|
valproic acid free REF070789
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
CPT 80165
|
| Hospital Charge Code |
2200419
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$147.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$93.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$13.54
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$131.75
|
| Rate for Payer: First Health Commercial |
$139.50
|
| Rate for Payer: First Health Workers Compensation |
$17.68
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$139.50
|
| Rate for Payer: GEHA Commercial |
$124.00
|
| Rate for Payer: GEHA Medicare |
$13.54
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$139.50
|
| Rate for Payer: Humana ChoiceCare |
$14.89
|
| Rate for Payer: Humana Medicare Advantage |
$13.54
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$22.75
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$13.54
|
| Rate for Payer: Multiplan All |
$141.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$23.02
|
| Rate for Payer: OMNI Networks Commercial |
$108.50
|
| Rate for Payer: One Health Plan PPO/POS |
$139.50
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$13.54
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$147.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$27.08
|
| Rate for Payer: Three Rivers Provider Network All |
$116.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.27
|
| Rate for Payer: United Healthcare Commercial |
$131.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$38.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.54
|
| Rate for Payer: United Payors & United Providers UP&UP |
$144.15
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$13.54
|
| Rate for Payer: Zelis Auto |
$62.00
|
| Rate for Payer: Zelis Medicare |
$11.51
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$16.25
|
| Rate for Payer: Zelis Worker's Compensation |
$12.50
|
|
|
valproic acid free REF070789
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
CPT 80165
|
| Hospital Charge Code |
2200419
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.50 |
| Max. Negotiated Rate |
$147.25 |
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$131.75
|
| Rate for Payer: First Health Commercial |
$139.50
|
| Rate for Payer: First Health Workers Compensation |
$17.68
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$139.50
|
| Rate for Payer: GEHA Commercial |
$108.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$139.50
|
| Rate for Payer: Multiplan All |
$141.05
|
| Rate for Payer: OMNI Networks Commercial |
$108.50
|
| Rate for Payer: One Health Plan PPO/POS |
$139.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$147.25
|
| Rate for Payer: Three Rivers Provider Network All |
$116.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$144.15
|
| Rate for Payer: Zelis Auto |
$62.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.50
|
|
|
VALPROIC ACID (Vitros)
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
CPT 80164
|
| Hospital Charge Code |
2232230
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$24.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$45.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$24.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$19.31
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$13.54
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: First Health Workers Compensation |
$27.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$68.40
|
| Rate for Payer: GEHA Commercial |
$60.80
|
| Rate for Payer: GEHA Medicare |
$13.54
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$68.40
|
| Rate for Payer: Humana ChoiceCare |
$14.89
|
| Rate for Payer: Humana Medicare Advantage |
$13.54
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$22.75
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$19.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$13.54
|
| Rate for Payer: Multiplan All |
$69.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$23.02
|
| Rate for Payer: OMNI Networks Commercial |
$53.20
|
| Rate for Payer: One Health Plan PPO/POS |
$68.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$22.75
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$19.70
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$13.54
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$72.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$27.08
|
| Rate for Payer: Three Rivers Provider Network All |
$57.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.27
|
| Rate for Payer: United Healthcare Commercial |
$64.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$19.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.54
|
| Rate for Payer: United Payors & United Providers UP&UP |
$70.68
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$13.54
|
| Rate for Payer: Zelis Auto |
$30.40
|
| Rate for Payer: Zelis Medicare |
$11.51
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$16.25
|
| Rate for Payer: Zelis Worker's Compensation |
$19.26
|
|
|
VALPROIC ACID (Vitros)
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
CPT 80164
|
| Hospital Charge Code |
2232230
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.26 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: First Health Workers Compensation |
$27.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$68.40
|
| Rate for Payer: GEHA Commercial |
$53.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$68.40
|
| Rate for Payer: Multiplan All |
$69.16
|
| Rate for Payer: OMNI Networks Commercial |
$53.20
|
| Rate for Payer: One Health Plan PPO/POS |
$68.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$72.20
|
| Rate for Payer: Three Rivers Provider Network All |
$57.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$70.68
|
| Rate for Payer: Zelis Auto |
$30.40
|
| Rate for Payer: Zelis Worker's Compensation |
