|
SMPL RPR SCALP/NECK/AX/GEN/TRNK20.1-30CM
|
Facility
|
OP
|
$724.00
|
|
| Hospital Charge Code |
8112006
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$181.00 |
| Max. Negotiated Rate |
$687.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$434.40
|
| Rate for Payer: Cash Price |
$434.40
|
| Rate for Payer: Cigna Commercial |
$615.40
|
| Rate for Payer: First Health Commercial |
$651.60
|
| Rate for Payer: First Health Workers Compensation |
$279.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$651.60
|
| Rate for Payer: GEHA Commercial |
$579.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$651.60
|
| Rate for Payer: Humana ChoiceCare |
$188.24
|
| Rate for Payer: Multiplan All |
$658.84
|
| Rate for Payer: New Mexico Health Connections Medicare |
$434.40
|
| Rate for Payer: OMNI Networks Commercial |
$506.80
|
| Rate for Payer: One Health Plan PPO/POS |
$651.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$687.80
|
| Rate for Payer: Three Rivers Provider Network All |
$543.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$637.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$181.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$673.32
|
| Rate for Payer: Zelis Auto |
$289.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$362.00
|
| Rate for Payer: Zelis Worker's Compensation |
$197.65
|
|
|
SMPL RPR SCALP/NECK/AX/GEN/TRNK20.1-30CM
|
Facility
|
OP
|
$365.00
|
|
|
Service Code
|
CPT 12006
|
| Hospital Charge Code |
21600171
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$99.64 |
| Max. Negotiated Rate |
$758.74 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$136.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$219.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$136.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$108.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$379.37
|
| Rate for Payer: Cash Price |
$219.00
|
| Rate for Payer: Cash Price |
$219.00
|
| Rate for Payer: Cigna Commercial |
$310.25
|
| Rate for Payer: First Health Commercial |
$328.50
|
| Rate for Payer: First Health Workers Compensation |
$140.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$328.50
|
| Rate for Payer: GEHA Commercial |
$292.00
|
| Rate for Payer: GEHA Medicare |
$379.37
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$328.50
|
| Rate for Payer: Humana ChoiceCare |
$417.31
|
| Rate for Payer: Humana Medicare Advantage |
$379.37
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$637.34
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$110.68
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$379.37
|
| Rate for Payer: Multiplan All |
$332.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$644.93
|
| Rate for Payer: OMNI Networks Commercial |
$255.50
|
| Rate for Payer: One Health Plan PPO/POS |
$328.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$127.79
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$110.68
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$379.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$346.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$758.74
|
| Rate for Payer: Three Rivers Provider Network All |
$273.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$371.78
|
| Rate for Payer: United Healthcare Managed Medicaid |
$110.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$379.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$339.45
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$379.37
|
| Rate for Payer: Zelis Auto |
$146.00
|
| Rate for Payer: Zelis Medicare |
$322.46
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$455.24
|
| Rate for Payer: Zelis Worker's Compensation |
$99.64
|
|
|
SMP RPR FEENL 7.6\12.5C
|
Facility
|
IP
|
$676.00
|
|
| Hospital Charge Code |
8150008
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$184.55 |
| Max. Negotiated Rate |
$642.20 |
| Rate for Payer: Cash Price |
$405.60
|
| Rate for Payer: Cigna Commercial |
$574.60
|
| Rate for Payer: First Health Commercial |
$608.40
|
| Rate for Payer: First Health Workers Compensation |
$261.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$608.40
|
| Rate for Payer: GEHA Commercial |
$473.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$608.40
|
| Rate for Payer: Multiplan All |
$615.16
|
| Rate for Payer: OMNI Networks Commercial |
$473.20
|
| Rate for Payer: One Health Plan PPO/POS |
$608.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$642.20
|
| Rate for Payer: Three Rivers Provider Network All |
$507.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$628.68
|
| Rate for Payer: Zelis Auto |
$270.40
|
| Rate for Payer: Zelis Worker's Compensation |
$184.55
|
|
|
SMP RPR FEENL 7.6\12.5C
|
Facility
|
OP
|
$676.00
|
|
| Hospital Charge Code |
8150008
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$169.00 |
| Max. Negotiated Rate |
