|
CL- BUPRENORPHINE SL 2 MG TAB
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 60687048121
|
| Hospital Charge Code |
3350484
|
|
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- BUPRENORPHINE SL 2 MG TAB
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 60687048121
|
| Hospital Charge Code |
3350484
|
|
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- BUROSUMAB-TWZA 20 MG/ML PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J0584
|
| Hospital Charge Code |
3350528
|
|
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- BUROSUMAB-TWZA 20 MG/ML PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J0584
|
| Hospital Charge Code |
3350528
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$968.28 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$530.10
|
| 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 |
$530.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$419.95
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$484.14
|
| 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 |
$532.55
|
| Rate for Payer: GEHA Medicare |
$484.14
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$532.55
|
| Rate for Payer: Humana Medicare Advantage |
$484.14
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$813.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$428.50
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$484.14
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$823.04
|
| 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 |
$494.76
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$428.50
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$484.14
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$968.28
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$474.46
|
| Rate for Payer: United Healthcare Managed Medicaid |
$428.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$484.14
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$484.14
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Medicare |
$411.52
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$580.97
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- BUTAMBEN-TETRACAIN-BENZOCAINE SPRAY
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
NDC 10223020101
|
| Hospital Charge Code |
3350017
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$72.07 |
| Max. Negotiated Rate |
$250.80 |
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cigna Commercial |
$224.40
|
| Rate for Payer: First Health Commercial |
$237.60
|
| Rate for Payer: First Health Workers Compensation |
$101.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$237.60
|
| Rate for Payer: GEHA Commercial |
$184.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$237.60
|
| Rate for Payer: Multiplan All |
$240.24
|
| Rate for Payer: OMNI Networks Commercial |
$184.80
|
| Rate for Payer: One Health Plan PPO/POS |
$237.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$250.80
|
| Rate for Payer: Three Rivers Provider Network All |
$198.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$245.52
|
| Rate for Payer: Zelis Auto |
$105.60
|
| Rate for Payer: Zelis Worker's Compensation |
$72.07
|
|
|
CL- BUTAMBEN-TETRACAIN-BENZOCAINE SPRAY
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
NDC 10223020101
|
| Hospital Charge Code |
3350017
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$66.00 |
| Max. Negotiated Rate |
$250.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$158.40
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cigna Commercial |
$224.40
|
| Rate for Payer: First Health Commercial |
$237.60
|
| Rate for Payer: First Health Workers Compensation |
$101.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$237.60
|
| Rate for Payer: GEHA Commercial |
$211.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$237.60
|
| Rate for Payer: Humana ChoiceCare |
$68.64
|
| Rate for Payer: Multiplan All |
$240.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$158.40
|
| Rate for Payer: OMNI Networks Commercial |
$184.80
|
| Rate for Payer: One Health Plan PPO/POS |
$237.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$250.80
|
| Rate for Payer: Three Rivers Provider Network All |
$198.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$232.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$66.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$245.52
|
| Rate for Payer: Zelis Auto |
$105.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$132.00
|
| Rate for Payer: Zelis Worker's Compensation |
$72.07
|
|
|
CL- CABAZITAXEL 1 MG
|
Facility
|
IP
|
$514.00
|
|
|
Service Code
|
CPT J9043
|
| Hospital Charge Code |
3350319
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$140.32 |
| Max. Negotiated Rate |
$488.30 |
| Rate for Payer: Cash Price |
$308.40
|
| Rate for Payer: Cigna Commercial |
$436.90
|
| Rate for Payer: First Health Commercial |
$462.60
|
| Rate for Payer: First Health Workers Compensation |
$198.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$462.60
|
| Rate for Payer: GEHA Commercial |
$359.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$462.60
|
| Rate for Payer: Multiplan All |
$467.74
|
| Rate for Payer: OMNI Networks Commercial |
$359.80
|
| Rate for Payer: One Health Plan PPO/POS |
$462.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$488.30
|
| Rate for Payer: Three Rivers Provider Network All |
$385.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$478.02
|
| Rate for Payer: Zelis Auto |
$205.60
|
| Rate for Payer: Zelis Worker's Compensation |
$140.32
|
|
|
CL- CABAZITAXEL 1 MG
|
Facility
|
OP
|
$514.00
|
|
|
Service Code
|
CPT J9043
|
| Hospital Charge Code |
3350319
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$140.32 |
| Max. Negotiated Rate |
$488.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$218.32
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$308.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$218.32
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$172.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$227.28
|
| Rate for Payer: Cash Price |
$308.40
|
| Rate for Payer: Cash Price |
$308.40
|
| Rate for Payer: Cigna Commercial |
$436.90
|
| Rate for Payer: First Health Commercial |
$462.60
|
| Rate for Payer: First Health Workers Compensation |
$198.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$462.60
|
| Rate for Payer: GEHA Commercial |
$250.01
|
| Rate for Payer: GEHA Medicare |
$227.28
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$462.60
