|
cedar mountain IgE REF602491
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299160
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.39
|
| 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 |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.22
|
| 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 |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: GEHA Medicare |
$5.22
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.22
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.87
|
| 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 |
$8.76
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.59
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.22
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10.44
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.12
|
| Rate for Payer: United Healthcare Commercial |
$47.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.22
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Medicare |
$4.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.26
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
cedar mountain IgE REF602491
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299160
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.93 |
| 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 |
$11.22
|
| 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 |
$7.93
|
|
|
CEFAZOLIN 2 GM VIAL
|
Facility
|
IP
|
$43.40
|
|
|
Service Code
|
CPT J0690
|
| Hospital Charge Code |
3303176
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$41.23 |
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cigna Commercial |
$36.89
|
| Rate for Payer: First Health Commercial |
$39.06
|
| Rate for Payer: First Health Workers Compensation |
$16.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$39.06
|
| Rate for Payer: GEHA Commercial |
$30.38
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$39.06
|
| Rate for Payer: Multiplan All |
$39.49
|
| Rate for Payer: OMNI Networks Commercial |
$30.38
|
| Rate for Payer: One Health Plan PPO/POS |
$39.06
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$41.23
|
| Rate for Payer: Three Rivers Provider Network All |
$32.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$40.36
|
| Rate for Payer: Zelis Auto |
$17.36
|
| Rate for Payer: Zelis Worker's Compensation |
$11.85
|
|
|
CEFAZOLIN 2 GM VIAL
|
Facility
|
OP
|
$43.40
|
|
|
Service Code
|
CPT J0690
|
| Hospital Charge Code |
3303176
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$41.23 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$26.04
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cigna Commercial |
$36.89
|
| Rate for Payer: First Health Commercial |
$39.06
|
| Rate for Payer: First Health Workers Compensation |
$16.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$39.06
|
| Rate for Payer: GEHA Commercial |
$0.88
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$39.06
|
| Rate for Payer: Humana ChoiceCare |
$11.28
|
| Rate for Payer: Multiplan All |
$39.49
|
| Rate for Payer: New Mexico Health Connections Medicare |
$26.04
|
| Rate for Payer: OMNI Networks Commercial |
$30.38
|
| Rate for Payer: One Health Plan PPO/POS |
$39.06
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$41.23
|
| Rate for Payer: Three Rivers Provider Network All |
$32.55
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$38.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.85
|
| Rate for Payer: United Payors & United Providers UP&UP |
$40.36
|
| Rate for Payer: Zelis Auto |
$17.36
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.70
|
| Rate for Payer: Zelis Worker's Compensation |
$11.85
|
|
|
ceFAZolin SODIUM 1GM
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
CPT J0690
|
| Hospital Charge Code |
3300155
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$6.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
ceFAZolin SODIUM 1GM
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
CPT J0690
|
| Hospital Charge Code |
3300155
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$0.88
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Humana ChoiceCare |
$2.34
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5.40
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.50
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
ceFAZolin SODIUM 1GM IM
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
CPT J0690
|
| Hospital Charge Code |
3370008
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$0.88
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Humana ChoiceCare |
$2.34
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5.40
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.50
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
ceFAZolin SODIUM 1GM IM
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
CPT J0690
|
| Hospital Charge Code |
3370008
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$6.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
CEFEPIME HCL 1GM FOR IVPB
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT J0692
|
| Hospital Charge Code |
3300156
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
CEFEPIME HCL 1GM FOR IVPB
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT J0692
|
| Hospital Charge Code |
3300156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.34 |
| 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: 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 |
$1.34
|
| 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
|
|
|
CEFEPIME HCL 2GM FOR IVPB
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
CPT J0692
|
| Hospital Charge Code |
3300157
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$11.05
|
| Rate for Payer: First Health Commercial |
$11.70
|
| Rate for Payer: First Health Workers Compensation |
$5.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11.70
|
| Rate for Payer: GEHA Commercial |
$1.34
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11.70
|
| Rate for Payer: Humana ChoiceCare |
$3.38
|
| Rate for Payer: Multiplan All |
$11.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.80
|
| Rate for Payer: OMNI Networks Commercial |
$9.10
|