$19.26
|
|
|
VALPROIC SYRUP 250MG/5ML
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 00121467540
|
| Hospital Charge Code |
3300933
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
VALPROIC SYRUP 250MG/5ML
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 00121467540
|
| Hospital Charge Code |
3300933
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$4.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Humana ChoiceCare |
$1.30
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.00
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
VALSARTAN 80MG TAB
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
NDC 65862057190
|
| Hospital Charge Code |
3300934
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$28.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$25.50
|
| Rate for Payer: First Health Commercial |
$27.00
|
| Rate for Payer: First Health Workers Compensation |
$11.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.00
|
| Rate for Payer: GEHA Commercial |
$24.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.00
|
| Rate for Payer: Humana ChoiceCare |
$7.80
|
| Rate for Payer: Multiplan All |
$27.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$18.00
|
| Rate for Payer: OMNI Networks Commercial |
$21.00
|
| Rate for Payer: One Health Plan PPO/POS |
$27.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$28.50
|
| Rate for Payer: Three Rivers Provider Network All |
$22.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$26.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$27.90
|
| Rate for Payer: Zelis Auto |
$12.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.19
|
|
|
VALSARTAN 80MG TAB
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
NDC 65862057190
|
| Hospital Charge Code |
3300934
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.19 |
| Max. Negotiated Rate |
$28.50 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$25.50
|
| Rate for Payer: First Health Commercial |
$27.00
|
| Rate for Payer: First Health Workers Compensation |
$11.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.00
|
| Rate for Payer: GEHA Commercial |
$21.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.00
|
| Rate for Payer: Multiplan All |
$27.30
|
| Rate for Payer: OMNI Networks Commercial |
$21.00
|
| Rate for Payer: One Health Plan PPO/POS |
$27.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$28.50
|
| Rate for Payer: Three Rivers Provider Network All |
$22.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$27.90
|
| Rate for Payer: Zelis Auto |
$12.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.19
|
|
|
VALVULOPLASTY AORTIC VLVE COMPLEX
|
Facility
|
IP
|
$7,380.00
|
|
|
Service Code
|
CPT 33391
|
| Hospital Charge Code |
6191069
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$2,014.74 |
| Max. Negotiated Rate |
$7,011.00 |
| Rate for Payer: Cash Price |
$4,428.00
|
| Rate for Payer: Cigna Commercial |
$6,273.00
|
| Rate for Payer: First Health Commercial |
$6,642.00
|
| Rate for Payer: First Health Workers Compensation |
$2,849.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,642.00
|
| Rate for Payer: GEHA Commercial |
$5,166.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,642.00
|
| Rate for Payer: Multiplan All |
$6,715.80
|
| Rate for Payer: OMNI Networks Commercial |
$5,166.00
|
| Rate for Payer: One Health Plan PPO/POS |
$6,642.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,011.00
|
| Rate for Payer: Three Rivers Provider Network All |
$5,535.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,863.40
|
| Rate for Payer: Zelis Auto |
$2,952.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2,014.74
|
|
|
VALVULOPLASTY AORTIC VLVE COMPLEX
|
Facility
|
OP
|
$7,380.00
|
|
|
Service Code
|
CPT 33391
|
| Hospital Charge Code |
6191069
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,845.00 |
| Max. Negotiated Rate |
$7,011.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,428.00
|
| Rate for Payer: Cash Price |
$4,428.00
|
| Rate for Payer: Cigna Commercial |
$6,273.00
|
| Rate for Payer: First Health Commercial |
$6,642.00
|
| Rate for Payer: First Health Workers Compensation |
$2,849.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,642.00
|
| Rate for Payer: GEHA Commercial |
$5,904.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,642.00
|
| Rate for Payer: Humana ChoiceCare |
$1,918.80
|
| Rate for Payer: Multiplan All |
$6,715.80
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,428.00
|
| Rate for Payer: OMNI Networks Commercial |
$5,166.00
|
| Rate for Payer: One Health Plan PPO/POS |
$6,642.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,011.00
|
| Rate for Payer: Three Rivers Provider Network All |
$5,535.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,494.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,845.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,863.40
|
| Rate for Payer: Zelis Auto |
$2,952.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,690.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2,014.74
|
|
|
VALVULOPLASTY AORTIC VLVE OPEN
|
Facility
|
IP
|
$6,233.00
|
|
|
Service Code
|
CPT 33390
|
| Hospital Charge Code |
6191068
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,701.61 |
| Max. Negotiated Rate |
$5,921.35 |
| Rate for Payer: Cash Price |
$3,739.80
|
| Rate for Payer: Cigna Commercial |
$5,298.05
|
| Rate for Payer: First Health Commercial |
$5,609.70
|
| Rate for Payer: First Health Workers Compensation |
$2,406.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,609.70
|
| Rate for Payer: GEHA Commercial |
$4,363.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,609.70
|
| Rate for Payer: Multiplan All |
$5,672.03
|
| Rate for Payer: OMNI Networks Commercial |
$4,363.10
|
| Rate for Payer: One Health Plan PPO/POS |
