|
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
|
|
|
CL- CEFTRIAXONE SODIUM FOR INJ 1GM
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
3350021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$8.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
CL- CEFTRIAXONE SODIUM FOR INJ 1GM
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
33050021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$0.47
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Humana ChoiceCare |
$3.12
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.20
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
CL- CEFTRIAXONE SODIUM FOR INJ 1GM
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
3350021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$0.47
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Humana ChoiceCare |
$3.12
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.20
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
CL- CEFTRIAXONE SODIUM FOR INJ 1GM
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
33050021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$8.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
CL- CEFTRIAXONE SODIUM FOR INJ 250MG
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
3302581
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$4.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
CL- CEFTRIAXONE SODIUM FOR INJ 250MG
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
3302581
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$0.47
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Humana ChoiceCare |
$1.82
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.20
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
CL- CEFTRIAXONE SODIUM FOR INJ 500MG
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
3302582
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$0.47
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Humana ChoiceCare |
$2.34
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5.40
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.50
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
CL- CEFTRIAXONE SODIUM FOR INJ 500MG
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
3302582
|
|
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- CHLOROPROCAINE 2% 400MG/20ML INJ SDV
|
Facility
|
IP
|
$163.45
|
|
|
Service Code
|
CPT J2402
|
| Hospital Charge Code |
3350516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.62 |
| Max. Negotiated Rate |
$155.28 |
| Rate for Payer: Cash Price |
$98.07
|
| Rate for Payer: Cigna Commercial |
$138.93
|
| Rate for Payer: First Health Commercial |
$147.10
|
| Rate for Payer: First Health Workers Compensation |
$63.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$147.10
|
| Rate for Payer: GEHA Commercial |
$114.42
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$147.10
|
| Rate for Payer: Multiplan All |
$148.74
|
| Rate for Payer: OMNI Networks Commercial |
$114.42
|
| Rate for Payer: One Health Plan PPO/POS |
$147.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$155.28
|
| Rate for Payer: Three Rivers Provider Network All |
$122.59
|
| Rate for Payer: United Payors & United Providers UP&UP |
$152.01
|
| Rate for Payer: Zelis Auto |
$65.38
|
| Rate for Payer: Zelis Worker's Compensation |
$44.62
|
|
|
CL- CHLOROPROCAINE 2% 400MG/20ML INJ SDV
|
Facility
|
OP
|
$163.45
|
|
|
Service Code
|
CPT J2402
|
| Hospital Charge Code |
3350516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.86 |
| Max. Negotiated Rate |
$155.28 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$98.07
|
| Rate for Payer: Cash Price |
$98.07
|
| Rate for Payer: Cigna Commercial |
$138.93
|
| Rate for Payer: First Health Commercial |
$147.10
|
| Rate for Payer: First Health Workers Compensation |
$63.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$147.10
|
| Rate for Payer: GEHA Commercial |
$130.76
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$147.10
|
| Rate for Payer: Humana ChoiceCare |
$42.50
|
| Rate for Payer: Multiplan All |
$148.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$98.07
|
| Rate for Payer: OMNI Networks Commercial |
$114.42
|
| Rate for Payer: One Health Plan PPO/POS |
$147.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$155.28
|
| Rate for Payer: Three Rivers Provider Network All |
$122.59
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$143.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$40.86
|
| Rate for Payer: United Payors & United Providers UP&UP |
$152.01
|
| Rate for Payer: Zelis Auto |
$65.38
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.72
|
| Rate for Payer: Zelis Worker's Compensation |
$44.62
|
|
|
CL- CIPROFLOXACIN HCL TAB 500MG
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
NDC 51079018201
|
| Hospital Charge Code |
3350098
|
|
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- CIPROFLOXACIN HCL TAB 500MG
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
NDC 51079018201
|
| Hospital Charge Code |
3350098
|
|
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- CISPLATIN 10 MG
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
CPT J9060
|
