|
VANCOMYCIN HCL 1GM VIAL
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
3300935
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.00 |
| Max. Negotiated Rate |
$30.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$27.20
|
| Rate for Payer: First Health Commercial |
$28.80
|
| Rate for Payer: First Health Workers Compensation |
$12.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$28.80
|
| Rate for Payer: GEHA Commercial |
$25.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$28.80
|
| Rate for Payer: Humana ChoiceCare |
$8.32
|
| Rate for Payer: Multiplan All |
$29.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$19.20
|
| Rate for Payer: OMNI Networks Commercial |
$22.40
|
| Rate for Payer: One Health Plan PPO/POS |
$28.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$30.40
|
| Rate for Payer: Three Rivers Provider Network All |
$24.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$28.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$29.76
|
| Rate for Payer: Zelis Auto |
$12.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$16.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.74
|
|
|
VANCOMYCIN HCL 750 MG VIAL
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
3303214
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.56 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$32.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
VANCOMYCIN HCL 750 MG VIAL
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
3303214
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.50 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$36.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Humana ChoiceCare |
$11.96
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.60
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$40.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$23.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
VANCOMYCIN ORAL 125MG/2.5ML (10ML TOTAL)
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 63323028420
|
| Hospital Charge Code |
3302520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$12.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Humana ChoiceCare |
$4.16
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.60
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
VANCOMYCIN ORAL 125MG/2.5ML (10ML TOTAL)
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 63323028420
|
| Hospital Charge Code |
3302520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$11.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
VANCOMYCIN ORAL 125MG/2.5ML KIT
|
Facility
|
IP
|
$511.00
|
|
|
Service Code
|
NDC 65628020405
|
| Hospital Charge Code |
3301801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$139.50 |
| Max. Negotiated Rate |
$485.45 |
| Rate for Payer: Cash Price |
$306.60
|
| Rate for Payer: Cigna Commercial |
$434.35
|
| Rate for Payer: First Health Commercial |
$459.90
|
| Rate for Payer: First Health Workers Compensation |
$197.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$459.90
|
| Rate for Payer: GEHA Commercial |
$357.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$459.90
|
| Rate for Payer: Multiplan All |
$465.01
|
| Rate for Payer: OMNI Networks Commercial |
$357.70
|
| Rate for Payer: One Health Plan PPO/POS |
$459.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$485.45
|
| Rate for Payer: Three Rivers Provider Network All |
$383.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$475.23
|
| Rate for Payer: Zelis Auto |
$204.40
|
| Rate for Payer: Zelis Worker's Compensation |
$139.50
|
|
|
VANCOMYCIN ORAL 125MG/2.5ML KIT
|
Facility
|
OP
|
$511.00
|
|
|
Service Code
|
NDC 65628020405
|
| Hospital Charge Code |
3301801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$127.75 |
| Max. Negotiated Rate |
$485.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$306.60
|
| Rate for Payer: Cash Price |
$306.60
|
| Rate for Payer: Cigna Commercial |
$434.35
|
| Rate for Payer: First Health Commercial |
$459.90
|
| Rate for Payer: First Health Workers Compensation |
$197.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$459.90
|
| Rate for Payer: GEHA Commercial |
$408.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$459.90
|
| Rate for Payer: Humana ChoiceCare |
$132.86
|
| Rate for Payer: Multiplan All |
$465.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$306.60
|
| Rate for Payer: OMNI Networks Commercial |
$357.70
|
| Rate for Payer: One Health Plan PPO/POS |
$459.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$485.45
|
| Rate for Payer: Three Rivers Provider Network All |
$383.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$449.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$127.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$475.23
|
| Rate for Payer: Zelis Auto |
$204.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$255.50
|
| Rate for Payer: Zelis Worker's Compensation |
$139.50
|
|
|
VANCOMYCIN PEAK (Vitros)
|
Facility
