|
CL- BACITRACIN OINT 500 UNIT/GM TUBE
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
NDC 45802006003
|
| Hospital Charge Code |
3350106
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
CL- BACITRACIN OINT 500 UNIT/GM TUBE
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
NDC 45802006003
|
| Hospital Charge Code |
3350106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.25 |
| 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: 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 |
$29.60
|
| 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
|
|
|
CL- BACITRACIN OINT 500 UNIT/GM U.D.
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 45802006070
|
| Hospital Charge Code |
3350107
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
CL- BACITRACIN OINT 500 UNIT/GM U.D.
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 45802006070
|
| Hospital Charge Code |
3350107
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$4.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Humana ChoiceCare |
$1.30
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.00
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
CL- BELETERO BALANCE VIAL
|
Facility
|
IP
|
$487.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3350200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$132.95 |
| Max. Negotiated Rate |
$462.65 |
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cigna Commercial |
$413.95
|
| Rate for Payer: First Health Commercial |
$438.30
|
| Rate for Payer: First Health Workers Compensation |
$188.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$438.30
|
| Rate for Payer: GEHA Commercial |
$340.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$438.30
|
| Rate for Payer: Multiplan All |
$443.17
|
| Rate for Payer: OMNI Networks Commercial |
$340.90
|
| Rate for Payer: One Health Plan PPO/POS |
$438.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$462.65
|
| Rate for Payer: Three Rivers Provider Network All |
$365.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$452.91
|
| Rate for Payer: Zelis Auto |
$194.80
|
| Rate for Payer: Zelis Worker's Compensation |
$132.95
|
|
|
CL- BELETERO BALANCE VIAL
|
Facility
|
OP
|
$487.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3350200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$121.75 |
| Max. Negotiated Rate |
$462.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$292.20
|
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cigna Commercial |
$413.95
|
| Rate for Payer: First Health Commercial |
$438.30
|
| Rate for Payer: First Health Workers Compensation |
$188.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$438.30
|
| Rate for Payer: GEHA Commercial |
$389.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$438.30
|
| Rate for Payer: Humana ChoiceCare |
$126.62
|
| Rate for Payer: Multiplan All |
$443.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$292.20
|
| Rate for Payer: OMNI Networks Commercial |
$340.90
|
| Rate for Payer: One Health Plan PPO/POS |
$438.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$462.65
|
| Rate for Payer: Three Rivers Provider Network All |
$365.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$428.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$121.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$452.91
|
| Rate for Payer: Zelis Auto |
$194.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$243.50
|
| Rate for Payer: Zelis Worker's Compensation |
$132.95
|
|
|
CL- BELLA/PHENOBARB 16.2MG/5ML ELIXIR
|
Facility
|
OP
|
$271.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.75 |
| Max. Negotiated Rate |
$257.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$162.60
|
| Rate for Payer: Cash Price |
$162.60
|
| Rate for Payer: Cigna Commercial |
$230.35
|
| Rate for Payer: First Health Commercial |
$243.90
|
| Rate for Payer: First Health Workers Compensation |
$104.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$243.90
|
| Rate for Payer: GEHA Commercial |
$216.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$243.90
|
| Rate for Payer: Humana ChoiceCare |
$70.46
|
| Rate for Payer: Multiplan All |
$246.61
|
| Rate for Payer: New Mexico Health Connections Medicare |
$162.60
|
| Rate for Payer: OMNI Networks Commercial |
$189.70
|
| Rate for Payer: One Health Plan PPO/POS |
$243.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$257.45
|
| Rate for Payer: Three Rivers Provider Network All |
$203.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$238.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$67.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$252.03
|
| Rate for Payer: Zelis Auto |
$108.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$135.50
|
| Rate for Payer: Zelis Worker's Compensation |
$73.98
|
|
|
CL- BELLA/PHENOBARB 16.2MG/5ML ELIXIR
|
Facility
|
IP
|
$271.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.98 |
| Max. Negotiated Rate |
$257.45 |
| Rate for Payer: Cash Price |
$162.60
|
| Rate for Payer: Cigna Commercial |
$230.35
|
| Rate for Payer: First Health Commercial |
$243.90
|
| Rate for Payer: First Health Workers Compensation |
$104.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$243.90
|
| Rate for Payer: GEHA Commercial |
$189.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$243.90
|
| Rate for Payer: Multiplan All |
$246.61
|
| Rate for Payer: OMNI Networks Commercial |
$189.70
|
| Rate for Payer: One Health Plan PPO/POS |
$243.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$257.45
|
| Rate for Payer: Three Rivers Provider Network All |
$203.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$252.03
|
| Rate for Payer: Zelis Auto |
$108.40
|
| Rate for Payer: Zelis Worker's Compensation |
$73.98
|
|
|
CL- BENDEKA 1 MG
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
CPT J9034
|
| Hospital Charge Code |
3350281
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.47 |
| Max. Negotiated Rate |
$69.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$35.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$43.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$35.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$28.27
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$13.49
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$62.05
|
| Rate for Payer: First Health Commercial |
$65.70
|
| Rate for Payer: First Health Workers Compensation |