| Hospital Charge Code |
3350285
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$2.52
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Humana ChoiceCare |
$1.56
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.60
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
CL- CISPLATIN 10 MG
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
CPT J9060
|
| Hospital Charge Code |
3350285
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
CL- CLONIDINE HCL TAB 0.1 MG
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350022
|
|
Hospital Revenue Code
|
636
|
| 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- CLONIDINE HCL TAB 0.1 MG
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350022
|
|
Hospital Revenue Code
|
636
|
| 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- CLOTRIMAZOLE CREAM 1%
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
NDC 00904782231
|
| Hospital Charge Code |
3350023
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.02 |
| Max. Negotiated Rate |
$52.25 |
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$46.75
|
| Rate for Payer: First Health Commercial |
$49.50
|
| Rate for Payer: First Health Workers Compensation |
$21.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$49.50
|
| Rate for Payer: GEHA Commercial |
$38.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$49.50
|
| Rate for Payer: Multiplan All |
$50.05
|
| Rate for Payer: OMNI Networks Commercial |
$38.50
|
| Rate for Payer: One Health Plan PPO/POS |
$49.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$52.25
|
| Rate for Payer: Three Rivers Provider Network All |
$41.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$51.15
|
| Rate for Payer: Zelis Auto |
$22.00
|
| Rate for Payer: Zelis Worker's Compensation |
$15.02
|
|
|
CL- CLOTRIMAZOLE CREAM 1%
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
NDC 00904782231
|
| Hospital Charge Code |
3350023
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.75 |
| Max. Negotiated Rate |
$52.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$46.75
|
| Rate for Payer: First Health Commercial |
$49.50
|
| Rate for Payer: First Health Workers Compensation |
$21.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$49.50
|
| Rate for Payer: GEHA Commercial |
$44.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$49.50
|
| Rate for Payer: Humana ChoiceCare |
$14.30
|
| Rate for Payer: Multiplan All |
$50.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$33.00
|
| Rate for Payer: OMNI Networks Commercial |
$38.50
|
| Rate for Payer: One Health Plan PPO/POS |
$49.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$52.25
|
| Rate for Payer: Three Rivers Provider Network All |
$41.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$48.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$51.15
|
| Rate for Payer: Zelis Auto |
$22.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$27.50
|
| Rate for Payer: Zelis Worker's Compensation |
$15.02
|
|
|
CL- CLOTRIMAZOLE SOLN 1%
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
NDC 51672203701
|
| Hospital Charge Code |
3350024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$45.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$40.80
|
| Rate for Payer: First Health Commercial |
$43.20
|
| Rate for Payer: First Health Workers Compensation |
$18.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$43.20
|
| Rate for Payer: GEHA Commercial |
$38.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$43.20
|
| Rate for Payer: Humana ChoiceCare |
$12.48
|
| Rate for Payer: Multiplan All |
$43.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$28.80
|
| Rate for Payer: OMNI Networks Commercial |
$33.60
|
| Rate for Payer: One Health Plan PPO/POS |
$43.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$45.60
|
| Rate for Payer: Three Rivers Provider Network All |
$36.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$42.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$44.64
|
| Rate for Payer: Zelis Auto |
$19.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$24.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.10
|
|
|
CL- CLOTRIMAZOLE SOLN 1%
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
NDC 51672203701
|
| Hospital Charge Code |
3350024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.10 |
| Max. Negotiated Rate |
$45.60 |
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$40.80
|
| Rate for Payer: First Health Commercial |
$43.20
|
| Rate for Payer: First Health Workers Compensation |
$18.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$43.20
|
| Rate for Payer: GEHA Commercial |
$33.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$43.20
|
| Rate for Payer: Multiplan All |
$43.68
|
| Rate for Payer: OMNI Networks Commercial |
$33.60
|
| Rate for Payer: One Health Plan PPO/POS |
$43.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$45.60
|
| Rate for Payer: Three Rivers Provider Network All |
$36.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$44.64
|
| Rate for Payer: Zelis Auto |
$19.20
|
| Rate for Payer: Zelis Worker's Compensation |
$13.10
|
|
|
CL- CORTISPORIN OTIC SUSP