$642.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$405.60
|
| Rate for Payer: Cash Price |
$405.60
|
| Rate for Payer: Cigna Commercial |
$574.60
|
| Rate for Payer: First Health Commercial |
$608.40
|
| Rate for Payer: First Health Workers Compensation |
$261.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$608.40
|
| Rate for Payer: GEHA Commercial |
$540.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$608.40
|
| Rate for Payer: Humana ChoiceCare |
$175.76
|
| Rate for Payer: Multiplan All |
$615.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$405.60
|
| Rate for Payer: OMNI Networks Commercial |
$473.20
|
| Rate for Payer: One Health Plan PPO/POS |
$608.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$642.20
|
| Rate for Payer: Three Rivers Provider Network All |
$507.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$594.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$169.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$628.68
|
| Rate for Payer: Zelis Auto |
$270.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$338.00
|
| Rate for Payer: Zelis Worker's Compensation |
$184.55
|
|
|
SOD FERRIC GLUC COMPLEX 62.5 MG/5 ML SDV
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
CPT J2916
|
| Hospital Charge Code |
3303168
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.22 |
| Max. Negotiated Rate |
$78.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$49.80
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cigna Commercial |
$70.55
|
| Rate for Payer: First Health Commercial |
$74.70
|
| Rate for Payer: First Health Workers Compensation |
$32.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$74.70
|
| Rate for Payer: GEHA Commercial |
$2.22
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$74.70
|
| Rate for Payer: Humana ChoiceCare |
$21.58
|
| Rate for Payer: Multiplan All |
$75.53
|
| Rate for Payer: New Mexico Health Connections Medicare |
$49.80
|
| Rate for Payer: OMNI Networks Commercial |
$58.10
|
| Rate for Payer: One Health Plan PPO/POS |
$74.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$78.85
|
| Rate for Payer: Three Rivers Provider Network All |
$62.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$73.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$20.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$77.19
|
| Rate for Payer: Zelis Auto |
$33.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$41.50
|
| Rate for Payer: Zelis Worker's Compensation |
$22.66
|
|
|
SOD FERRIC GLUC COMPLEX 62.5 MG/5 ML SDV
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
CPT J2916
|
| Hospital Charge Code |
3303168
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.66 |
| Max. Negotiated Rate |
$78.85 |
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cigna Commercial |
$70.55
|
| Rate for Payer: First Health Commercial |
$74.70
|
| Rate for Payer: First Health Workers Compensation |
$32.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$74.70
|
| Rate for Payer: GEHA Commercial |
$58.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$74.70
|
| Rate for Payer: Multiplan All |
$75.53
|
| Rate for Payer: OMNI Networks Commercial |
$58.10
|
| Rate for Payer: One Health Plan PPO/POS |
$74.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$78.85
|
| Rate for Payer: Three Rivers Provider Network All |
$62.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$77.19
|
| Rate for Payer: Zelis Auto |
$33.20
|
| Rate for Payer: Zelis Worker's Compensation |
$22.66
|
|
|
SODIUM ARTERIAL
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
CPT 84295
|
| Hospital Charge Code |
4210020
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$87.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$55.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$6.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$4.81
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$78.20
|
| Rate for Payer: First Health Commercial |
$82.80
|
| Rate for Payer: First Health Workers Compensation |
$8.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$82.80
|
| Rate for Payer: GEHA Commercial |
$73.60
|
| Rate for Payer: GEHA Medicare |
$4.81
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$82.80
|
| Rate for Payer: Humana ChoiceCare |
$5.29
|
| Rate for Payer: Humana Medicare Advantage |
$4.81
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$4.81
|
| Rate for Payer: Multiplan All |
$83.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.18
|
| Rate for Payer: OMNI Networks Commercial |
$64.40
|
| Rate for Payer: One Health Plan PPO/POS |
$82.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.08
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.00
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$4.81
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$87.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$9.62
|
