|
SUBSQ HOSP I/P OR OBS CARE PER DAY/50 MI
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
CPT 99233
|
| Hospital Charge Code |
21999415
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$64.16 |
| Max. Negotiated Rate |
$223.25 |
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$199.75
|
| Rate for Payer: First Health Commercial |
$211.50
|
| Rate for Payer: First Health Workers Compensation |
$90.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$211.50
|
| Rate for Payer: GEHA Commercial |
$164.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$211.50
|
| Rate for Payer: Multiplan All |
$213.85
|
| Rate for Payer: OMNI Networks Commercial |
$164.50
|
| Rate for Payer: One Health Plan PPO/POS |
$211.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$223.25
|
| Rate for Payer: Three Rivers Provider Network All |
$176.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$218.55
|
| Rate for Payer: Zelis Auto |
$94.00
|
| Rate for Payer: Zelis Worker's Compensation |
$64.16
|
|
|
SUBSQNT PSYCH CCM
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
CPT 99493
|
| Hospital Charge Code |
9199508
|
|
Hospital Revenue Code
|
529
|
| Min. Negotiated Rate |
$180.18 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: First Health Workers Compensation |
$254.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$462.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
| Rate for Payer: Zelis Worker's Compensation |
$180.18
|
|
|
SUBSQNT PSYCH CCM
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
CPT 99493
|
| Hospital Charge Code |
9199508
|
|
Hospital Revenue Code
|
529
|
| Min. Negotiated Rate |
$74.66 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$396.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$87.83
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: First Health Workers Compensation |
$254.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$528.00
|
| Rate for Payer: GEHA Medicare |
$87.83
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Humana ChoiceCare |
$96.61
|
| Rate for Payer: Humana Medicare Advantage |
$87.83
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$147.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$87.83
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$149.31
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$87.83
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$175.66
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$86.07
|
| Rate for Payer: United Healthcare Managed Medicaid |
$165.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$87.83
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$87.83
|
| Rate for Payer: Zelis Auto |
$264.00
|
| Rate for Payer: Zelis Medicare |
$74.66
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$105.40
|
| Rate for Payer: Zelis Worker's Compensation |
$180.18
|
|
|
SUCCINYLCHOLINE INJ 20MG/ML
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
CPT J0330
|
| Hospital Charge Code |
3300864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$119.00
|
| Rate for Payer: First Health Commercial |
$126.00
|
| Rate for Payer: First Health Workers Compensation |
$54.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$126.00
|
| Rate for Payer: GEHA Commercial |
$112.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$126.00
|
| Rate for Payer: Humana ChoiceCare |
$36.40
|
| Rate for Payer: Multiplan All |
$127.40
|
| Rate for Payer: New Mexico Health Connections Medicare |
$84.00
|
| Rate for Payer: OMNI Networks Commercial |
$98.00
|
| Rate for Payer: One Health Plan PPO/POS |
$126.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$133.00
|
| Rate for Payer: Three Rivers Provider Network All |
$105.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$123.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$35.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$130.20
|
| Rate for Payer: Zelis Auto |
$56.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$70.00
|
| Rate for Payer: Zelis Worker's Compensation |
$38.22
|
|
|
SUCCINYLCHOLINE INJ 20MG/ML
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
CPT J0330
|
| Hospital Charge Code |
3300864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$119.00
|
| Rate for Payer: First Health Commercial |
$126.00
|
| Rate for Payer: First Health Workers Compensation |
$54.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$126.00
|
| Rate for Payer: GEHA Commercial |
$98.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$126.00
|
| Rate for Payer: Multiplan All |
$127.40
|
| Rate for Payer: OMNI Networks Commercial |
$98.00
|
| Rate for Payer: One Health Plan PPO/POS |
$126.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$133.00
|
| Rate for Payer: Three Rivers Provider Network All |
$105.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$130.20
|
| Rate for Payer: Zelis Auto |
$56.00
|
| Rate for Payer: Zelis Worker's Compensation |
$38.22
|
|
|
SUCRALFATE 1GM TAB
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 00093221001
|
| Hospital Charge Code |
3300865
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$7.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
