|
CL- ALUM MAG HYD SIMETH U.D.
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 00121176130
|
| Hospital Charge Code |
3350005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$7.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
CL- AMERIGEL 28GM TUBE
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
NDC 61470101401
|
| Hospital Charge Code |
3350094
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.25 |
| Max. Negotiated Rate |
$122.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$77.40
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$109.65
|
| Rate for Payer: First Health Commercial |
$116.10
|
| Rate for Payer: First Health Workers Compensation |
$49.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$116.10
|
| Rate for Payer: GEHA Commercial |
$103.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$116.10
|
| Rate for Payer: Humana ChoiceCare |
$33.54
|
| Rate for Payer: Multiplan All |
$117.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$77.40
|
| Rate for Payer: OMNI Networks Commercial |
$90.30
|
| Rate for Payer: One Health Plan PPO/POS |
$116.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$122.55
|
| Rate for Payer: Three Rivers Provider Network All |
$96.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$113.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$32.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$119.97
|
| Rate for Payer: Zelis Auto |
$51.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$64.50
|
| Rate for Payer: Zelis Worker's Compensation |
$35.22
|
|
|
CL- AMERIGEL 28GM TUBE
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
NDC 61470101401
|
| Hospital Charge Code |
3350094
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.22 |
| Max. Negotiated Rate |
$122.55 |
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$109.65
|
| Rate for Payer: First Health Commercial |
$116.10
|
| Rate for Payer: First Health Workers Compensation |
$49.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$116.10
|
| Rate for Payer: GEHA Commercial |
$90.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$116.10
|
| Rate for Payer: Multiplan All |
$117.39
|
| Rate for Payer: OMNI Networks Commercial |
$90.30
|
| Rate for Payer: One Health Plan PPO/POS |
$116.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$122.55
|
| Rate for Payer: Three Rivers Provider Network All |
$96.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$119.97
|
| Rate for Payer: Zelis Auto |
$51.60
|
| Rate for Payer: Zelis Worker's Compensation |
$35.22
|
|
|
clam, IgE REF602529
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299202
|
|
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
|
|
|
clam, IgE REF602529
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299202
|
|
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
|
|
|
CL- AMPICILLIN 1GM VIAL
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
3350118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$49.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$44.20
|
| Rate for Payer: First Health Commercial |
$46.80
|
| Rate for Payer: First Health Workers Compensation |
$20.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$46.80
|
| Rate for Payer: GEHA Commercial |
$0.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$46.80
|
| Rate for Payer: Humana ChoiceCare |
$13.52
|
| Rate for Payer: Multiplan All |
$47.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.20
|
| Rate for Payer: OMNI Networks Commercial |
$36.40
|
| Rate for Payer: One Health Plan PPO/POS |
$46.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$49.40
|
| Rate for Payer: Three Rivers Provider Network All |
$39.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$45.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$48.36
|
| Rate for Payer: Zelis Auto |
$20.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$26.00
|
| Rate for Payer: Zelis Worker's Compensation |
$14.20
|
|
|
CL- AMPICILLIN 1GM VIAL
|
Facility
|
IP
|
$52.00
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
3350118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.20 |
| Max. Negotiated Rate |
$49.40 |
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$44.20
|
| Rate for Payer: First Health Commercial |
$46.80
|
| Rate for Payer: First Health Workers Compensation |
$20.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$46.80
|
| Rate for Payer: GEHA Commercial |
$36.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$46.80
|
| Rate for Payer: Multiplan All |
$47.32
|
| Rate for Payer: OMNI Networks Commercial |
$36.40
|
| Rate for Payer: One Health Plan PPO/POS |
$46.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$49.40
|
| Rate for Payer: Three Rivers Provider Network All |
$39.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$48.36
|
| Rate for Payer: Zelis Auto |
$20.80
|
| Rate for Payer: Zelis Worker's Compensation |
$14.20
|
|
|
CLARITHROMYCIN 250 MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00781196160
|
| Hospital Charge Code |
3302979
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
CLARITHROMYCIN 250 MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00781196160
|
| Hospital Charge Code |
3302979
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
CL- ASPIRIN CHEW 81 MG TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350527
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
CL- ASPIRIN CHEW 81 MG TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350527