| Rate for Payer: Three Rivers Provider Network All |
$69.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.71
|
| Rate for Payer: United Healthcare Commercial |
$78.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.81
|
| Rate for Payer: United Payors & United Providers UP&UP |
$85.56
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$4.81
|
| Rate for Payer: Zelis Auto |
$36.80
|
| Rate for Payer: Zelis Medicare |
$4.09
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.77
|
| Rate for Payer: Zelis Worker's Compensation |
$6.08
|
|
|
SODIUM ARTERIAL
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
CPT 84295
|
| Hospital Charge Code |
4210020
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$87.40 |
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$78.20
|
| Rate for Payer: First Health Commercial |
$82.80
|
| Rate for Payer: First Health Workers Compensation |
$8.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$82.80
|
| Rate for Payer: GEHA Commercial |
$64.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$82.80
|
| Rate for Payer: Multiplan All |
$83.72
|
| Rate for Payer: OMNI Networks Commercial |
$64.40
|
| Rate for Payer: One Health Plan PPO/POS |
$82.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$87.40
|
| Rate for Payer: Three Rivers Provider Network All |
$69.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$85.56
|
| Rate for Payer: Zelis Auto |
$36.80
|
| Rate for Payer: Zelis Worker's Compensation |
$6.08
|
|
|
SODIUM BICARBONATE INJ 4.2% - INFANT
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
NDC 00409553414
|
| Hospital Charge Code |
3300833
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.50 |
| Max. Negotiated Rate |
$81.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$73.10
|
| Rate for Payer: First Health Commercial |
$77.40
|
| Rate for Payer: First Health Workers Compensation |
$33.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$77.40
|
| Rate for Payer: GEHA Commercial |
$68.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$77.40
|
| Rate for Payer: Humana ChoiceCare |
$22.36
|
| Rate for Payer: Multiplan All |
$78.26
|
| Rate for Payer: New Mexico Health Connections Medicare |
$51.60
|
| Rate for Payer: OMNI Networks Commercial |
$60.20
|
| Rate for Payer: One Health Plan PPO/POS |
$77.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$81.70
|
| Rate for Payer: Three Rivers Provider Network All |
$64.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$75.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$79.98
|
| Rate for Payer: Zelis Auto |
$34.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$43.00
|
| Rate for Payer: Zelis Worker's Compensation |
$23.48
|
|
|
SODIUM BICARBONATE INJ 4.2% - INFANT
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
NDC 00409553414
|
| Hospital Charge Code |
3300833
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.48 |
| Max. Negotiated Rate |
$81.70 |
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$73.10
|
| Rate for Payer: First Health Commercial |
$77.40
|
| Rate for Payer: First Health Workers Compensation |
$33.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$77.40
|
| Rate for Payer: GEHA Commercial |
$60.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$77.40
|
| Rate for Payer: Multiplan All |
$78.26
|
| Rate for Payer: OMNI Networks Commercial |
$60.20
|
| Rate for Payer: One Health Plan PPO/POS |
$77.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$81.70
|
| Rate for Payer: Three Rivers Provider Network All |
$64.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$79.98
|
| Rate for Payer: Zelis Auto |
$34.40
|
| Rate for Payer: Zelis Worker's Compensation |
$23.48
|
|
|
SODIUM BICARBONATE INJ 4.2% - NEUT
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300834
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$136.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$122.40
|
| Rate for Payer: First Health Commercial |
$129.60
|
| Rate for Payer: First Health Workers Compensation |
$55.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$129.60
|
| Rate for Payer: GEHA Commercial |
$115.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$129.60
|
| Rate for Payer: Humana ChoiceCare |
$37.44
|
| Rate for Payer: Multiplan All |
$131.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$86.40
|
| Rate for Payer: OMNI Networks Commercial |
$100.80
|
| Rate for Payer: One Health Plan PPO/POS |
$129.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$136.80
|
| Rate for Payer: Three Rivers Provider Network All |
$108.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$126.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$36.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$133.92
|
| Rate for Payer: Zelis Auto |
$57.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$72.00
|
| Rate for Payer: Zelis Worker's Compensation |
$39.31