SUCRALFATE 1GM TAB
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 00093221001
|
| Hospital Charge Code |
3300865
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$8.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Humana ChoiceCare |
$2.60
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.00
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
SUCRALFATE SUSP 1G/10ML (CARAFATE)
|
Facility
|
IP
|
$71.00
|
|
|
Service Code
|
NDC 68094004362
|
| Hospital Charge Code |
3302501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.38 |
| Max. Negotiated Rate |
$67.45 |
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cigna Commercial |
$60.35
|
| Rate for Payer: First Health Commercial |
$63.90
|
| Rate for Payer: First Health Workers Compensation |
$27.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$63.90
|
| Rate for Payer: GEHA Commercial |
$49.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$63.90
|
| Rate for Payer: Multiplan All |
$64.61
|
| Rate for Payer: OMNI Networks Commercial |
$49.70
|
| Rate for Payer: One Health Plan PPO/POS |
$63.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$67.45
|
| Rate for Payer: Three Rivers Provider Network All |
$53.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$66.03
|
| Rate for Payer: Zelis Auto |
$28.40
|
| Rate for Payer: Zelis Worker's Compensation |
$19.38
|
|
|
SUCRALFATE SUSP 1G/10ML (CARAFATE)
|
Facility
|
OP
|
$71.00
|
|
|
Service Code
|
NDC 68094004362
|
| Hospital Charge Code |
3302501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.75 |
| Max. Negotiated Rate |
$67.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$42.60
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cigna Commercial |
$60.35
|
| Rate for Payer: First Health Commercial |
$63.90
|
| Rate for Payer: First Health Workers Compensation |
$27.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$63.90
|
| Rate for Payer: GEHA Commercial |
$56.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$63.90
|
| Rate for Payer: Humana ChoiceCare |
$18.46
|
| Rate for Payer: Multiplan All |
$64.61
|
| Rate for Payer: New Mexico Health Connections Medicare |
$42.60
|
| Rate for Payer: OMNI Networks Commercial |
$49.70
|
| Rate for Payer: One Health Plan PPO/POS |
$63.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$67.45
|
| Rate for Payer: Three Rivers Provider Network All |
$53.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$62.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$17.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$66.03
|
| Rate for Payer: Zelis Auto |
$28.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$35.50
|
| Rate for Payer: Zelis Worker's Compensation |
$19.38
|
|
|
SUGAMMADEX 200 MG/2 ML INJ
|
Facility
|
OP
|
$685.00
|
|
|
Service Code
|
NDC 00006542312
|
| Hospital Charge Code |
3303048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$171.25 |
| Max. Negotiated Rate |
$650.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$411.00
|
| Rate for Payer: Cash Price |
$411.00
|
| Rate for Payer: Cigna Commercial |
$582.25
|
| Rate for Payer: First Health Commercial |
$616.50
|
| Rate for Payer: First Health Workers Compensation |
$264.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$616.50
|
| Rate for Payer: GEHA Commercial |
$548.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$616.50
|
| Rate for Payer: Humana ChoiceCare |
$178.10
|
| Rate for Payer: Multiplan All |
$623.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$411.00
|
| Rate for Payer: OMNI Networks Commercial |
$479.50
|
| Rate for Payer: One Health Plan PPO/POS |
$616.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$650.75
|
| Rate for Payer: Three Rivers Provider Network All |
$513.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$602.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$171.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$637.05
|
| Rate for Payer: Zelis Auto |
$274.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$342.50
|
| Rate for Payer: Zelis Worker's Compensation |
$187.00
|
|
|
SUGAMMADEX 200 MG/2 ML INJ
|
Facility
|
IP
|
$685.00
|
|
|
Service Code
|
NDC 00006542312
|
| Hospital Charge Code |
3303048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$187.00 |
| Max. Negotiated Rate |
$650.75 |
| Rate for Payer: Cash Price |
$411.00
|
| Rate for Payer: Cigna Commercial |
$582.25
|
| Rate for Payer: First Health Commercial |
$616.50
|
| Rate for Payer: First Health Workers Compensation |
$264.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$616.50
|
| Rate for Payer: GEHA Commercial |
$479.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$616.50
|
| Rate for Payer: Multiplan All |
$623.35
|
| Rate for Payer: OMNI Networks Commercial |
$479.50
|
| Rate for Payer: One Health Plan PPO/POS |
$616.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$650.75
|
| Rate for Payer: Three Rivers Provider Network All |
$513.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$637.05
|
| Rate for Payer: Zelis Auto |
$274.00
|
| Rate for Payer: Zelis Worker's Compensation |
$187.00
|
|
|
SUGAMMADEX 500MG/5ML INJ.