$5,609.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,921.35
|
| Rate for Payer: Three Rivers Provider Network All |
$4,674.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,796.69
|
| Rate for Payer: Zelis Auto |
$2,493.20
|
| Rate for Payer: Zelis Worker's Compensation |
$1,701.61
|
|
|
VALVULOPLASTY AORTIC VLVE OPEN
|
Facility
|
OP
|
$6,233.00
|
|
|
Service Code
|
CPT 33390
|
| Hospital Charge Code |
6191068
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,558.25 |
| Max. Negotiated Rate |
$5,921.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,739.80
|
| Rate for Payer: Cash Price |
$3,739.80
|
| Rate for Payer: Cigna Commercial |
$5,298.05
|
| Rate for Payer: First Health Commercial |
$5,609.70
|
| Rate for Payer: First Health Workers Compensation |
$2,406.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,609.70
|
| Rate for Payer: GEHA Commercial |
$4,986.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,609.70
|
| Rate for Payer: Humana ChoiceCare |
$1,620.58
|
| Rate for Payer: Multiplan All |
$5,672.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,739.80
|
| Rate for Payer: OMNI Networks Commercial |
$4,363.10
|
| Rate for Payer: One Health Plan PPO/POS |
$5,609.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,921.35
|
| Rate for Payer: Three Rivers Provider Network All |
$4,674.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,485.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,558.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,796.69
|
| Rate for Payer: Zelis Auto |
$2,493.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,116.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1,701.61
|
|
|
VANCOMYCIN 1000 MG/200 ML PREMIX IVPB
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
3303131
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.49 |
| Max. Negotiated Rate |
$113.05 |
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$101.15
|
| Rate for Payer: First Health Commercial |
$107.10
|
| Rate for Payer: First Health Workers Compensation |
$45.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$107.10
|
| Rate for Payer: GEHA Commercial |
$83.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$107.10
|
| Rate for Payer: Multiplan All |
$108.29
|
| Rate for Payer: OMNI Networks Commercial |
$83.30
|
| Rate for Payer: One Health Plan PPO/POS |
$107.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$113.05
|
| Rate for Payer: Three Rivers Provider Network All |
$89.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$110.67
|
| Rate for Payer: Zelis Auto |
$47.60
|
| Rate for Payer: Zelis Worker's Compensation |
$32.49
|
|
|
VANCOMYCIN 1000 MG/200 ML PREMIX IVPB
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
3303131
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.75 |
| Max. Negotiated Rate |
$113.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$101.15
|
| Rate for Payer: First Health Commercial |
$107.10
|
| Rate for Payer: First Health Workers Compensation |
$45.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$107.10
|
| Rate for Payer: GEHA Commercial |
$95.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$107.10
|
| Rate for Payer: Humana ChoiceCare |
$30.94
|
| Rate for Payer: Multiplan All |
$108.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$71.40
|
| Rate for Payer: OMNI Networks Commercial |
$83.30
|
| Rate for Payer: One Health Plan PPO/POS |
$107.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$113.05
|
| Rate for Payer: Three Rivers Provider Network All |
$89.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$104.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$29.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$110.67
|
| Rate for Payer: Zelis Auto |
$47.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$59.50
|
| Rate for Payer: Zelis Worker's Compensation |
$32.49
|
|
|
VANCOMYCIN 1250 MG/250 ML PREMIX IVPB
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
3303132
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
VANCOMYCIN 1250 MG/250 ML PREMIX IVPB
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
3303132
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
VANCOMYCIN 1500 MG/300 ML PREMIX IVPB
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
3303129
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$64.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$134.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Humana ChoiceCare |
$43.68
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$100.80
|
| Rate for Payer: OMNI Networks Commercial |
$117.60
|
| Rate for Payer: One Health Plan PPO/POS |
$151.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$147.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$84.00
|
| Rate for Payer: Zelis Worker's Compensation |
$45.86
|
|
|
VANCOMYCIN 1500 MG/300 ML PREMIX IVPB
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
3303129
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.86 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$64.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$117.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: OMNI Networks Commercial |
$117.60
|
| Rate for Payer: One Health Plan PPO/POS |
$151.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Worker's Compensation |
$45.86
|
|
|
VANCOMYCIN 1750 MG/350 ML PREMIX IVPB
|
Facility
|
IP
|
$190.15
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
3303189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.91 |
| Max. Negotiated Rate |
$180.64 |
| Rate for Payer: Cash Price |
$114.09
|
| Rate for Payer: Cigna Commercial |
$161.63
|
| Rate for Payer: First Health Commercial |
$171.13
|
| Rate for Payer: First Health Workers Compensation |
$73.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$171.13
|
| Rate for Payer: GEHA Commercial |