|
|
|
SODIUM BICARBONATE INJ 4.2% - NEUT
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300834
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.31 |
| Max. Negotiated Rate |
$136.80 |
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$122.40
|
| Rate for Payer: First Health Commercial |
$129.60
|
| Rate for Payer: First Health Workers Compensation |
$55.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$129.60
|
| Rate for Payer: GEHA Commercial |
$100.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$129.60
|
| Rate for Payer: Multiplan All |
$131.04
|
| Rate for Payer: OMNI Networks Commercial |
$100.80
|
| Rate for Payer: One Health Plan PPO/POS |
$129.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$136.80
|
| Rate for Payer: Three Rivers Provider Network All |
$108.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$133.92
|
| Rate for Payer: Zelis Auto |
$57.60
|
| Rate for Payer: Zelis Worker's Compensation |
$39.31
|
|
|
SODIUM BICARBONATE INJ 8.4% - ADULT
|
Facility
|
IP
|
$113.00
|
|
|
Service Code
|
NDC 76329335201
|
| Hospital Charge Code |
3300837
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.85 |
| Max. Negotiated Rate |
$107.35 |
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cigna Commercial |
$96.05
|
| Rate for Payer: First Health Commercial |
$101.70
|
| Rate for Payer: First Health Workers Compensation |
$43.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$101.70
|
| Rate for Payer: GEHA Commercial |
$79.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$101.70
|
| Rate for Payer: Multiplan All |
$102.83
|
| Rate for Payer: OMNI Networks Commercial |
$79.10
|
| Rate for Payer: One Health Plan PPO/POS |
$101.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$107.35
|
| Rate for Payer: Three Rivers Provider Network All |
$84.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$105.09
|
| Rate for Payer: Zelis Auto |
$45.20
|
| Rate for Payer: Zelis Worker's Compensation |
$30.85
|
|
|
SODIUM BICARBONATE INJ 8.4% - ADULT
|
Facility
|
OP
|
$113.00
|
|
|
Service Code
|
NDC 76329335201
|
| Hospital Charge Code |
3300837
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.25 |
| Max. Negotiated Rate |
$107.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$67.80
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cigna Commercial |
$96.05
|
| Rate for Payer: First Health Commercial |
$101.70
|
| Rate for Payer: First Health Workers Compensation |
$43.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$101.70
|
| Rate for Payer: GEHA Commercial |
$90.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$101.70
|
| Rate for Payer: Humana ChoiceCare |
$29.38
|
| Rate for Payer: Multiplan All |
$102.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$67.80
|
| Rate for Payer: OMNI Networks Commercial |
$79.10
|
| Rate for Payer: One Health Plan PPO/POS |
$101.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$107.35
|
| Rate for Payer: Three Rivers Provider Network All |
$84.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$99.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$28.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$105.09
|
| Rate for Payer: Zelis Auto |
$45.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$56.50
|
| Rate for Payer: Zelis Worker's Compensation |
$30.85
|
|
|
SODIUM BICARBONATE INJ 8.4% - PEDI
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
NDC 00409490014
|
| Hospital Charge Code |
3300835
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.94 |
| Max. Negotiated Rate |
$100.70 |
| 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 |
$40.93
|
| 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 |
$28.94
|
|
|
SODIUM BICARBONATE INJ 8.4% - PEDI
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
NDC 00409490014
|
| Hospital Charge Code |
3300835
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.50 |
| Max. Negotiated Rate |
$100.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$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 |
$40.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$95.40
|
| Rate for Payer: GEHA Commercial |
$84.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$95.40
|
| Rate for Payer: Humana ChoiceCare |
$27.56
|
| Rate for Payer: Multiplan All |
$96.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$63.60
|
| 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: TriWest Veterans Administration/VAPC3 |
$93.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$98.58
|
| Rate for Payer: Zelis Auto |
$42.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$53.00
|
| Rate for Payer: Zelis Worker's Compensation |
$28.94
|
|
|
SODIUM BICARBONATE INJ 8.4% - VIAL
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
NDC 00409662514
|
| Hospital Charge Code |
3300836
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.93 |