| Rate for Payer: One Health Plan PPO/POS |
$11.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12.35
|
| Rate for Payer: Three Rivers Provider Network All |
$9.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12.09
|
| Rate for Payer: Zelis Auto |
$5.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.55
|
|
|
CEFEPIME HCL 2GM FOR IVPB
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
CPT J0692
|
| Hospital Charge Code |
3300157
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.55 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$11.05
|
| Rate for Payer: First Health Commercial |
$11.70
|
| Rate for Payer: First Health Workers Compensation |
$5.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11.70
|
| Rate for Payer: GEHA Commercial |
$9.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11.70
|
| Rate for Payer: Multiplan All |
$11.83
|
| Rate for Payer: OMNI Networks Commercial |
$9.10
|
| Rate for Payer: One Health Plan PPO/POS |
$11.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12.35
|
| Rate for Payer: Three Rivers Provider Network All |
$9.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12.09
|
| Rate for Payer: Zelis Auto |
$5.20
|
| Rate for Payer: Zelis Worker's Compensation |
$3.55
|
|
|
CEFIXIME ORAL CAPSULE 400MG
|
Facility
|
OP
|
$124.09
|
|
|
Service Code
|
NDC 67877058433
|
| Hospital Charge Code |
3392768
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.02 |
| Max. Negotiated Rate |
$117.89 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$74.45
|
| Rate for Payer: Cash Price |
$74.45
|
| Rate for Payer: Cigna Commercial |
$105.48
|
| Rate for Payer: First Health Commercial |
$111.68
|
| Rate for Payer: First Health Workers Compensation |
$47.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$111.68
|
| Rate for Payer: GEHA Commercial |
$99.27
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$111.68
|
| Rate for Payer: Humana ChoiceCare |
$32.26
|
| Rate for Payer: Multiplan All |
$112.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$74.45
|
| Rate for Payer: OMNI Networks Commercial |
$86.86
|
| Rate for Payer: One Health Plan PPO/POS |
$111.68
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$117.89
|
| Rate for Payer: Three Rivers Provider Network All |
$93.07
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$109.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.02
|
| Rate for Payer: United Payors & United Providers UP&UP |
$115.40
|
| Rate for Payer: Zelis Auto |
$49.64
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$62.05
|
| Rate for Payer: Zelis Worker's Compensation |
$33.88
|
|
|
CEFIXIME ORAL CAPSULE 400MG
|
Facility
|
IP
|
$124.09
|
|
|
Service Code
|
NDC 67877058433
|
| Hospital Charge Code |
3392768
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.88 |
| Max. Negotiated Rate |
$117.89 |
| Rate for Payer: Cash Price |
$74.45
|
| Rate for Payer: Cigna Commercial |
$105.48
|
| Rate for Payer: First Health Commercial |
$111.68
|
| Rate for Payer: First Health Workers Compensation |
$47.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$111.68
|
| Rate for Payer: GEHA Commercial |
$86.86
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$111.68
|
| Rate for Payer: Multiplan All |
$112.92
|
| Rate for Payer: OMNI Networks Commercial |
$86.86
|
| Rate for Payer: One Health Plan PPO/POS |
$111.68
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$117.89
|
| Rate for Payer: Three Rivers Provider Network All |
$93.07
|
| Rate for Payer: United Payors & United Providers UP&UP |
$115.40
|
| Rate for Payer: Zelis Auto |
$49.64
|
| Rate for Payer: Zelis Worker's Compensation |
$33.88
|
|
|
CEFOTETAN 1 GM
|
Facility
|
IP
|
$198.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3303238
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$54.05 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cigna Commercial |
$168.30
|
| Rate for Payer: First Health Commercial |
$178.20
|
| Rate for Payer: First Health Workers Compensation |
$76.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$178.20
|
| Rate for Payer: GEHA Commercial |
$138.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$178.20
|
| Rate for Payer: Multiplan All |
$180.18
|
| Rate for Payer: OMNI Networks Commercial |
$138.60
|
| Rate for Payer: One Health Plan PPO/POS |
$178.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$188.10
|
| Rate for Payer: Three Rivers Provider Network All |
$148.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$184.14
|
| Rate for Payer: Zelis Auto |
$79.20
|
| Rate for Payer: Zelis Worker's Compensation |
$54.05
|
|
|
CEFOTETAN 1 GM
|
Facility
|
OP
|
$198.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3303238
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$49.50 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$118.80
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cigna Commercial |
$168.30
|
| Rate for Payer: First Health Commercial |
$178.20
|
| Rate for Payer: First Health Workers Compensation |
$76.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$178.20
|
| Rate for Payer: GEHA Commercial |
$158.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$178.20
|
| Rate for Payer: Humana ChoiceCare |
$51.48
|
| Rate for Payer: Multiplan All |
$180.18
|
| Rate for Payer: New Mexico Health Connections Medicare |
$118.80
|
| Rate for Payer: OMNI Networks Commercial |
$138.60
|
| Rate for Payer: One Health Plan PPO/POS |
$178.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$188.10
|
| Rate for Payer: Three Rivers Provider Network All |
$148.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$174.24
|
| Rate for Payer: United Healthcare Commercial |
$168.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$49.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$184.14
|
| Rate for Payer: Zelis Auto |
$79.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$99.00
|
| Rate for Payer: Zelis Worker's Compensation |
$54.05
|
|
|
CEFOXITIN 2 GM PWVL
|
Facility
|
IP
|
$211.55
|
|
|
Service Code
|
CPT J0694
|
| Hospital Charge Code |
3302851
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.75 |
| Max. Negotiated Rate |
$200.97 |
