.99
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$6.92
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$4.76
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$50.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$9.52
|
| Rate for Payer: Three Rivers Provider Network All |
$39.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.66
|
| Rate for Payer: United Healthcare Commercial |
$45.05
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.76
|
| Rate for Payer: United Payors & United Providers UP&UP |
$49.29
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$4.76
|
| Rate for Payer: Zelis Auto |
$21.20
|
| Rate for Payer: Zelis Medicare |
$4.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.71
|
| Rate for Payer: Zelis Worker's Compensation |
$5.95
|
|
|
POTASSIUM (Vitros)
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
CPT 84132
|
| Hospital Charge Code |
2232196
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$50.35 |
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$45.05
|
| Rate for Payer: First Health Commercial |
$47.70
|
| Rate for Payer: First Health Workers Compensation |
$8.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$47.70
|
| Rate for Payer: GEHA Commercial |
$37.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$47.70
|
| Rate for Payer: Multiplan All |
$48.23
|
| Rate for Payer: OMNI Networks Commercial |
$37.10
|
| Rate for Payer: One Health Plan PPO/POS |
$47.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$50.35
|
| Rate for Payer: Three Rivers Provider Network All |
$39.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$49.29
|
| Rate for Payer: Zelis Auto |
$21.20
|
| Rate for Payer: Zelis Worker's Compensation |
$5.95
|
|
|
POVIDONE-IODINE OINT 10%
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300743
|
|
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
|
|
|
POVIDONE-IODINE OINT 10%
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300743
|
|
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
|
|