|
Facility
|
IP
|
$181.00
|
|
|
Service Code
|
NDC 61314064511
|
| Hospital Charge Code |
3350066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.41 |
| Max. Negotiated Rate |
$171.95 |
| Rate for Payer: Cash Price |
$108.60
|
| Rate for Payer: Cigna Commercial |
$153.85
|
| Rate for Payer: First Health Commercial |
$162.90
|
| Rate for Payer: First Health Workers Compensation |
$69.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$162.90
|
| Rate for Payer: GEHA Commercial |
$126.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$162.90
|
| Rate for Payer: Multiplan All |
$164.71
|
| Rate for Payer: OMNI Networks Commercial |
$126.70
|
| Rate for Payer: One Health Plan PPO/POS |
$162.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$171.95
|
| Rate for Payer: Three Rivers Provider Network All |
$135.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$168.33
|
| Rate for Payer: Zelis Auto |
$72.40
|
| Rate for Payer: Zelis Worker's Compensation |
$49.41
|
|
|
CL- CORTISPORIN OTIC SUSP
|
Facility
|
OP
|
$181.00
|
|
|
Service Code
|
NDC 61314064511
|
| Hospital Charge Code |
3350066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.25 |
| Max. Negotiated Rate |
$171.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$108.60
|
| Rate for Payer: Cash Price |
$108.60
|
| Rate for Payer: Cigna Commercial |
$153.85
|
| Rate for Payer: First Health Commercial |
$162.90
|
| Rate for Payer: First Health Workers Compensation |
$69.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$162.90
|
| Rate for Payer: GEHA Commercial |
$144.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$162.90
|
| Rate for Payer: Humana ChoiceCare |
$47.06
|
| Rate for Payer: Multiplan All |
$164.71
|
| Rate for Payer: New Mexico Health Connections Medicare |
$108.60
|
| Rate for Payer: OMNI Networks Commercial |
$126.70
|
| Rate for Payer: One Health Plan PPO/POS |
$162.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$171.95
|
| Rate for Payer: Three Rivers Provider Network All |
$135.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$159.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$45.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$168.33
|
| Rate for Payer: Zelis Auto |
$72.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$90.50
|
| Rate for Payer: Zelis Worker's Compensation |
$49.41
|
|
|
CL- COVID-19 MODERNA 0.25 ML 6MOS-11YRS
|
Facility
|
IP
|
$593.00
|
|
|
Service Code
|
CPT 91321
|
| Hospital Charge Code |
3350545
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$161.89 |
| Max. Negotiated Rate |
$563.35 |
| Rate for Payer: Cash Price |
$355.80
|
| Rate for Payer: Cigna Commercial |
$504.05
|
| Rate for Payer: First Health Commercial |
$533.70
|
| Rate for Payer: First Health Workers Compensation |
$228.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$533.70
|
| Rate for Payer: GEHA Commercial |
$415.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$533.70
|
| Rate for Payer: Multiplan All |
$539.63
|
| Rate for Payer: OMNI Networks Commercial |
$415.10
|
| Rate for Payer: One Health Plan PPO/POS |
$533.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$563.35
|
| Rate for Payer: Three Rivers Provider Network All |
$444.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$551.49
|
| Rate for Payer: Zelis Auto |
$237.20
|
| Rate for Payer: Zelis Worker's Compensation |
$161.89
|
|
|
CL- COVID-19 MODERNA 0.25 ML 6MOS-11YRS
|
Facility
|
OP
|
$593.00
|
|
|
Service Code
|
CPT 91321
|
| Hospital Charge Code |
3350545
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.18 |
| Max. Negotiated Rate |
$563.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$220.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$355.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$220.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$174.75
|
| Rate for Payer: Cash Price |
$355.80
|
| Rate for Payer: Cash Price |
$355.80
|
| Rate for Payer: Cigna Commercial |
$504.05
|
| Rate for Payer: First Health Commercial |
$533.70
|
| Rate for Payer: First Health Workers Compensation |
$228.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$533.70
|
| Rate for Payer: GEHA Commercial |
$161.77
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$533.70
|
| Rate for Payer: Humana ChoiceCare |
$154.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$178.31
|
| Rate for Payer: Multiplan All |
$539.63
|
| Rate for Payer: New Mexico Health Connections Medicare |
$355.80
|
| Rate for Payer: OMNI Networks Commercial |
$415.10
|
| Rate for Payer: One Health Plan PPO/POS |
$533.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$205.88
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$178.31
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$563.35
|
| Rate for Payer: Three Rivers Provider Network All |
$444.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$521.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$178.31
|
| Rate for Payer: United Payors & United Providers UP&UP |
$551.49
|
| Rate for Payer: Zelis Auto |
$237.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$296.50
|
| Rate for Payer: Zelis Worker's Compensation |
$161.89
|
|