|
IP
|
$231.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
2232232
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.01 |
| Max. Negotiated Rate |
$219.45 |
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$196.35
|
| Rate for Payer: First Health Commercial |
$207.90
|
| Rate for Payer: First Health Workers Compensation |
$26.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$207.90
|
| Rate for Payer: GEHA Commercial |
$161.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$207.90
|
| Rate for Payer: Multiplan All |
$210.21
|
| Rate for Payer: OMNI Networks Commercial |
$161.70
|
| Rate for Payer: One Health Plan PPO/POS |
$207.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$219.45
|
| Rate for Payer: Three Rivers Provider Network All |
$173.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$214.83
|
| Rate for Payer: Zelis Auto |
$92.40
|
| Rate for Payer: Zelis Worker's Compensation |
$19.01
|
|
|
VANCOMYCIN PEAK (Vitros)
|
Facility
|
OP
|
$231.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
2232232
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$219.45 |
| 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 |
$138.60
|
| 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 |
$138.60
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$196.35
|
| Rate for Payer: First Health Commercial |
$207.90
|
| Rate for Payer: First Health Workers Compensation |
$26.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$207.90
|
| Rate for Payer: GEHA Commercial |
$184.80
|
| Rate for Payer: GEHA Medicare |
$13.54
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$207.90
|
| 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 |
$210.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$23.02
|
| Rate for Payer: OMNI Networks Commercial |
$161.70
|
| Rate for Payer: One Health Plan PPO/POS |
$207.90
|
| 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 |
$219.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$27.08
|
| Rate for Payer: Three Rivers Provider Network All |
$173.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.27
|
| Rate for Payer: United Healthcare Commercial |
$196.35
|
| 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 |
$214.83
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$13.54
|
| Rate for Payer: Zelis Auto |
$92.40
|
| Rate for Payer: Zelis Medicare |
$11.51
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$16.25
|
| Rate for Payer: Zelis Worker's Compensation |
$19.01
|
|
|
VANCOMYCIN RANDOM (Vitros)
|
Facility
|
IP
|
$231.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
2232233
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.01 |
| Max. Negotiated Rate |
$219.45 |
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$196.35
|
| Rate for Payer: First Health Commercial |
$207.90
|
| Rate for Payer: First Health Workers Compensation |
$26.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$207.90
|
| Rate for Payer: GEHA Commercial |
$161.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$207.90
|
| Rate for Payer: Multiplan All |
$210.21
|
| Rate for Payer: OMNI Networks Commercial |
$161.70
|
| Rate for Payer: One Health Plan PPO/POS |
$207.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$219.45
|
| Rate for Payer: Three Rivers Provider Network All |
$173.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$214.83
|
| Rate for Payer: Zelis Auto |
$92.40
|
| Rate for Payer: Zelis Worker's Compensation |
$19.01
|
|
|
VANCOMYCIN RANDOM (Vitros)
|
Facility
|
OP
|
$231.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
2232233
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$219.45 |
| 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 |
$138.60
|
| 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 |
$138.60
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$196.35
|
| Rate for Payer: First Health Commercial |
$207.90
|
| Rate for Payer: First Health Workers Compensation |
$26.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$207.90
|
| Rate for Payer: GEHA Commercial |
$184.80
|
| Rate for Payer: GEHA Medicare |
$13.54
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$207.90
|
| 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 |
$210.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$23.02
|
| Rate for Payer: OMNI Networks Commercial |
$161.70
|
| Rate for Payer: One Health Plan PPO/POS |
$207.90
|
| 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 |
$219.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$27.08
|
| Rate for Payer: Three Rivers Provider Network All |
$173.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.27
|
| Rate for Payer: United Healthcare Commercial |
$196.35
|
| 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 |
$214.83
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$13.54
|
| Rate for Payer: Zelis Auto |
$92.40
|
| Rate for Payer: Zelis Medicare |
$11.51
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$16.25