|
Facility
|
OP
|
$1,040.60
|
|
|
Service Code
|
NDC 00006542515
|
| Hospital Charge Code |
3302047
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$260.15 |
| Max. Negotiated Rate |
$988.57 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$624.36
|
| Rate for Payer: Cash Price |
$624.36
|
| Rate for Payer: Cigna Commercial |
$884.51
|
| Rate for Payer: First Health Commercial |
$936.54
|
| Rate for Payer: First Health Workers Compensation |
$401.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$936.54
|
| Rate for Payer: GEHA Commercial |
$832.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$936.54
|
| Rate for Payer: Humana ChoiceCare |
$270.56
|
| Rate for Payer: Multiplan All |
$946.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$624.36
|
| Rate for Payer: OMNI Networks Commercial |
$728.42
|
| Rate for Payer: One Health Plan PPO/POS |
$936.54
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$988.57
|
| Rate for Payer: Three Rivers Provider Network All |
$780.45
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$915.73
|
| Rate for Payer: United Healthcare Managed Medicaid |
$260.15
|
| Rate for Payer: United Payors & United Providers UP&UP |
$967.76
|
| Rate for Payer: Zelis Auto |
$416.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$520.30
|
| Rate for Payer: Zelis Worker's Compensation |
$284.08
|
|
|
SUGAMMADEX 500MG/5ML INJ.
|
Facility
|
IP
|
$1,040.60
|
|
|
Service Code
|
NDC 00006542515
|
| Hospital Charge Code |
3302047
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$284.08 |
| Max. Negotiated Rate |
$988.57 |
| Rate for Payer: Cash Price |
$624.36
|
| Rate for Payer: Cigna Commercial |
$884.51
|
| Rate for Payer: First Health Commercial |
$936.54
|
| Rate for Payer: First Health Workers Compensation |
$401.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$936.54
|
| Rate for Payer: GEHA Commercial |
$728.42
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$936.54
|
| Rate for Payer: Multiplan All |
$946.95
|
| Rate for Payer: OMNI Networks Commercial |
$728.42
|
| Rate for Payer: One Health Plan PPO/POS |
$936.54
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$988.57
|
| Rate for Payer: Three Rivers Provider Network All |
$780.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$967.76
|
| Rate for Payer: Zelis Auto |
$416.24
|
| Rate for Payer: Zelis Worker's Compensation |
$284.08
|
|
|
SULFASALAZINE 500MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 59762500005
|
| Hospital Charge Code |
3302990
|
|
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
|
|
|
SULFASALAZINE 500MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 59762500005
|
| Hospital Charge Code |
3302990
|
|
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
|
|
|
SULFASALAZINE 500MG TAB - NF
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
NDC 00591079601
|
| Hospital Charge Code |
3301296
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| 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: 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 |
$13.60
|
| 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
|
|
|
SULFASALAZINE 500MG TAB - NF
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
NDC 00591079601
|
| Hospital Charge Code |
3301296
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
SULFATE UA POP
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 84392
|
| Hospital Charge Code |
2299386
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.67 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.88
|
| 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 |
$9.88
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.49
|
| 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 |
$7.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: GEHA Medicare |
$5.49
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$6.04
|
| Rate for Payer: Humana Medicare Advantage |
$5.49
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$9.22
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.99
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.49
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.33
|
| 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 |
$9.23
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.99
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.49
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10.98
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.38
|
| Rate for Payer: United Healthcare Commercial |
$47.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.49
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.49
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Medicare |
$4.67
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.59
|
| Rate for Payer: Zelis Worker's Compensation |
$5.54
|
|
|
SULFATE UA POP
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 84392
|
| Hospital Charge Code |
2299386
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.54 |
| 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 |
$7.83
|