| Rate for Payer: Cash Price |
$126.93
|
| Rate for Payer: Cigna Commercial |
$179.82
|
| Rate for Payer: First Health Commercial |
$190.40
|
| Rate for Payer: First Health Workers Compensation |
$81.68
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$190.40
|
| Rate for Payer: GEHA Commercial |
$148.09
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$190.40
|
| Rate for Payer: Multiplan All |
$192.51
|
| Rate for Payer: OMNI Networks Commercial |
$148.09
|
| Rate for Payer: One Health Plan PPO/POS |
$190.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$200.97
|
| Rate for Payer: Three Rivers Provider Network All |
$158.66
|
| Rate for Payer: United Payors & United Providers UP&UP |
$196.74
|
| Rate for Payer: Zelis Auto |
$84.62
|
| Rate for Payer: Zelis Worker's Compensation |
$57.75
|
|
|
CEFOXITIN 2 GM PWVL
|
Facility
|
OP
|
$211.55
|
|
|
Service Code
|
CPT J0694
|
| Hospital Charge Code |
3302851
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.26 |
| Max. Negotiated Rate |
$200.97 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$126.93
|
| Rate for Payer: Cash Price |
$126.93
|
| Rate for Payer: Cash Price |
$126.93
|
| Rate for Payer: Cigna Commercial |
$179.82
|
| Rate for Payer: First Health Commercial |
$190.40
|
| Rate for Payer: First Health Workers Compensation |
$81.68
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$190.40
|
| Rate for Payer: GEHA Commercial |
$5.26
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$190.40
|
| Rate for Payer: Humana ChoiceCare |
$55.00
|
| Rate for Payer: Multiplan All |
$192.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$126.93
|
| Rate for Payer: OMNI Networks Commercial |
$148.09
|
| Rate for Payer: One Health Plan PPO/POS |
$190.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$200.97
|
| Rate for Payer: Three Rivers Provider Network All |
$158.66
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$186.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$52.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$196.74
|
| Rate for Payer: Zelis Auto |
$84.62
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$105.78
|
| Rate for Payer: Zelis Worker's Compensation |
$57.75
|
|
|
cefOXitin SODIUM 1GM FOR IVPB
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT J0694
|
| Hospital Charge Code |
3300158
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.40 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$116.45
|
| Rate for Payer: First Health Commercial |
$123.30
|
| Rate for Payer: First Health Workers Compensation |
$52.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$123.30
|
| Rate for Payer: GEHA Commercial |
$95.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$123.30
|
| Rate for Payer: Multiplan All |
$124.67
|
| Rate for Payer: OMNI Networks Commercial |
$95.90
|
| Rate for Payer: One Health Plan PPO/POS |
$123.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$130.15
|
| Rate for Payer: Three Rivers Provider Network All |
$102.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$127.41
|
| Rate for Payer: Zelis Auto |
$54.80
|
| Rate for Payer: Zelis Worker's Compensation |
$37.40
|
|
|
cefOXitin SODIUM 1GM FOR IVPB
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT J0694
|
| Hospital Charge Code |
3300158
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.26 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$82.20
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$116.45
|
| Rate for Payer: First Health Commercial |
$123.30
|
| Rate for Payer: First Health Workers Compensation |
$52.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$123.30
|
| Rate for Payer: GEHA Commercial |
$5.26
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$123.30
|
| Rate for Payer: Humana ChoiceCare |
$35.62
|
| Rate for Payer: Multiplan All |
$124.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$82.20
|
| Rate for Payer: OMNI Networks Commercial |
$95.90
|
| Rate for Payer: One Health Plan PPO/POS |
$123.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$130.15
|
| Rate for Payer: Three Rivers Provider Network All |
$102.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$120.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$34.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$127.41
|
| Rate for Payer: Zelis Auto |
$54.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$68.50
|
| Rate for Payer: Zelis Worker's Compensation |
$37.40
|
|
|
CEFTAZIDIME FOR INJ 1GM
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
CPT J0713
|
| Hospital Charge Code |
3300969
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$25.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
CEFTAZIDIME FOR INJ 1GM
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
CPT J0713
|
| Hospital Charge Code |
3300969
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22.20
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$1.73
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Humana ChoiceCare |
$9.62
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.20
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$32.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$18.50
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
CEFTRIAXONE SOD 500 MG INJ
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
3303047
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$0.47
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Humana ChoiceCare |
$2.34
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5.40
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.50
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
CEFTRIAXONE SOD 500 MG INJ
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
3303047
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$6.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
cefTRIAXone SODIUM 250MG
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
3300160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$0.47
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Humana ChoiceCare |
$3.12
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.20
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