|
| Rate for Payer: Zelis Worker's Compensation |
$19.01
|
|
|
VANCOMYCIN TROUGH (Vitros)
|
Facility
|
OP
|
$231.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
2232231
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$219.45 |
| 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 |
$138.60
|
| 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 |
$138.60
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$196.35
|
| Rate for Payer: First Health Commercial |
$207.90
|
| Rate for Payer: First Health Workers Compensation |
$26.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$207.90
|
| Rate for Payer: GEHA Commercial |
$184.80
|
| Rate for Payer: GEHA Medicare |
$13.54
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$207.90
|
| 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 |
$210.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$23.02
|
| Rate for Payer: OMNI Networks Commercial |
$161.70
|
| Rate for Payer: One Health Plan PPO/POS |
$207.90
|
| 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 |
$219.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$27.08
|
| Rate for Payer: Three Rivers Provider Network All |
$173.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.27
|
| Rate for Payer: United Healthcare Commercial |
$196.35
|
| 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 |
$214.83
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$13.54
|
| Rate for Payer: Zelis Auto |
$92.40
|
| Rate for Payer: Zelis Medicare |
$11.51
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$16.25
|
| Rate for Payer: Zelis Worker's Compensation |
$19.01
|
|
|
VANCOMYCIN TROUGH (Vitros)
|
Facility
|
IP
|
$231.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
2232231
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.01 |
| Max. Negotiated Rate |
$219.45 |
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$196.35
|
| Rate for Payer: First Health Commercial |
$207.90
|
| Rate for Payer: First Health Workers Compensation |
$26.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$207.90
|
| Rate for Payer: GEHA Commercial |
$161.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$207.90
|
| Rate for Payer: Multiplan All |
$210.21
|
| Rate for Payer: OMNI Networks Commercial |
$161.70
|
| Rate for Payer: One Health Plan PPO/POS |
$207.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$219.45
|
| Rate for Payer: Three Rivers Provider Network All |
$173.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$214.83
|
| Rate for Payer: Zelis Auto |
$92.40
|
| Rate for Payer: Zelis Worker's Compensation |
$19.01
|
|
|
VAPOTHERM CANNULA
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 99070
|
| Hospital Charge Code |
4000706
|
|
Hospital Revenue Code
|
271
|
| 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
|
|
|
VAPOTHERM CANNULA
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT 99070
|
| Hospital Charge Code |
4000706
|
|
Hospital Revenue Code
|
271
|
| 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
|
|
|
VAPOTHERM SETUP AND MAINTENANCE
|
Facility
|
IP
|
$267.00
|
|
|
Service Code
|
CPT 99070
|
| Hospital Charge Code |
4099070
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$72.89 |
| Max. Negotiated Rate |
$253.65 |
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cigna Commercial |
$226.95
|
| Rate for Payer: First Health Commercial |
$240.30
|
| Rate for Payer: First Health Workers Compensation |
$103.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$240.30
|
| Rate for Payer: GEHA Commercial |
$186.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$240.30
|
| Rate for Payer: Multiplan All |
$242.97
|
| Rate for Payer: OMNI Networks Commercial |
$186.90
|
| Rate for Payer: One Health Plan PPO/POS |
$240.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$253.65
|
| Rate for Payer: Three Rivers Provider Network All |
$200.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$248.31
|
| Rate for Payer: Zelis Auto |
$106.80
|
| Rate for Payer: Zelis Worker's Compensation |
$72.89
|
|
|
VAPOTHERM SETUP AND MAINTENANCE
|
Facility
|
OP
|
$267.00
|
|
|
Service Code
|
CPT 99070
|
| Hospital Charge Code |
4099070
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$66.75 |
| Max. Negotiated Rate |
$253.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$160.20
|
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cigna Commercial |
$226.95
|
| Rate for Payer: First Health Commercial |
$240.30
|
| Rate for Payer: First Health Workers Compensation |
$103.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$240.30
|
| Rate for Payer: GEHA Commercial |
$213.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$240.30
|
| Rate for Payer: Humana ChoiceCare |
$69.42
|
| Rate for Payer: Multiplan All |
$242.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$160.20
|
| Rate for Payer: OMNI Networks Commercial |
$186.90
|
| Rate for Payer: One Health Plan PPO/POS |
$240.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$253.65