|
| Rate for Payer: Humana ChoiceCare |
$250.01
|
| Rate for Payer: Humana Medicare Advantage |
$227.28
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$381.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$176.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$227.28
|
| Rate for Payer: Multiplan All |
$467.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$386.38
|
| Rate for Payer: OMNI Networks Commercial |
$359.80
|
| Rate for Payer: One Health Plan PPO/POS |
$462.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$203.77
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$176.48
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$227.28
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$488.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$454.56
|
| Rate for Payer: Three Rivers Provider Network All |
$385.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$222.73
|
| Rate for Payer: United Healthcare Managed Medicaid |
$176.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$227.28
|
| Rate for Payer: United Payors & United Providers UP&UP |
$478.02
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$227.28
|
| Rate for Payer: Zelis Auto |
$205.60
|
| Rate for Payer: Zelis Medicare |
$193.19
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$272.74
|
| Rate for Payer: Zelis Worker's Compensation |
$140.32
|
|
|
CL- CADEXOMER IODINE 5 GM PAD
|
Facility
|
IP
|
$41.00
|
|
|
Service Code
|
NDC 40565012251
|
| Hospital Charge Code |
3350492
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$28.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
CL- CADEXOMER IODINE 5 GM PAD
|
Facility
|
OP
|
$41.00
|
|
|
Service Code
|
NDC 40565012251
|
| Hospital Charge Code |
3350492
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$32.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Humana ChoiceCare |
$10.66
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.60
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$36.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.50
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
CL- CARBAMIDE PEROXIDE 6.5% OTIC SOLN
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
NDC 00135009163
|
| Hospital Charge Code |
3350019
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.83 |
| Max. Negotiated Rate |
$34.20 |
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$30.60
|
| Rate for Payer: First Health Commercial |
$32.40
|
| Rate for Payer: First Health Workers Compensation |
$13.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$32.40
|
| Rate for Payer: GEHA Commercial |
$25.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$32.40
|
| Rate for Payer: Multiplan All |
$32.76
|
| Rate for Payer: OMNI Networks Commercial |
$25.20
|
| Rate for Payer: One Health Plan PPO/POS |
$32.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$34.20
|
| Rate for Payer: Three Rivers Provider Network All |
$27.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$33.48
|
| Rate for Payer: Zelis Auto |
$14.40
|
| Rate for Payer: Zelis Worker's Compensation |
$9.83
|
|
|
CL- CARBAMIDE PEROXIDE 6.5% OTIC SOLN
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 00904662735
|
| Hospital Charge Code |
3350020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$16.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Humana ChoiceCare |
$5.20
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.00
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
|
CL- CARBAMIDE PEROXIDE 6.5% OTIC SOLN
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
NDC 00135009163
|
| Hospital Charge Code |
3350019
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$34.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$30.60
|
| Rate for Payer: First Health Commercial |
$32.40
|
| Rate for Payer: First Health Workers Compensation |
$13.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$32.40
|
| Rate for Payer: GEHA Commercial |
$28.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$32.40
|
| Rate for Payer: Humana ChoiceCare |
$9.36
|
| Rate for Payer: Multiplan All |
$32.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$21.60
|
| Rate for Payer: OMNI Networks Commercial |
$25.20
|
| Rate for Payer: One Health Plan PPO/POS |
$32.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$34.20
|
| Rate for Payer: Three Rivers Provider Network All |
$27.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$31.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$33.48
|
| Rate for Payer: Zelis Auto |
$14.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.83
|
|
|
CL- CARBAMIDE PEROXIDE 6.5% OTIC SOLN
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 00904662735
|
| Hospital Charge Code |
3350020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$14.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
|
CL- CARBOPLATIN 50 MG
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
CPT J9045
|
| Hospital Charge Code |
3350283
|
|
Hospital Revenue Code
|
636
|
| 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: 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 |
$2.72
|
| 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- CARBOPLATIN 50 MG
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
CPT J9045
|
| Hospital Charge Code |
3350283
|
|
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
|
|
|
CL- CARFILZOMIB 1 MG
|
Facility
|
OP
|
$111.00
|
|
|
Service Code
|
CPT J9047
|
| Hospital Charge Code |
3350322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.30 |
| Max. Negotiated Rate |
$111.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$46.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$66.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$46.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$36.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$55.65
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cigna Commercial |
$94.35
|
| Rate for Payer: First Health Commercial |
$99.90
|
| Rate for Payer: First Health Workers Compensation |
$42.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$99.90
|
| Rate for Payer: GEHA Commercial |
$61.22
|
| Rate for Payer: GEHA Medicare |
$55.65
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$99.90
|
| Rate for Payer: Humana ChoiceCare |
$61.22
|
| Rate for Payer: Humana Medicare Advantage |
$55.65
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$93.49
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$37.66