| 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 |
$5.54
|
|
|
SULFA-TRIMETHOPRIM 800-160MG TAB
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 42292002808
|
| Hospital Charge Code |
3300868
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
SULFA-TRIMETHOPRIM 800-160MG TAB
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 42292002808
|
| Hospital Charge Code |
3300868
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Humana ChoiceCare |
$1.56
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.60
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
SULFA-TRIMETHOPRIM 800MG-160MG/20ML SUSP
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
NDC 00121085340
|
| Hospital Charge Code |
3302927
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.38 |
| Max. Negotiated Rate |
$46.55 |
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$41.65
|
| Rate for Payer: First Health Commercial |
$44.10
|
| Rate for Payer: First Health Workers Compensation |
$18.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$44.10
|
| Rate for Payer: GEHA Commercial |
$34.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$44.10
|
| Rate for Payer: Multiplan All |
$44.59
|
| Rate for Payer: OMNI Networks Commercial |
$34.30
|
| Rate for Payer: One Health Plan PPO/POS |
$44.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$46.55
|
| Rate for Payer: Three Rivers Provider Network All |
$36.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$45.57
|
| Rate for Payer: Zelis Auto |
$19.60
|
| Rate for Payer: Zelis Worker's Compensation |
$13.38
|
|
|
SULFA-TRIMETHOPRIM 800MG-160MG/20ML SUSP
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
NDC 00121085340
|
| Hospital Charge Code |
3302927
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$46.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$41.65
|
| Rate for Payer: First Health Commercial |
$44.10
|
| Rate for Payer: First Health Workers Compensation |
$18.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$44.10
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$44.10
|
| Rate for Payer: Humana ChoiceCare |
$12.74
|
| Rate for Payer: Multiplan All |
$44.59
|
| Rate for Payer: New Mexico Health Connections Medicare |
$29.40
|
| Rate for Payer: OMNI Networks Commercial |
$34.30
|
| Rate for Payer: One Health Plan PPO/POS |
$44.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$46.55
|
| Rate for Payer: Three Rivers Provider Network All |
$36.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$43.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$45.57
|
| Rate for Payer: Zelis Auto |
$19.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$24.50
|
| Rate for Payer: Zelis Worker's Compensation |
$13.38
|
|
|
SULF COLLD DOSE 20MC
|
Facility
|
IP
|
$480.00
|
|
|
Service Code
|
CPT A9541
|
| Hospital Charge Code |
2410057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$131.04 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Cash Price |
$288.00
|
| Rate for Payer: Cigna Commercial |
$408.00
|
| Rate for Payer: First Health Commercial |
$432.00
|
| Rate for Payer: First Health Workers Compensation |
$185.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$432.00
|
| Rate for Payer: GEHA Commercial |
$336.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$432.00
|
| Rate for Payer: Multiplan All |
$436.80
|
| Rate for Payer: OMNI Networks Commercial |
$336.00
|
| Rate for Payer: One Health Plan PPO/POS |
$432.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$456.00
|
| Rate for Payer: Three Rivers Provider Network All |
$360.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$446.40
|
| Rate for Payer: Zelis Auto |
$192.00
|
| Rate for Payer: Zelis Worker's Compensation |
$131.04
|
|
|
SULF COLLD DOSE 20MC
|
Facility
|
OP
|
$480.00
|
|
|
Service Code
|
CPT A9541
|
| Hospital Charge Code |
2410057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$120.00 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$288.00
|
| Rate for Payer: Cash Price |
$288.00
|
| Rate for Payer: Cigna Commercial |
$408.00
|
| Rate for Payer: First Health Commercial |
$432.00
|
| Rate for Payer: First Health Workers Compensation |
$185.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$432.00
|
| Rate for Payer: GEHA Commercial |
$384.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$432.00
|
| Rate for Payer: Humana ChoiceCare |
$124.80
|
| Rate for Payer: Multiplan All |
$436.80
|
| Rate for Payer: New Mexico Health Connections Medicare |
$288.00
|
| Rate for Payer: OMNI Networks Commercial |
$336.00
|
| Rate for Payer: One Health Plan PPO/POS |
$432.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$456.00
|
| Rate for Payer: Three Rivers Provider Network All |
$360.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$422.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$120.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$446.40
|
| Rate for Payer: Zelis Auto |
$192.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$240.00
|
| Rate for Payer: Zelis Worker's Compensation |
$131.04
|
|
