|
CL- COVID-19VACC MRNA 0.5ML NON MEDICARE
|
Facility
|
OP
|
$639.00
|
|
|
Service Code
|
CPT 91322
|
| Hospital Charge Code |
3350544
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$166.14 |
| Max. Negotiated Rate |
$607.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$242.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$383.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$242.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$192.09
|
| Rate for Payer: Cash Price |
$383.40
|
| Rate for Payer: Cash Price |
$383.40
|
| Rate for Payer: Cigna Commercial |
$543.15
|
| Rate for Payer: First Health Commercial |
$575.10
|
| Rate for Payer: First Health Workers Compensation |
$246.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$575.10
|
| Rate for Payer: GEHA Commercial |
$177.81
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$575.10
|
| Rate for Payer: Humana ChoiceCare |
$166.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$196.00
|
| Rate for Payer: Multiplan All |
$581.49
|
| Rate for Payer: New Mexico Health Connections Medicare |
$383.40
|
| Rate for Payer: OMNI Networks Commercial |
$447.30
|
| Rate for Payer: One Health Plan PPO/POS |
$575.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$226.31
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$196.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$607.05
|
| Rate for Payer: Three Rivers Provider Network All |
$479.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$562.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$196.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$594.27
|
| Rate for Payer: Zelis Auto |
$255.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$319.50
|
| Rate for Payer: Zelis Worker's Compensation |
$174.45
|
|
|
CL- COVID-19VACC MRNA 0.5ML NON MEDICARE
|
Facility
|
IP
|
$639.00
|
|
|
Service Code
|
CPT 91322
|
| Hospital Charge Code |
3350544
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$174.45 |
| Max. Negotiated Rate |
$607.05 |
| Rate for Payer: Cash Price |
$383.40
|
| Rate for Payer: Cigna Commercial |
$543.15
|
| Rate for Payer: First Health Commercial |
$575.10
|
| Rate for Payer: First Health Workers Compensation |
$246.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$575.10
|
| Rate for Payer: GEHA Commercial |
$447.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$575.10
|
| Rate for Payer: Multiplan All |
$581.49
|
| Rate for Payer: OMNI Networks Commercial |
$447.30
|
| Rate for Payer: One Health Plan PPO/POS |
$575.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$607.05
|
| Rate for Payer: Three Rivers Provider Network All |
$479.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$594.27
|
| Rate for Payer: Zelis Auto |
$255.60
|
| Rate for Payer: Zelis Worker's Compensation |
$174.45
|
|
|
CL- COVID-19 VACC MRNA SY 0.5ML MEDICARE
|
Facility
|
IP
|
$639.00
|
|
|
Service Code
|
CPT 91322
|
| Hospital Charge Code |
3350543
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$174.45 |
| Max. Negotiated Rate |
$607.05 |
| Rate for Payer: Cash Price |
$383.40
|
| Rate for Payer: Cigna Commercial |
$543.15
|
| Rate for Payer: First Health Commercial |
$575.10
|
| Rate for Payer: First Health Workers Compensation |
$246.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$575.10
|
| Rate for Payer: GEHA Commercial |
$447.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$575.10
|
| Rate for Payer: Multiplan All |
$581.49
|
| Rate for Payer: OMNI Networks Commercial |
$447.30
|
| Rate for Payer: One Health Plan PPO/POS |
$575.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$607.05
|
| Rate for Payer: Three Rivers Provider Network All |
$479.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$594.27
|
| Rate for Payer: Zelis Auto |
$255.60
|
| Rate for Payer: Zelis Worker's Compensation |
$174.45
|
|
|
CL- COVID-19 VACC MRNA SY 0.5ML MEDICARE
|
Facility
|
OP
|
$639.00
|
|
|
Service Code
|
CPT 91322
|
| Hospital Charge Code |
3350543
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$166.14 |
| Max. Negotiated Rate |
$607.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$242.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$383.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$242.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$192.09
|
| Rate for Payer: Cash Price |
$383.40
|
| Rate for Payer: Cash Price |
$383.40
|
| Rate for Payer: Cigna Commercial |
$543.15
|
| Rate for Payer: First Health Commercial |
$575.10
|
| Rate for Payer: First Health Workers Compensation |
$246.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$575.10
|
| Rate for Payer: GEHA Commercial |
$177.81
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$575.10
|
| Rate for Payer: Humana ChoiceCare |
$166.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$196.00
|
| Rate for Payer: Multiplan All |
$581.49
|
| Rate for Payer: New Mexico Health Connections Medicare |
$383.40
|
| Rate for Payer: OMNI Networks Commercial |
$447.30
|
| Rate for Payer: One Health Plan PPO/POS |
$575.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$226.31
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$196.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$607.05
|
| Rate for Payer: Three Rivers Provider Network All |
$479.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$562.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$196.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$594.27
|
| Rate for Payer: Zelis Auto |
$255.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$319.50
|
| Rate for Payer: Zelis Worker's Compensation |
$174.45
|
|
|
CL- CYANOCOBALAMIN INJ 1000MCG/ML
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
CPT J3420
|
| Hospital Charge Code |
3350026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.11 |