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$55.65
|
| Rate for Payer: Multiplan All |
$101.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$94.61
|
| Rate for Payer: OMNI Networks Commercial |
$77.70
|
| Rate for Payer: One Health Plan PPO/POS |
$99.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$43.48
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$37.66
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$55.65
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$105.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$111.30
|
| Rate for Payer: Three Rivers Provider Network All |
$83.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$54.54
|
| Rate for Payer: United Healthcare Managed Medicaid |
$37.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$55.65
|
| Rate for Payer: United Payors & United Providers UP&UP |
$103.23
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$55.65
|
| Rate for Payer: Zelis Auto |
$44.40
|
| Rate for Payer: Zelis Medicare |
$47.30
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$66.78
|
| Rate for Payer: Zelis Worker's Compensation |
$30.30
|
|
|
CL- CARFILZOMIB 1 MG
|
Facility
|
IP
|
$111.00
|
|
|
Service Code
|
CPT J9047
|
| Hospital Charge Code |
3350322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.30 |
| Max. Negotiated Rate |
$105.45 |
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cigna Commercial |
$94.35
|
| Rate for Payer: First Health Commercial |
$99.90
|
| Rate for Payer: First Health Workers Compensation |
$42.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$99.90
|
| Rate for Payer: GEHA Commercial |
$77.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$99.90
|
| Rate for Payer: Multiplan All |
$101.01
|
| Rate for Payer: OMNI Networks Commercial |
$77.70
|
| Rate for Payer: One Health Plan PPO/POS |
$99.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$105.45
|
| Rate for Payer: Three Rivers Provider Network All |
$83.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$103.23
|
| Rate for Payer: Zelis Auto |
$44.40
|
| Rate for Payer: Zelis Worker's Compensation |
$30.30
|
|
|
CL- CATHFLO ACTIVASE 1MG
|
Facility
|
OP
|
$267.00
|
|
|
Service Code
|
CPT J2997
|
| Hospital Charge Code |
3350275
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.89 |
| Max. Negotiated Rate |
$253.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$102.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$160.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$102.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$81.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$94.45
|
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cigna Commercial |
$226.95
|
| Rate for Payer: First Health Commercial |
$240.30
|
| Rate for Payer: First Health Workers Compensation |
$103.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$240.30
|
| Rate for Payer: GEHA Commercial |
$103.89
|
| Rate for Payer: GEHA Medicare |
$94.45
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$240.30
|
| Rate for Payer: Humana ChoiceCare |
$103.89
|
| Rate for Payer: Humana Medicare Advantage |
$94.45
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$158.68
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$82.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$94.45
|
| Rate for Payer: Multiplan All |
$242.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$160.56
|
| Rate for Payer: OMNI Networks Commercial |
$186.90
|
| Rate for Payer: One Health Plan PPO/POS |
$240.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$95.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$82.98
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$94.45
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$253.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$188.90
|
| Rate for Payer: Three Rivers Provider Network All |
$200.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$92.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$82.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$94.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$248.31
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$94.45
|
| Rate for Payer: Zelis Auto |
$106.80
|
| Rate for Payer: Zelis Medicare |
$80.28
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$113.34
|
| Rate for Payer: Zelis Worker's Compensation |
$72.89
|
|
|
CL- CATHFLO ACTIVASE 1MG
|
Facility
|
IP
|
$267.00
|
|
|
Service Code
|
CPT J2997
|
| Hospital Charge Code |
3350275
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.89 |
| Max. Negotiated Rate |
$253.65 |
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cigna Commercial |
$226.95
|
| Rate for Payer: First Health Commercial |
$240.30
|
| Rate for Payer: First Health Workers Compensation |
$103.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$240.30
|
| Rate for Payer: GEHA Commercial |
$186.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$240.30
|
| Rate for Payer: Multiplan All |
$242.97
|
| Rate for Payer: OMNI Networks Commercial |
$186.90
|
| Rate for Payer: One Health Plan PPO/POS |
$240.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$253.65
|
| Rate for Payer: Three Rivers Provider Network All |
$200.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$248.31
|
| Rate for Payer: Zelis Auto |
$106.80
|
| Rate for Payer: Zelis Worker's Compensation |
$72.89
|
|
|
CL- Cefazolin 1 GM vial
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
CPT J0690
|
| Hospital Charge Code |
3350394
|
|
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
|
|
|
CL- Cefazolin 1 GM vial
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
CPT J0690
|
| Hospital Charge Code |
3350394
|
|
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
|
|
|
CL- CEFTRIAXON 1GM - PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
3350427
|
|
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- CEFTRIAXON 1GM - PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
3350427
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| 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 |
$0.47
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.00
|
| 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: 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 |
$0.00
|
| 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- CEFTRIAXONE 500 MG
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
3350231
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