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
CL- ASPIRIN CHEW TAB 81MG
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350008
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
CL- ASPIRIN CHEW TAB 81MG
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350008
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
CL- ASPIRIN TAB 325 MG
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 57896090101
|
| Hospital Charge Code |
3350009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
CL- ASPIRIN TAB 325 MG
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 57896090101
|
| Hospital Charge Code |
3350009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
CL- ATEZOLIZUMAB 1200 MG/ 20 ML INJ
|
Facility
|
IP
|
$79.00
|
|
|
Service Code
|
CPT J9022
|
| Hospital Charge Code |
3350482
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.57 |
| Max. Negotiated Rate |
$75.05 |
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$67.15
|
| Rate for Payer: First Health Commercial |
$71.10
|
| Rate for Payer: First Health Workers Compensation |
$30.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$71.10
|
| Rate for Payer: GEHA Commercial |
$55.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$71.10
|
| Rate for Payer: Multiplan All |
$71.89
|
| Rate for Payer: OMNI Networks Commercial |
$55.30
|
| Rate for Payer: One Health Plan PPO/POS |
$71.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$75.05
|
| Rate for Payer: Three Rivers Provider Network All |
$59.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$73.47
|
| Rate for Payer: Zelis Auto |
$31.60
|
| Rate for Payer: Zelis Worker's Compensation |
$21.57
|
|
|
CL- ATEZOLIZUMAB 1200 MG/ 20 ML INJ
|
Facility
|
OP
|
$79.00
|
|
|
Service Code
|
CPT J9022
|
| Hospital Charge Code |
3350482
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.57 |
| Max. Negotiated Rate |
$182.68 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$132.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$47.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$132.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$104.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$91.34
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$67.15
|
| Rate for Payer: First Health Commercial |
$71.10
|
| Rate for Payer: First Health Workers Compensation |
$30.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$71.10
|
| Rate for Payer: GEHA Commercial |
$100.47
|
| Rate for Payer: GEHA Medicare |
$91.34
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$71.10
|
| Rate for Payer: Humana ChoiceCare |
$100.47
|
| Rate for Payer: Humana Medicare Advantage |
$91.34
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$153.45
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$106.97
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$91.34
|
| Rate for Payer: Multiplan All |
$71.89
|
| Rate for Payer: New Mexico Health Connections Medicare |
$155.28
|
| Rate for Payer: OMNI Networks Commercial |
$55.30
|
| Rate for Payer: One Health Plan PPO/POS |
$71.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$123.51
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$106.97
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$91.34
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$75.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$182.68
|
| Rate for Payer: Three Rivers Provider Network All |
$59.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$89.51
|
| Rate for Payer: United Healthcare Managed Medicaid |
$106.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.34
|
| Rate for Payer: United Payors & United Providers UP&UP |
$73.47
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$91.34
|
| Rate for Payer: Zelis Auto |
$31.60
|
| Rate for Payer: Zelis Medicare |
$77.64
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$109.61
|
| Rate for Payer: Zelis Worker's Compensation |
$21.57
|
|
|
CL- AVASTIN 10 MG
|
Facility
|
IP
|
$247.00
|
|
|
Service Code
|
CPT J9035
|
| Hospital Charge Code |
3350278
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.43 |
| Max. Negotiated Rate |
$234.65 |
| Rate for Payer: Cash Price |
$148.20
|
| Rate for Payer: Cigna Commercial |
$209.95
|
| Rate for Payer: First Health Commercial |
$222.30
|
| Rate for Payer: First Health Workers Compensation |
$95.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$222.30
|
| Rate for Payer: GEHA Commercial |
$172.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$222.30
|
| Rate for Payer: Multiplan All |
$224.77
|
| Rate for Payer: OMNI Networks Commercial |
$172.90
|
| Rate for Payer: One Health Plan PPO/POS |
$222.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$234.65
|
| Rate for Payer: Three Rivers Provider Network All |
$185.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$229.71
|
| Rate for Payer: Zelis Auto |
$98.80
|
| Rate for Payer: Zelis Worker's Compensation |
$67.43
|
|
|
CL- AVASTIN 10 MG
|
Facility
|
OP
|
$247.00
|
|
|
Service Code
|
CPT J9035
|
| Hospital Charge Code |
3350278
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.22 |
| Max. Negotiated Rate |
$234.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$102.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$148.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$102.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$81.37
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$73.20
|
