|
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
|
|
|
CL- DILTIAZEM HCL 60MG TAB
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350239
|
|
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- DILTIAZEM HCL 60MG TAB
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350239
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.00
|
| 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 |
$8.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Humana ChoiceCare |
$2.60
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.00
|
| 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: TriWest Veterans Administration/VAPC3 |
$8.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
CL- DIPHENHYDRAMINE ELIXIR 12.5MG/5ML
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
CPT Q0163
|
| Hospital Charge Code |
3350031
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$6.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
CL- DIPHENHYDRAMINE ELIXIR 12.5MG/5ML
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
CPT Q0163
|
| Hospital Charge Code |
3350031
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$7.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Humana ChoiceCare |
$2.34
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5.40
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.50
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
CL- DIPHENHYDRAMINE HCL CAP 25MG
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
CPT J1200
|
| Hospital Charge Code |
3350030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
CL- DIPHENHYDRAMINE HCL CAP 25MG
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
CPT J1200
|
| Hospital Charge Code |
3350030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$0.84
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
CL- DIPHENHYDRAMINE HCL INJ 50MG/ML
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
CPT J1200
|
| Hospital Charge Code |
3350032
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.84 |
| 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 |
$0.84
|
| 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- DIPHENHYDRAMINE HCL INJ 50MG/ML
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
CPT J1200
|
| Hospital Charge Code |
3350032
|
|
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- DOCETAXEL 1 MG
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
CPT J9171
|
| Hospital Charge Code |
3350292
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
CL- DOCETAXEL 1 MG
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
CPT J9171
|
| Hospital Charge Code |
3350292
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$4.16 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$4.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$4.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3.29
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$0.69
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3.36
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$3.88
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3.36
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.36
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
CL- DOCUSATE 100 MG/10 ML U.D.
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350409
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
CL- DOCUSATE 100 MG/10 ML U.D.
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350409
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$4.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Humana ChoiceCare |
$1.30
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.00
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
CL- DOXORUBICIN HCL 10 MG
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
CPT J9000
|
| Hospital Charge Code |
3350294
|
|
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- DOXORUBICIN HCL 10 MG
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
CPT J9000
|
| Hospital Charge Code |
3350294
|
|
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 |
$3.32
|
| 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- DOXORUBICIN HCL LIPOSOMAL 10 MG
|
Facility
|
IP
|
$1,100.00
|
|
|
Service Code
|
CPT Q2050
|
| Hospital Charge Code |
3350328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$300.30 |
| Max. Negotiated Rate |
$1,045.00 |
| Rate for Payer: Cash Price |
$660.00
|
| Rate for Payer: Cigna Commercial |
$935.00
|
| Rate for Payer: First Health Commercial |
$990.00
|
| Rate for Payer: First Health Workers Compensation |
$424.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$990.00
|
| Rate for Payer: GEHA Commercial |
$770.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$990.00
|
| Rate for Payer: Multiplan All |
$1,001.00
|
| Rate for Payer: OMNI Networks Commercial |
$770.00
|
| Rate for Payer: One Health Plan PPO/POS |
$990.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,045.00
|
| Rate for Payer: Three Rivers Provider Network All |
$825.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,023.00
|
| Rate for Payer: Zelis Auto |
$440.00
|
| Rate for Payer: Zelis Worker's Compensation |
$300.30
|
|
|
CL- DOXORUBICIN HCL LIPOSOMAL 10 MG
|
Facility
|
OP
|
$1,100.00
|
|
|
Service Code
|
CPT Q2050
|
| Hospital Charge Code |
3350328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.20 |
| Max. Negotiated Rate |
$1,045.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$732.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$660.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$732.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$580.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$108.47
|
| Rate for Payer: Cash Price |
$660.00
|
| Rate for Payer: Cash Price |
$660.00
|
| Rate for Payer: Cigna Commercial |
$935.00
|
| Rate for Payer: First Health Commercial |
$990.00
|
| Rate for Payer: First Health Workers Compensation |
$424.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$990.00