|
| Rate for Payer: Three Rivers Provider Network All |
$200.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$234.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$66.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$248.31
|
| Rate for Payer: Zelis Auto |
$106.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$133.50
|
| Rate for Payer: Zelis Worker's Compensation |
$72.89
|
|
|
VAPOTHERM WATER BAG
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
CPT 99070
|
| Hospital Charge Code |
4000705
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$9.55 |
| Max. Negotiated Rate |
$33.25 |
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$29.75
|
| Rate for Payer: First Health Commercial |
$31.50
|
| Rate for Payer: First Health Workers Compensation |
$13.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$31.50
|
| Rate for Payer: GEHA Commercial |
$24.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$31.50
|
| Rate for Payer: Multiplan All |
$31.85
|
| Rate for Payer: OMNI Networks Commercial |
$24.50
|
| Rate for Payer: One Health Plan PPO/POS |
$31.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$33.25
|
| Rate for Payer: Three Rivers Provider Network All |
$26.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$32.55
|
| Rate for Payer: Zelis Auto |
$14.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.55
|
|
|
VAPOTHERM WATER BAG
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
CPT 99070
|
| Hospital Charge Code |
4000705
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$33.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$29.75
|
| Rate for Payer: First Health Commercial |
$31.50
|
| Rate for Payer: First Health Workers Compensation |
$13.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$31.50
|
| Rate for Payer: GEHA Commercial |
$28.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$31.50
|
| Rate for Payer: Humana ChoiceCare |
$9.10
|
| Rate for Payer: Multiplan All |
$31.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$21.00
|
| Rate for Payer: OMNI Networks Commercial |
$24.50
|
| Rate for Payer: One Health Plan PPO/POS |
$31.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$33.25
|
| Rate for Payer: Three Rivers Provider Network All |
$26.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$30.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$32.55
|
| Rate for Payer: Zelis Auto |
$14.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.50
|
| Rate for Payer: Zelis Worker's Compensation |
$9.55
|
|
|
VAPRISOL 20MG/100ML IN D5W
|
Facility
|
IP
|
$3,774.00
|
|
|
Service Code
|
CPT C9488
|
| Hospital Charge Code |
3300205
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,030.30 |
| Max. Negotiated Rate |
$3,585.30 |
| Rate for Payer: Cash Price |
$2,264.40
|
| Rate for Payer: Cigna Commercial |
$3,207.90
|
| Rate for Payer: First Health Commercial |
$3,396.60
|
| Rate for Payer: First Health Workers Compensation |
$1,457.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,396.60
|
| Rate for Payer: GEHA Commercial |
$2,641.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,396.60
|
| Rate for Payer: Multiplan All |
$3,434.34
|
| Rate for Payer: OMNI Networks Commercial |
$2,641.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,396.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,585.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,830.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,509.82
|
| Rate for Payer: Zelis Auto |
$1,509.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1,030.30
|
|
|
VAPRISOL 20MG/100ML IN D5W
|
Facility
|
OP
|
$3,774.00
|
|
|
Service Code
|
CPT C9488
|
| Hospital Charge Code |
3300205
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.39 |
| Max. Negotiated Rate |
$3,585.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$44.67
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,264.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$44.67
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$35.39
|
| Rate for Payer: Cash Price |
$2,264.40
|
| Rate for Payer: Cash Price |
$2,264.40
|
| Rate for Payer: Cigna Commercial |
$3,207.90
|
| Rate for Payer: First Health Commercial |
$3,396.60
|
| Rate for Payer: First Health Workers Compensation |
$1,457.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,396.60
|
| Rate for Payer: GEHA Commercial |
$3,019.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,396.60
|
| Rate for Payer: Humana ChoiceCare |
$981.24
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$36.11
|
| Rate for Payer: Multiplan All |
$3,434.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,264.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,641.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,396.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$41.69