$133.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$171.13
|
| Rate for Payer: Multiplan All |
$173.04
|
| Rate for Payer: OMNI Networks Commercial |
$133.10
|
| Rate for Payer: One Health Plan PPO/POS |
$171.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$180.64
|
| Rate for Payer: Three Rivers Provider Network All |
$142.61
|
| Rate for Payer: United Payors & United Providers UP&UP |
$176.84
|
| Rate for Payer: Zelis Auto |
$76.06
|
| Rate for Payer: Zelis Worker's Compensation |
$51.91
|
|
|
VANCOMYCIN 1750 MG/350 ML PREMIX IVPB
|
Facility
|
OP
|
$190.15
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
3303189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.54 |
| Max. Negotiated Rate |
$180.64 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$114.09
|
| Rate for Payer: Cash Price |
$114.09
|
| Rate for Payer: Cigna Commercial |
$161.63
|
| Rate for Payer: First Health Commercial |
$171.13
|
| Rate for Payer: First Health Workers Compensation |
$73.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$171.13
|
| Rate for Payer: GEHA Commercial |
$152.12
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$171.13
|
| Rate for Payer: Humana ChoiceCare |
$49.44
|
| Rate for Payer: Multiplan All |
$173.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$114.09
|
| Rate for Payer: OMNI Networks Commercial |
$133.10
|
| Rate for Payer: One Health Plan PPO/POS |
$171.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$180.64
|
| Rate for Payer: Three Rivers Provider Network All |
$142.61
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$167.33
|
| Rate for Payer: United Healthcare Managed Medicaid |
$47.54
|
| Rate for Payer: United Payors & United Providers UP&UP |
$176.84
|
| Rate for Payer: Zelis Auto |
$76.06
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$95.08
|
| Rate for Payer: Zelis Worker's Compensation |
$51.91
|
|
|
VANCOMYCIN 2000 MG/400 ML PREMIX IVPB
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
3303130
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$152.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
VANCOMYCIN 2000 MG/400 ML PREMIX IVPB
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
3303130
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.50 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$174.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Humana ChoiceCare |
$56.68
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$130.80
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$191.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$54.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$109.00
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
VANCOMYCIN 5 GM (FOR SURGICAL USE ONLY)
|
Facility
|
OP
|
$187.00
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
3302831
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.75 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$112.20
|
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cigna Commercial |
$158.95
|
| Rate for Payer: First Health Commercial |
$168.30
|
| Rate for Payer: First Health Workers Compensation |
$72.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$168.30
|
| Rate for Payer: GEHA Commercial |
$149.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$168.30
|
| Rate for Payer: Humana ChoiceCare |
$48.62
|
| Rate for Payer: Multiplan All |
$170.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$112.20
|
| Rate for Payer: OMNI Networks Commercial |
$130.90
|
| Rate for Payer: One Health Plan PPO/POS |
$168.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$177.65
|
| Rate for Payer: Three Rivers Provider Network All |
$140.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$164.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$46.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$173.91
|
| Rate for Payer: Zelis Auto |
$74.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$93.50
|
| Rate for Payer: Zelis Worker's Compensation |
$51.05
|
|
|
VANCOMYCIN 5 GM (FOR SURGICAL USE ONLY)
|
Facility
|
IP
|
$187.00
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
3302831
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.05 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cigna Commercial |
$158.95
|
| Rate for Payer: First Health Commercial |
$168.30
|
| Rate for Payer: First Health Workers Compensation |
$72.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$168.30
|
| Rate for Payer: GEHA Commercial |
$130.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$168.30
|
| Rate for Payer: Multiplan All |
$170.17
|
| Rate for Payer: OMNI Networks Commercial |
$130.90
|
| Rate for Payer: One Health Plan PPO/POS |
$168.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$177.65
|
| Rate for Payer: Three Rivers Provider Network All |
$140.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$173.91
|
| Rate for Payer: Zelis Auto |
$74.80
|
| Rate for Payer: Zelis Worker's Compensation |
$51.05
|
|
|
VANCOMYCIN HCL 1GM VIAL
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
3300935
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$30.40 |
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$27.20
|
| Rate for Payer: First Health Commercial |
$28.80
|
| Rate for Payer: First Health Workers Compensation |
$12.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$28.80
|
| Rate for Payer: GEHA Commercial |
$22.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$28.80
|
| Rate for Payer: Multiplan All |
$29.12
|
| Rate for Payer: OMNI Networks Commercial |
$22.40
|
| Rate for Payer: One Health Plan PPO/POS |
$28.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$30.40
|
| Rate for Payer: Three Rivers Provider Network All |
$24.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$29.76
|
| Rate for Payer: Zelis Auto |
$12.80
|
| Rate for Payer: Zelis Worker's Compensation |
$8.74
|
|