|
| Rate for Payer: GEHA Commercial |
$119.32
|
| Rate for Payer: GEHA Medicare |
$108.47
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$990.00
|
| Rate for Payer: Humana ChoiceCare |
$119.32
|
| Rate for Payer: Humana Medicare Advantage |
$108.47
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$182.23
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$592.28
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$108.47
|
| Rate for Payer: Multiplan All |
$1,001.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$184.40
|
| Rate for Payer: OMNI Networks Commercial |
$770.00
|
| Rate for Payer: One Health Plan PPO/POS |
$990.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$683.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$592.28
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$108.47
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,045.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$216.94
|
| Rate for Payer: Three Rivers Provider Network All |
$825.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$106.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$592.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.47
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,023.00
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$108.47
|
| Rate for Payer: Zelis Auto |
$440.00
|
| Rate for Payer: Zelis Medicare |
$92.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$130.16
|
| Rate for Payer: Zelis Worker's Compensation |
$300.30
|
|
|
CL- DROPERIDOL 5MG/2 ML
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
CPT J1790
|
| Hospital Charge Code |
3350522
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.39 |
| Max. Negotiated Rate |
$62.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$56.10
|
| Rate for Payer: First Health Commercial |
$59.40
|
| Rate for Payer: First Health Workers Compensation |
$25.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$59.40
|
| Rate for Payer: GEHA Commercial |
$8.39
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$59.40
|
| Rate for Payer: Humana ChoiceCare |
$17.16
|
| Rate for Payer: Multiplan All |
$60.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$39.60
|
| Rate for Payer: OMNI Networks Commercial |
$46.20
|
| Rate for Payer: One Health Plan PPO/POS |
$59.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$62.70
|
| Rate for Payer: Three Rivers Provider Network All |
$49.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$58.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$61.38
|
| Rate for Payer: Zelis Auto |
$26.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.02
|
|
|
CL- DROPERIDOL 5MG/2 ML
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
CPT J1790
|
| Hospital Charge Code |
3350522
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.02 |
| Max. Negotiated Rate |
$62.70 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$56.10
|
| Rate for Payer: First Health Commercial |
$59.40
|
| Rate for Payer: First Health Workers Compensation |
$25.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$59.40
|
| Rate for Payer: GEHA Commercial |
$46.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$59.40
|
| Rate for Payer: Multiplan All |
$60.06
|
| Rate for Payer: OMNI Networks Commercial |
$46.20
|
| Rate for Payer: One Health Plan PPO/POS |
$59.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$62.70
|
| Rate for Payer: Three Rivers Provider Network All |
$49.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$61.38
|
| Rate for Payer: Zelis Auto |
$26.40
|
| Rate for Payer: Zelis Worker's Compensation |
$18.02
|
|
|
CL- DUROLANE 60MG/3ML INJ
|
Facility
|
OP
|
$3,194.00
|
|
|
Service Code
|
CPT J7318
|
| Hospital Charge Code |
3350403
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.75 |
| Max. Negotiated Rate |
$3,034.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$10.63
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,916.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$10.63
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$8.43
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6.77
|
| Rate for Payer: Cash Price |
$1,916.40
|
| Rate for Payer: Cash Price |
$1,916.40
|
| Rate for Payer: Cigna Commercial |
$2,714.90
|
| Rate for Payer: First Health Commercial |
$2,874.60
|
| Rate for Payer: First Health Workers Compensation |
$1,233.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,874.60
|
| Rate for Payer: GEHA Commercial |
$7.45
|
| Rate for Payer: GEHA Medicare |
$6.77
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,874.60
|
| Rate for Payer: Humana ChoiceCare |
$7.45
|
| Rate for Payer: Humana Medicare Advantage |
$6.77
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$11.37
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$8.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6.77
|
| Rate for Payer: Multiplan All |
$2,906.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.51
|
| Rate for Payer: OMNI Networks Commercial |
$2,235.80
|
| Rate for Payer: One Health Plan PPO/POS |
$2,874.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$9.93
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$8.60
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6.77
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,034.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$13.54
|
| Rate for Payer: Three Rivers Provider Network All |
$2,395.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.63
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.77
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,970.42
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6.77
|
| Rate for Payer: Zelis Auto |
$1,277.60
|
| Rate for Payer: Zelis Medicare |
$5.75
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.12
|
| Rate for Payer: Zelis Worker's Compensation |
$871.96
|
|
|
CL- DUROLANE 60MG/3ML INJ