| 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: 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 |
$1.11
|
| 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- CYANOCOBALAMIN INJ 1000MCG/ML
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
CPT J3420
|
| Hospital Charge Code |
3350026
|
|
Hospital Revenue Code
|
636
|
| 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- CYCLOPHOSHAMIDE 100 MG VIAL
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
CPT J9070
|
| Hospital Charge Code |
3350288
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.12 |
| Max. Negotiated Rate |
$108.30 |
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$96.90
|
| Rate for Payer: First Health Commercial |
$102.60
|
| Rate for Payer: First Health Workers Compensation |
$44.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$102.60
|
| Rate for Payer: GEHA Commercial |
$79.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$102.60
|
| Rate for Payer: Multiplan All |
$103.74
|
| Rate for Payer: OMNI Networks Commercial |
$79.80
|
| Rate for Payer: One Health Plan PPO/POS |
$102.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$108.30
|
| Rate for Payer: Three Rivers Provider Network All |
$85.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$106.02
|
| Rate for Payer: Zelis Auto |
$45.60
|
| Rate for Payer: Zelis Worker's Compensation |
$31.12
|
|
|
CL- CYCLOPHOSHAMIDE 100 MG VIAL
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
CPT J9070
|
| Hospital Charge Code |
3350288
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.50 |
| Max. Negotiated Rate |
$108.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$96.90
|
| Rate for Payer: First Health Commercial |
$102.60
|
| Rate for Payer: First Health Workers Compensation |
$44.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$102.60
|
| Rate for Payer: GEHA Commercial |
$91.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$102.60
|
| Rate for Payer: Humana ChoiceCare |
$29.64
|
| Rate for Payer: Multiplan All |
$103.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$68.40
|
| Rate for Payer: OMNI Networks Commercial |
$79.80
|
| Rate for Payer: One Health Plan PPO/POS |
$102.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$108.30
|
| Rate for Payer: Three Rivers Provider Network All |
$85.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$100.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$28.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$106.02
|
| Rate for Payer: Zelis Auto |
$45.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$57.00
|
| Rate for Payer: Zelis Worker's Compensation |
$31.12
|
|
|
CL- DARATUMUBA 10 MG
|
Facility
|
OP
|
$159.00
|
|
|
Service Code
|
CPT J9145
|
| Hospital Charge Code |
3350290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.41 |
| Max. Negotiated Rate |
$151.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$70.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$95.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$70.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$55.67
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$71.37
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cigna Commercial |
$135.15
|
| Rate for Payer: First Health Commercial |
$143.10
|
| Rate for Payer: First Health Workers Compensation |
$61.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$143.10
|
| Rate for Payer: GEHA Commercial |
$78.51
|
| Rate for Payer: GEHA Medicare |
$71.37
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$143.10
|
| Rate for Payer: Humana ChoiceCare |
$78.51
|
| Rate for Payer: Humana Medicare Advantage |
$71.37
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$119.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$56.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$71.37
|
| Rate for Payer: Multiplan All |
$144.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$121.33
|
| Rate for Payer: OMNI Networks Commercial |
$111.30
|
| Rate for Payer: One Health Plan PPO/POS |
$143.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$65.59
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$56.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$71.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$151.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$142.74
|
| Rate for Payer: Three Rivers Provider Network All |
$119.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$69.94
|
| Rate for Payer: United Healthcare Managed Medicaid |
$56.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$71.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$147.87
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$71.37
|
| Rate for Payer: Zelis Auto |
$63.60
|
| Rate for Payer: Zelis Medicare |
$60.66
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$85.64
|
| Rate for Payer: Zelis Worker's Compensation |
$43.41
|
|
|
CL- DARATUMUBA 10 MG
|
Facility
|
IP
|
$159.00
|
|
|
Service Code
|
CPT J9145
|
| Hospital Charge Code |
3350290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.41 |
| Max. Negotiated Rate |
$151.05 |
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cigna Commercial |
$135.15
|
| Rate for Payer: First Health Commercial |
$143.10
|
| Rate for Payer: First Health Workers Compensation |
$61.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$143.10
|
| Rate for Payer: GEHA Commercial |
$111.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$143.10
|
| Rate for Payer: Multiplan All |
$144.69
|
| Rate for Payer: OMNI Networks Commercial |
$111.30
|
| Rate for Payer: One Health Plan PPO/POS |
$143.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$151.05
|
| Rate for Payer: Three Rivers Provider Network All |
$119.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$147.87
|
| Rate for Payer: Zelis Auto |
$63.60
|
| Rate for Payer: Zelis Worker's Compensation |
$43.41
|
|
|
CL- DELESTROGEN 20MG/ML INJ.