$28.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$65.70
|
| Rate for Payer: GEHA Commercial |
$14.84
|
| Rate for Payer: GEHA Medicare |
$13.49
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$65.70
|
| Rate for Payer: Humana ChoiceCare |
$14.84
|
| Rate for Payer: Humana Medicare Advantage |
$13.49
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$22.66
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$28.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$13.49
|
| Rate for Payer: Multiplan All |
$66.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.93
|
| Rate for Payer: OMNI Networks Commercial |
$51.10
|
| Rate for Payer: One Health Plan PPO/POS |
$65.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$33.31
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$28.85
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$13.49
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$69.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$26.98
|
| Rate for Payer: Three Rivers Provider Network All |
$54.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.22
|
| Rate for Payer: United Healthcare Managed Medicaid |
$28.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.49
|
| Rate for Payer: United Payors & United Providers UP&UP |
$67.89
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$13.49
|
| Rate for Payer: Zelis Auto |
$29.20
|
| Rate for Payer: Zelis Medicare |
$11.47
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$16.19
|
| Rate for Payer: Zelis Worker's Compensation |
$19.93
|
|
|
CL- BENDEKA 1 MG
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
CPT J9034
|
| Hospital Charge Code |
3350281
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.93 |
| Max. Negotiated Rate |
$69.35 |
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$62.05
|
| Rate for Payer: First Health Commercial |
$65.70
|
| Rate for Payer: First Health Workers Compensation |
$28.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$65.70
|
| Rate for Payer: GEHA Commercial |
$51.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$65.70
|
| Rate for Payer: Multiplan All |
$66.43
|
| Rate for Payer: OMNI Networks Commercial |
$51.10
|
| Rate for Payer: One Health Plan PPO/POS |
$65.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$69.35
|
| Rate for Payer: Three Rivers Provider Network All |
$54.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$67.89
|
| Rate for Payer: Zelis Auto |
$29.20
|
| Rate for Payer: Zelis Worker's Compensation |
$19.93
|
|
|
CL- BENRALIZUMAB 30 MG/1 ML INJ PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J0517
|
| Hospital Charge Code |
3350491
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$329.18 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$255.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$255.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$202.68
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$164.59
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$181.05
|
| Rate for Payer: GEHA Medicare |
$164.59
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$181.05
|
| Rate for Payer: Humana Medicare Advantage |
$164.59
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$276.51
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$206.80
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$164.59
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$279.80
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$238.78
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$206.80
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$164.59
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$329.18
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$161.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$206.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$164.59
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$164.59
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Medicare |
$139.90
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$197.51
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- BENRALIZUMAB 30 MG/1 ML INJ PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J0517
|
| Hospital Charge Code |
3350491
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- BENZOIN TINCTURE
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
NDC 00395024392
|
| Hospital Charge Code |
3350146
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.75 |
| Max. Negotiated Rate |
$29.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$18.60
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$26.35
|
| Rate for Payer: First Health Commercial |
$27.90
|
| Rate for Payer: First Health Workers Compensation |
$11.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.90
|
| Rate for Payer: GEHA Commercial |
$24.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.90
|
| Rate for Payer: Humana ChoiceCare |
$8.06
|
| Rate for Payer: Multiplan All |
$28.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$18.60
|
| Rate for Payer: OMNI Networks Commercial |
$21.70
|
| Rate for Payer: One Health Plan PPO/POS |
$27.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$29.45
|
| Rate for Payer: Three Rivers Provider Network All |
$23.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$27.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$28.83
|
| Rate for Payer: Zelis Auto |
$12.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.50
|
| Rate for Payer: Zelis Worker's Compensation |
$8.46
|
|
|
CL- BENZOIN TINCTURE
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
NDC 00395024392
|
| Hospital Charge Code |
3350146
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$29.45 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$26.35
|
| Rate for Payer: First Health Commercial |
$27.90
|
| Rate for Payer: First Health Workers Compensation |
$11.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.90
|
| Rate for Payer: GEHA Commercial |
$21.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.90
|
| Rate for Payer: Multiplan All |
$28.21
|
| Rate for Payer: OMNI Networks Commercial |
$21.70
|
| Rate for Payer: One Health Plan PPO/POS |
$27.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$29.45
|
| Rate for Payer: Three Rivers Provider Network All |
$23.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$28.83
|
| Rate for Payer: Zelis Auto |
$12.40
|
| Rate for Payer: Zelis Worker's Compensation |
$8.46
|
|
|
CL- BET NA PHOS ACE 6MG/ML INJ.