| Max. Negotiated Rate |
$79.80 |
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$71.40
|
| Rate for Payer: First Health Commercial |
$75.60
|
| Rate for Payer: First Health Workers Compensation |
$32.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$75.60
|
| Rate for Payer: GEHA Commercial |
$58.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$75.60
|
| Rate for Payer: Multiplan All |
$76.44
|
| Rate for Payer: OMNI Networks Commercial |
$58.80
|
| Rate for Payer: One Health Plan PPO/POS |
$75.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$79.80
|
| Rate for Payer: Three Rivers Provider Network All |
$63.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$78.12
|
| Rate for Payer: Zelis Auto |
$33.60
|
| Rate for Payer: Zelis Worker's Compensation |
$22.93
|
|
|
SODIUM BICARBONATE INJ 8.4% - VIAL
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
NDC 00409662514
|
| Hospital Charge Code |
3300836
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$79.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$71.40
|
| Rate for Payer: First Health Commercial |
$75.60
|
| Rate for Payer: First Health Workers Compensation |
$32.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$75.60
|
| Rate for Payer: GEHA Commercial |
$67.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$75.60
|
| Rate for Payer: Humana ChoiceCare |
$21.84
|
| Rate for Payer: Multiplan All |
$76.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$50.40
|
| Rate for Payer: OMNI Networks Commercial |
$58.80
|
| Rate for Payer: One Health Plan PPO/POS |
$75.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$79.80
|
| Rate for Payer: Three Rivers Provider Network All |
$63.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$73.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$78.12
|
| Rate for Payer: Zelis Auto |
$33.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$42.00
|
| Rate for Payer: Zelis Worker's Compensation |
$22.93
|
|
|
SODIUM BICARBONATE TAB 650MG
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00223172101
|
| Hospital Charge Code |
3300838
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
SODIUM BICARBONATE TAB 650MG
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00223172101
|
| Hospital Charge Code |
3300838
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
SODIUM CHLORIDE 0.45% 1000 ML
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
CPT J7030
|
| Hospital Charge Code |
3300840
|
|
Hospital Revenue Code
|
258
|
| 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
|
|
|
SODIUM CHLORIDE 0.45% 1000 ML
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
CPT J7030
|
| Hospital Charge Code |
3300840
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.15 |
| 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 |
$2.15
|
| 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
|
|
|
SODIUM CHLORIDE 0.9% - 1000 ML
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
CPT J7030
|
| Hospital Charge Code |
3300847
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$14.45
|
| Rate for Payer: First Health Commercial |
$15.30
|
| Rate for Payer: First Health Workers Compensation |
$6.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15.30
|
| Rate for Payer: GEHA Commercial |
$11.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15.30
|
| Rate for Payer: Multiplan All |
$15.47
|
| Rate for Payer: OMNI Networks Commercial |
$11.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16.15
|
| Rate for Payer: Three Rivers Provider Network All |
$12.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15.81
|
| Rate for Payer: Zelis Auto |
$6.80
|
| Rate for Payer: Zelis Worker's Compensation |
$4.64
|
|
|
SODIUM CHLORIDE 0.9% - 1000 ML
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
CPT J7030
|
| Hospital Charge Code |
3300847
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$14.45
|
| Rate for Payer: First Health Commercial |
$15.30
|
| Rate for Payer: First Health Workers Compensation |
$6.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15.30
|
| Rate for Payer: GEHA Commercial |
$2.15
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15.30
|
| Rate for Payer: Humana ChoiceCare |
$4.42
|
| Rate for Payer: Multiplan All |
$15.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10.20
|
| Rate for Payer: OMNI Networks Commercial |
$11.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16.15
|
| Rate for Payer: Three Rivers Provider Network All |
$12.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15.81
|
| Rate for Payer: Zelis Auto |
$6.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.50
|
| Rate for Payer: Zelis Worker's Compensation |
$4.64
|
|
|
SODIUM CHLORIDE 0.9% - 100ML MINI BAG +
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300848
|
|
Hospital Revenue Code
|
258
|
| 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
|
|