|
Facility
|
IP
|
$208.00
|
|
|
Service Code
|
CPT J1380
|
| Hospital Charge Code |
3350153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.78 |
| Max. Negotiated Rate |
$197.60 |
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cigna Commercial |
$176.80
|
| Rate for Payer: First Health Commercial |
$187.20
|
| Rate for Payer: First Health Workers Compensation |
$80.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$187.20
|
| Rate for Payer: GEHA Commercial |
$145.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$187.20
|
| Rate for Payer: Multiplan All |
$189.28
|
| Rate for Payer: OMNI Networks Commercial |
$145.60
|
| Rate for Payer: One Health Plan PPO/POS |
$187.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$197.60
|
| Rate for Payer: Three Rivers Provider Network All |
$156.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$193.44
|
| Rate for Payer: Zelis Auto |
$83.20
|
| Rate for Payer: Zelis Worker's Compensation |
$56.78
|
|
|
CL- DELESTROGEN 20MG/ML INJ.
|
Facility
|
OP
|
$208.00
|
|
|
Service Code
|
CPT J1380
|
| Hospital Charge Code |
3350153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.97 |
| Max. Negotiated Rate |
$197.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$124.80
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cigna Commercial |
$176.80
|
| Rate for Payer: First Health Commercial |
$187.20
|
| Rate for Payer: First Health Workers Compensation |
$80.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$187.20
|
| Rate for Payer: GEHA Commercial |
$7.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$187.20
|
| Rate for Payer: Humana ChoiceCare |
$54.08
|
| Rate for Payer: Multiplan All |
$189.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$124.80
|
| Rate for Payer: OMNI Networks Commercial |
$145.60
|
| Rate for Payer: One Health Plan PPO/POS |
$187.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$197.60
|
| Rate for Payer: Three Rivers Provider Network All |
$156.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$183.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$52.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$193.44
|
| Rate for Payer: Zelis Auto |
$83.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$104.00
|
| Rate for Payer: Zelis Worker's Compensation |
$56.78
|
|
|
CL- DENOSUMAB 1 MG
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
CPT J0897
|
| Hospital Charge Code |
3350351
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.56 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: First Health Commercial |
$51.30
|
| Rate for Payer: First Health Workers Compensation |
$22.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$51.30
|
| Rate for Payer: GEHA Commercial |
$39.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$51.30
|
| Rate for Payer: Multiplan All |
$51.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.90
|
| Rate for Payer: One Health Plan PPO/POS |
$51.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$54.15
|
| Rate for Payer: Three Rivers Provider Network All |
$42.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.01
|
| Rate for Payer: Zelis Auto |
$22.80
|
| Rate for Payer: Zelis Worker's Compensation |
$15.56
|
|
|
CL- DENOSUMAB 1 MG
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
CPT J0897
|
| Hospital Charge Code |
3350351
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.56 |
| Max. Negotiated Rate |
$58.76 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$22.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$34.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$22.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$17.48
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$29.38
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: First Health Commercial |
$51.30
|
| Rate for Payer: First Health Workers Compensation |
$22.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$51.30
|
| Rate for Payer: GEHA Commercial |
$32.32
|
| Rate for Payer: GEHA Medicare |
$29.38
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$51.30
|
| Rate for Payer: Humana ChoiceCare |
$32.32
|
| Rate for Payer: Humana Medicare Advantage |
$29.38
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$49.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$17.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$29.38
|
| Rate for Payer: Multiplan All |
$51.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$49.95
|
| Rate for Payer: OMNI Networks Commercial |
$39.90
|
| Rate for Payer: One Health Plan PPO/POS |
$51.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$20.59
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$17.84
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$29.38
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$54.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$58.76
|
| Rate for Payer: Three Rivers Provider Network All |
$42.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$28.79
|
| Rate for Payer: United Healthcare Managed Medicaid |
$17.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.38
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$29.38
|
| Rate for Payer: Zelis Auto |
$22.80
|
| Rate for Payer: Zelis Medicare |
$24.97
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$35.26
|
| Rate for Payer: Zelis Worker's Compensation |
$15.56
|
|
|
CL- DEPO-MEDROL 80MG/ML - DC'd item #
|
Facility
|
OP
|
$79.00
|
|
|
Service Code
|
CPT J1040
|
| Hospital Charge Code |