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
CPT J0702
|
| Hospital Charge Code |
3350011
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.66 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$43.35
|
| Rate for Payer: First Health Commercial |
$45.90
|
| Rate for Payer: First Health Workers Compensation |
$19.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.90
|
| Rate for Payer: GEHA Commercial |
$7.66
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.90
|
| Rate for Payer: Humana ChoiceCare |
$13.26
|
| Rate for Payer: Multiplan All |
$46.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.60
|
| Rate for Payer: OMNI Networks Commercial |
$35.70
|
| Rate for Payer: One Health Plan PPO/POS |
$45.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$48.45
|
| Rate for Payer: Three Rivers Provider Network All |
$38.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$44.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$47.43
|
| Rate for Payer: Zelis Auto |
$20.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$25.50
|
| Rate for Payer: Zelis Worker's Compensation |
$13.92
|
|
|
CL- BET NA PHOS ACE 6MG/ML INJ.
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT J0702
|
| Hospital Charge Code |
3350011
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.92 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$43.35
|
| Rate for Payer: First Health Commercial |
$45.90
|
| Rate for Payer: First Health Workers Compensation |
$19.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.90
|
| Rate for Payer: GEHA Commercial |
$35.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.90
|
| Rate for Payer: Multiplan All |
$46.41
|
| Rate for Payer: OMNI Networks Commercial |
$35.70
|
| Rate for Payer: One Health Plan PPO/POS |
$45.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$48.45
|
| Rate for Payer: Three Rivers Provider Network All |
$38.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$47.43
|
| Rate for Payer: Zelis Auto |
$20.40
|
| Rate for Payer: Zelis Worker's Compensation |
$13.92
|
|
|
CL- BEVACIZUMAB-BVZR 25 MG/ML
|
Facility
|
OP
|
$7,532.00
|
|
|
Service Code
|
CPT Q5118
|
| Hospital Charge Code |
3350444
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$7,155.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$94.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,519.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$94.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$75.08
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$25.77
|
| Rate for Payer: Cash Price |
$4,519.20
|
| Rate for Payer: Cash Price |
$4,519.20
|
| Rate for Payer: Cigna Commercial |
$6,402.20
|
| Rate for Payer: First Health Commercial |
$6,778.80
|
| Rate for Payer: First Health Workers Compensation |
$2,908.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,778.80
|
| Rate for Payer: GEHA Commercial |
$28.35
|
| Rate for Payer: GEHA Medicare |
$25.77
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,778.80
|
| Rate for Payer: Humana ChoiceCare |
$28.35
|
| Rate for Payer: Humana Medicare Advantage |
$25.77
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$43.29
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$76.61
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$25.77
|
| Rate for Payer: Multiplan All |
$6,854.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$43.81
|
| Rate for Payer: OMNI Networks Commercial |
$5,272.40
|
| Rate for Payer: One Health Plan PPO/POS |
$6,778.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$88.45
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$76.61
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$25.77
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,155.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$51.54
|
| Rate for Payer: Three Rivers Provider Network All |
$5,649.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$25.25
|
| Rate for Payer: United Healthcare Managed Medicaid |
$76.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.77
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,004.76
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$25.77
|
| Rate for Payer: Zelis Auto |
$3,012.80
|
| Rate for Payer: Zelis Medicare |
$21.90
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$30.92
|
| Rate for Payer: Zelis Worker's Compensation |
$2,056.24
|
|
|
CL- BEVACIZUMAB-BVZR 25 MG/ML
|
Facility
|
IP
|
$7,532.00
|
|
|
Service Code
|
CPT Q5118
|
| Hospital Charge Code |
3350444
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,056.24 |
| Max. Negotiated Rate |
$7,155.40 |
| Rate for Payer: Cash Price |
$4,519.20
|
| Rate for Payer: Cigna Commercial |
$6,402.20
|
| Rate for Payer: First Health Commercial |
$6,778.80
|
| Rate for Payer: First Health Workers Compensation |
$2,908.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,778.80
|
| Rate for Payer: GEHA Commercial |
$5,272.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,778.80
|
| Rate for Payer: Multiplan All |
$6,854.12
|
| Rate for Payer: OMNI Networks Commercial |
$5,272.40
|
| Rate for Payer: One Health Plan PPO/POS |
$6,778.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,155.40
|
| Rate for Payer: Three Rivers Provider Network All |
$5,649.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,004.76
|
| Rate for Payer: Zelis Auto |
$3,012.80
|
| Rate for Payer: Zelis Worker's Compensation |
$2,056.24
|
|
|
CL- BEXSERO 0.5ML - PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
3350207
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$206.87 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$206.87
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$206.87
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$163.88