| Rate for Payer: Cash Price |
$148.20
|
| Rate for Payer: Cash Price |
$148.20
|
| Rate for Payer: Cigna Commercial |
$209.95
|
| Rate for Payer: First Health Commercial |
$222.30
|
| Rate for Payer: First Health Workers Compensation |
$95.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$222.30
|
| Rate for Payer: GEHA Commercial |
$80.52
|
| Rate for Payer: GEHA Medicare |
$73.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$222.30
|
| Rate for Payer: Humana ChoiceCare |
$80.52
|
| Rate for Payer: Humana Medicare Advantage |
$73.20
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$122.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$83.03
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$73.20
|
| Rate for Payer: Multiplan All |
$224.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$124.44
|
| Rate for Payer: OMNI Networks Commercial |
$172.90
|
| Rate for Payer: One Health Plan PPO/POS |
$222.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$95.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$83.03
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$73.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$234.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$146.40
|
| Rate for Payer: Three Rivers Provider Network All |
$185.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$71.74
|
| Rate for Payer: United Healthcare Managed Medicaid |
$83.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$73.20
|
| Rate for Payer: United Payors & United Providers UP&UP |
$229.71
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$73.20
|
| Rate for Payer: Zelis Auto |
$98.80
|
| Rate for Payer: Zelis Medicare |
$62.22
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$87.84
|
| Rate for Payer: Zelis Worker's Compensation |
$67.43
|
|
|
CL- AZACITIDINE 10 MG
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
CPT J9025
|
| Hospital Charge Code |
3350280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
CL- AZACITIDINE 10 MG
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
CPT J9025
|
| Hospital Charge Code |
3350280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$5.19 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$5.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$5.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$4.11
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$0.63
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$4.20
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$4.84
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$4.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.20
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
CL- AZITHROMYCIN 250 MG TAB
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
CPT Q0144
|
| Hospital Charge Code |
3350269
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
CL- AZITHROMYCIN 250 MG TAB
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
CPT Q0144
|
| Hospital Charge Code |
3350269
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.25 |
| 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: 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 |
$7.20
|
| 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
|
|
|
CL- BACITRACIN 50,000 UNITS - OR
|
Facility
|
OP
|
$79.00
|
|
|
Service Code
|
NDC 63323032931
|
| Hospital Charge Code |
3350105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.75 |
| Max. Negotiated Rate |
$75.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$67.15
|
| Rate for Payer: First Health Commercial |
$71.10
|
| Rate for Payer: First Health Workers Compensation |
$30.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$71.10
|
| Rate for Payer: GEHA Commercial |
$63.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$71.10
|
| Rate for Payer: Humana ChoiceCare |
$20.54
|
| Rate for Payer: Multiplan All |
$71.89
|
| Rate for Payer: New Mexico Health Connections Medicare |
$47.40
|
| Rate for Payer: OMNI Networks Commercial |
$55.30
|
| Rate for Payer: One Health Plan PPO/POS |
$71.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$75.05
|
| Rate for Payer: Three Rivers Provider Network All |
$59.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$69.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$19.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$73.47
|
| Rate for Payer: Zelis Auto |
$31.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$39.50
|
| Rate for Payer: Zelis Worker's Compensation |
$21.57
|
|
|
CL- BACITRACIN 50,000 UNITS - OR
|
Facility
|
IP
|
$79.00
|
|
|
Service Code
|
NDC 63323032931
|
| Hospital Charge Code |
3350105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.57 |
| Max. Negotiated Rate |
$75.05 |
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$67.15
|
| Rate for Payer: First Health Commercial |
$71.10
|
| Rate for Payer: First Health Workers Compensation |
$30.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$71.10
|
| Rate for Payer: GEHA Commercial |
$55.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$71.10
|
| Rate for Payer: Multiplan All |
$71.89
|
| Rate for Payer: OMNI Networks Commercial |
$55.30
|
| Rate for Payer: One Health Plan PPO/POS |
$71.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$75.05
|
| Rate for Payer: Three Rivers Provider Network All |
$59.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$73.47
|
| Rate for Payer: Zelis Auto |
$31.60
|
| Rate for Payer: Zelis Worker's Compensation |
$21.57
|
|