3350144
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.75 |
| Max. Negotiated Rate |
$75.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$67.15
|
| Rate for Payer: First Health Commercial |
$71.10
|
| Rate for Payer: First Health Workers Compensation |
$30.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$71.10
|
| Rate for Payer: GEHA Commercial |
$63.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$71.10
|
| Rate for Payer: Humana ChoiceCare |
$20.54
|
| Rate for Payer: Multiplan All |
$71.89
|
| Rate for Payer: New Mexico Health Connections Medicare |
$47.40
|
| Rate for Payer: OMNI Networks Commercial |
$55.30
|
| Rate for Payer: One Health Plan PPO/POS |
$71.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$75.05
|
| Rate for Payer: Three Rivers Provider Network All |
$59.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$69.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$19.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$73.47
|
| Rate for Payer: Zelis Auto |
$31.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$39.50
|
| Rate for Payer: Zelis Worker's Compensation |
$21.57
|
|
|
CL- DEPO-MEDROL 80MG/ML - DC'd item #
|
Facility
|
IP
|
$79.00
|
|
|
Service Code
|
CPT J1040
|
| Hospital Charge Code |
3350144
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.57 |
| Max. Negotiated Rate |
$75.05 |
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$67.15
|
| Rate for Payer: First Health Commercial |
$71.10
|
| Rate for Payer: First Health Workers Compensation |
$30.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$71.10
|
| Rate for Payer: GEHA Commercial |
$55.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$71.10
|
| Rate for Payer: Multiplan All |
$71.89
|
| Rate for Payer: OMNI Networks Commercial |
$55.30
|
| Rate for Payer: One Health Plan PPO/POS |
$71.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$75.05
|
| Rate for Payer: Three Rivers Provider Network All |
$59.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$73.47
|
| Rate for Payer: Zelis Auto |
$31.60
|
| Rate for Payer: Zelis Worker's Compensation |
$21.57
|
|
|
CL- DEPO-PROVERA 150MG - PT OWN MED
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J1050
|
| Hospital Charge Code |
3350197
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| 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: 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: 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- DEPO-PROVERA 150MG - PT OWN MED
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J1050
|
| Hospital Charge Code |
3350197
|
|
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- DEXAMETHASONE INJ 4MG/ML
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
CPT J1100
|
| Hospital Charge Code |
3350027
|
|
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- DEXAMETHASONE INJ 4MG/ML
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
CPT J1100
|
| Hospital Charge Code |
3350027
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| 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 |
$0.10
|
| 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- DEXAMETHASONE ORAL SOL. 1 MG/ML
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
CPT J8540
|
| Hospital Charge Code |
3350407
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
CL- DEXAMETHASONE ORAL SOL. 1 MG/ML
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
CPT J8540
|
| Hospital Charge Code |
3350407
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$0.02
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Humana ChoiceCare |
$2.08
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.80
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
CL- DICYCLOMINE HCL CAP 10MG
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 51079011820
|
| Hospital Charge Code |
3350028
|
|
Hospital Revenue Code
|
250
|
| 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- DICYCLOMINE HCL CAP 10MG
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 51079011820
|
| Hospital Charge Code |
3350028
|
|
Hospital Revenue Code
|
250
|
| 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: 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 |
$4.80
|
| 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- DICYCLOMINE HCL INJ 10MG/ML
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
CPT J0500
|
| Hospital Charge Code |
3350029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.50 |
| Max. Negotiated Rate |
$49.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$44.20
|
| Rate for Payer: First Health Commercial |
$46.80
|
| Rate for Payer: First Health Workers Compensation |
$20.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$46.80
|
| Rate for Payer: GEHA Commercial |
$12.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$46.80
|
| Rate for Payer: Humana ChoiceCare |
$13.52
|
| Rate for Payer: Multiplan All |
$47.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.20
|
| Rate for Payer: OMNI Networks Commercial |
$36.40
|
| Rate for Payer: One Health Plan PPO/POS |
$46.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$49.40
|
| Rate for Payer: Three Rivers Provider Network All |
$39.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$45.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$48.36
|
| Rate for Payer: Zelis Auto |
$20.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$26.00
|
| Rate for Payer: Zelis Worker's Compensation |
$14.20
|
|