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$167.22
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$193.07
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$167.22
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.01
|
| Rate for Payer: United Healthcare Managed Medicaid |
$167.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.01
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- BEXSERO 0.5ML - PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
3350207
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- BLEOMYCIN 15 UNITS
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
CPT J9040
|
| Hospital Charge Code |
3350282
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.75 |
| Max. Negotiated Rate |
$71.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$63.75
|
| Rate for Payer: First Health Commercial |
$67.50
|
| Rate for Payer: First Health Workers Compensation |
$28.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$67.50
|
| Rate for Payer: GEHA Commercial |
$23.68
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$67.50
|
| Rate for Payer: Humana ChoiceCare |
$19.50
|
| Rate for Payer: Multiplan All |
$68.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$45.00
|
| Rate for Payer: OMNI Networks Commercial |
$52.50
|
| Rate for Payer: One Health Plan PPO/POS |
$67.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$71.25
|
| Rate for Payer: Three Rivers Provider Network All |
$56.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$66.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$18.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$69.75
|
| Rate for Payer: Zelis Auto |
$30.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$37.50
|
| Rate for Payer: Zelis Worker's Compensation |
$20.48
|
|
|
CL- BLEOMYCIN 15 UNITS
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
CPT J9040
|
| Hospital Charge Code |
3350282
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.48 |
| Max. Negotiated Rate |
$71.25 |
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$63.75
|
| Rate for Payer: First Health Commercial |
$67.50
|
| Rate for Payer: First Health Workers Compensation |
$28.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$67.50
|
| Rate for Payer: GEHA Commercial |
$52.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$67.50
|
| Rate for Payer: Multiplan All |
$68.25
|
| Rate for Payer: OMNI Networks Commercial |
$52.50
|
| Rate for Payer: One Health Plan PPO/POS |
$67.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$71.25
|
| Rate for Payer: Three Rivers Provider Network All |
$56.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$69.75
|
| Rate for Payer: Zelis Auto |
$30.00
|
| Rate for Payer: Zelis Worker's Compensation |
$20.48
|
|
|
CL- BLT CREAM
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3350148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$17.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$15.30
|
| Rate for Payer: First Health Commercial |
$16.20
|
| Rate for Payer: First Health Workers Compensation |
$6.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$16.20
|
| Rate for Payer: GEHA Commercial |
$14.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$16.20
|
| Rate for Payer: Humana ChoiceCare |
$4.68
|
| Rate for Payer: Multiplan All |
$16.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10.80
|
| Rate for Payer: OMNI Networks Commercial |
$12.60
|
| Rate for Payer: One Health Plan PPO/POS |
$16.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$17.10
|
| Rate for Payer: Three Rivers Provider Network All |
$13.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$15.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$16.74
|
| Rate for Payer: Zelis Auto |
$7.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$9.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.91
|
|
|
CL- BLT CREAM
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3350148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$17.10 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$15.30
|
| Rate for Payer: First Health Commercial |
$16.20
|
| Rate for Payer: First Health Workers Compensation |
$6.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$16.20
|
| Rate for Payer: GEHA Commercial |
$12.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$16.20
|
| Rate for Payer: Multiplan All |
$16.38
|
| Rate for Payer: OMNI Networks Commercial |
$12.60
|
| Rate for Payer: One Health Plan PPO/POS |
$16.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$17.10
|
| Rate for Payer: Three Rivers Provider Network All |
$13.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$16.74
|
| Rate for Payer: Zelis Auto |
$7.20
|
| Rate for Payer: Zelis Worker's Compensation |
$4.91
|
|
|
CL- BORTEZOMIB 0.1 MG
|
Facility
|
IP
|
$135.00
|
|
|
Service Code
|
CPT J9041
|
| Hospital Charge Code |
3350362
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.85 |
| Max. Negotiated Rate |
$128.25 |
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$114.75
|
| Rate for Payer: First Health Commercial |
$121.50
|
| Rate for Payer: First Health Workers Compensation |
$52.12
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$121.50
|
| Rate for Payer: GEHA Commercial |
$94.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$121.50
|
| Rate for Payer: Multiplan All |
$122.85
|
| Rate for Payer: OMNI Networks Commercial |
$94.50
|
| Rate for Payer: One Health Plan PPO/POS |
$121.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$128.25
|
| Rate for Payer: Three Rivers Provider Network All |
$101.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$125.55
|
| Rate for Payer: Zelis Auto |
$54.00
|
| Rate for Payer: Zelis Worker's Compensation |
$36.85
|
|