|
Facility
|
IP
|
$3,194.00
|
|
|
Service Code
|
CPT J7318
|
| Hospital Charge Code |
3350403
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$871.96 |
| Max. Negotiated Rate |
$3,034.30 |
| Rate for Payer: Cash Price |
$1,916.40
|
| Rate for Payer: Cigna Commercial |
$2,714.90
|
| Rate for Payer: First Health Commercial |
$2,874.60
|
| Rate for Payer: First Health Workers Compensation |
$1,233.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,874.60
|
| Rate for Payer: GEHA Commercial |
$2,235.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,874.60
|
| Rate for Payer: Multiplan All |
$2,906.54
|
| Rate for Payer: OMNI Networks Commercial |
$2,235.80
|
| Rate for Payer: One Health Plan PPO/POS |
$2,874.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,034.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,395.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,970.42
|
| Rate for Payer: Zelis Auto |
$1,277.60
|
| Rate for Payer: Zelis Worker's Compensation |
$871.96
|
|
|
CL- DUROLANE 60MG/3ML INJ -- Pt OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J7318
|
| Hospital Charge Code |
3350411
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$13.54 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$10.63
|
| 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 |
$10.63
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$8.43
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6.77
|
| 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 |
$7.45
|
| Rate for Payer: GEHA Medicare |
$6.77
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$7.45
|
| Rate for Payer: Humana Medicare Advantage |
$6.77
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$11.37
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$8.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6.77
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.51
|
| 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 |
$9.93
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$8.60
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6.77
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$13.54
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.63
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.77
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6.77
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Medicare |
$5.75
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.12
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- DUROLANE 60MG/3ML INJ -- Pt OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J7318
|
| Hospital Charge Code |
3350411
|
|
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- DURVALUMAB 10 MG
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
CPT J9173
|
| Hospital Charge Code |
3350314
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.42 |
| Max. Negotiated Rate |
$213.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$142.02
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$135.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$142.02
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$112.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$85.12
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$191.25
|
| Rate for Payer: First Health Commercial |
$202.50
|
| Rate for Payer: First Health Workers Compensation |
$86.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$202.50
|
| Rate for Payer: GEHA Commercial |
$93.63
|
| Rate for Payer: GEHA Medicare |
$85.12
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$202.50
|
| Rate for Payer: Humana ChoiceCare |
$93.63
|
| Rate for Payer: Humana Medicare Advantage |
$85.12
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$143.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$114.80
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$85.12
|
| Rate for Payer: Multiplan All |
$204.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$144.70
|
| Rate for Payer: OMNI Networks Commercial |
$157.50
|
| Rate for Payer: One Health Plan PPO/POS |
$202.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$132.55
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$114.80
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$85.12
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$213.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$170.24
|
| Rate for Payer: Three Rivers Provider Network All |
$168.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$83.42
|
| Rate for Payer: United Healthcare Managed Medicaid |
$114.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$85.12
|
| Rate for Payer: United Payors & United Providers UP&UP |
$209.25
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$85.12
|
| Rate for Payer: Zelis Auto |
$90.00
|
| Rate for Payer: Zelis Medicare |
$72.35
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$102.14
|
| Rate for Payer: Zelis Worker's Compensation |
$61.42
|
|
|
CL- DURVALUMAB 10 MG
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
CPT J9173
|
| Hospital Charge Code |
3350314
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.42 |
| Max. Negotiated Rate |
$213.75 |
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$191.25
|
| Rate for Payer: First Health Commercial |
$202.50
|
| Rate for Payer: First Health Workers Compensation |
$86.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$202.50
|
| Rate for Payer: GEHA Commercial |
$157.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$202.50
|
| Rate for Payer: Multiplan All |
$204.75
|
| Rate for Payer: OMNI Networks Commercial |
$157.50
|
| Rate for Payer: One Health Plan PPO/POS |
$202.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$213.75
|
| Rate for Payer: Three Rivers Provider Network All |
$168.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$209.25
|
| Rate for Payer: Zelis Auto |
$90.00
|
| Rate for Payer: Zelis Worker's Compensation |
$61.42
|
|