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$36.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,585.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,830.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,321.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$36.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,509.82
|
| Rate for Payer: Zelis Auto |
$1,509.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,887.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,030.30
|
|
|
VARIBAR HONEY - 250 ML
|
Facility
|
OP
|
$322.00
|
|
|
Service Code
|
NDC 32909012207
|
| Hospital Charge Code |
3302925
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.50 |
| Max. Negotiated Rate |
$305.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$193.20
|
| Rate for Payer: Cash Price |
$193.20
|
| Rate for Payer: Cigna Commercial |
$273.70
|
| Rate for Payer: First Health Commercial |
$289.80
|
| Rate for Payer: First Health Workers Compensation |
$124.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$289.80
|
| Rate for Payer: GEHA Commercial |
$257.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$289.80
|
| Rate for Payer: Humana ChoiceCare |
$83.72
|
| Rate for Payer: Multiplan All |
$293.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$193.20
|
| Rate for Payer: OMNI Networks Commercial |
$225.40
|
| Rate for Payer: One Health Plan PPO/POS |
$289.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$305.90
|
| Rate for Payer: Three Rivers Provider Network All |
$241.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$283.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$80.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$299.46
|
| Rate for Payer: Zelis Auto |
$128.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$161.00
|
| Rate for Payer: Zelis Worker's Compensation |
$87.91
|
|
|
VARIBAR HONEY - 250 ML
|
Facility
|
IP
|
$322.00
|
|
|
Service Code
|
NDC 32909012207
|
| Hospital Charge Code |
3302925
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$87.91 |
| Max. Negotiated Rate |
$305.90 |
| Rate for Payer: Cash Price |
$193.20
|
| Rate for Payer: Cigna Commercial |
$273.70
|
| Rate for Payer: First Health Commercial |
$289.80
|
| Rate for Payer: First Health Workers Compensation |
$124.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$289.80
|
| Rate for Payer: GEHA Commercial |
$225.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$289.80
|
| Rate for Payer: Multiplan All |
$293.02
|
| Rate for Payer: OMNI Networks Commercial |
$225.40
|
| Rate for Payer: One Health Plan PPO/POS |
$289.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$305.90
|
| Rate for Payer: Three Rivers Provider Network All |
$241.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$299.46
|
| Rate for Payer: Zelis Auto |
$128.80
|
| Rate for Payer: Zelis Worker's Compensation |
$87.91
|
|
|
VARIBAR NECTAR - 240 ML
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
NDC 32909011500
|
| Hospital Charge Code |
3302926
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.31 |
| Max. Negotiated Rate |
$115.90 |
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$103.70
|
| Rate for Payer: First Health Commercial |
$109.80
|
| Rate for Payer: First Health Workers Compensation |
$47.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$109.80
|
| Rate for Payer: GEHA Commercial |
$85.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$109.80
|
| Rate for Payer: Multiplan All |
$111.02
|
| Rate for Payer: OMNI Networks Commercial |
$85.40
|
| Rate for Payer: One Health Plan PPO/POS |
$109.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$115.90
|
| Rate for Payer: Three Rivers Provider Network All |
$91.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$113.46
|
| Rate for Payer: Zelis Auto |
$48.80
|
| Rate for Payer: Zelis Worker's Compensation |
$33.31
|
|
|
VARIBAR NECTAR - 240 ML
|
Facility
|
OP
|
$122.00
|
|
|
Service Code
|
NDC 32909011500
|
| Hospital Charge Code |
3302926
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.50 |
| Max. Negotiated Rate |
$115.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$103.70
|
| Rate for Payer: First Health Commercial |
$109.80
|
| Rate for Payer: First Health Workers Compensation |
$47.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$109.80
|
| Rate for Payer: GEHA Commercial |
$97.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$109.80
|
| Rate for Payer: Humana ChoiceCare |
$31.72
|
| Rate for Payer: Multiplan All |
$111.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$73.20
|
| Rate for Payer: OMNI Networks Commercial |
$85.40
|
| Rate for Payer: One Health Plan PPO/POS |
$109.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$115.90
|
| Rate for Payer: Three Rivers Provider Network All |
$91.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$107.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$30.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$113.46
|
| Rate for Payer: Zelis Auto |
$48.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$61.00
|
| Rate for Payer: Zelis Worker's Compensation |
$33.31
|
|
