|
CL- Flu Vaccine Quad- Non Medicare
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT 90656
|
| Hospital Charge Code |
3350391
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.92 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$43.35
|
| Rate for Payer: First Health Commercial |
$45.90
|
| Rate for Payer: First Health Workers Compensation |
$19.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.90
|
| Rate for Payer: GEHA Commercial |
$35.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.90
|
| Rate for Payer: Multiplan All |
$46.41
|
| Rate for Payer: OMNI Networks Commercial |
$35.70
|
| Rate for Payer: One Health Plan PPO/POS |
$45.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$48.45
|
| Rate for Payer: Three Rivers Provider Network All |
$38.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$47.43
|
| Rate for Payer: Zelis Auto |
$20.40
|
| Rate for Payer: Zelis Worker's Compensation |
$13.92
|
|
|
CL- Flu Vaccine Quad- Non Medicare - RHC
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT 90656
|
| Hospital Charge Code |
3350379
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.92 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$43.35
|
| Rate for Payer: First Health Commercial |
$45.90
|
| Rate for Payer: First Health Workers Compensation |
$19.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.90
|
| Rate for Payer: GEHA Commercial |
$35.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.90
|
| Rate for Payer: Multiplan All |
$46.41
|
| Rate for Payer: OMNI Networks Commercial |
$35.70
|
| Rate for Payer: One Health Plan PPO/POS |
$45.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$48.45
|
| Rate for Payer: Three Rivers Provider Network All |
$38.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$47.43
|
| Rate for Payer: Zelis Auto |
$20.40
|
| Rate for Payer: Zelis Worker's Compensation |
$13.92
|
|
|
CL- Flu Vaccine Quad- Non Medicare - RHC
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
CPT 90656
|
| Hospital Charge Code |
3350379
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.26 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$36.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$36.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$28.80
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$43.35
|
| Rate for Payer: First Health Commercial |
$45.90
|
| Rate for Payer: First Health Workers Compensation |
$19.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.90
|
| Rate for Payer: GEHA Commercial |
$25.54
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.90
|
| Rate for Payer: Humana ChoiceCare |
$13.26
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$29.39
|
| Rate for Payer: Multiplan All |
$46.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.60
|
| Rate for Payer: OMNI Networks Commercial |
$35.70
|
| Rate for Payer: One Health Plan PPO/POS |
$45.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$33.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$29.39
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$48.45
|
| Rate for Payer: Three Rivers Provider Network All |
$38.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$44.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$29.39
|
| Rate for Payer: United Payors & United Providers UP&UP |
$47.43
|
| Rate for Payer: Zelis Auto |
$20.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$25.50
|
| Rate for Payer: Zelis Worker's Compensation |
$13.92
|
|
|
CL- FOSAPREPITANT DIMEGLUMINE 1 MG
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
CPT J1453
|
| Hospital Charge Code |
3350296
|
|
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- FOSAPREPITANT DIMEGLUMINE 1 MG
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
CPT J1453
|
| Hospital Charge Code |
3350296
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2.06
|
| 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 |
$0.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Humana ChoiceCare |
$1.56
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2.10
|
| 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: Presbyterian Health Plan Exchange |
$2.42
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2.10
|
| 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 |
$2.10
|
| 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- FULVESTRANT 25 MG
|
Facility
|
OP
|
$297.00
|
|
|
Service Code
|
CPT J9395
|
| Hospital Charge Code |
3350302
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$282.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$138.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$178.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$138.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$109.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6.73
|
| Rate for Payer: Cash Price |
$178.20
|
| Rate for Payer: Cash Price |
$178.20
|
| Rate for Payer: Cigna Commercial |
$252.45
|
| Rate for Payer: First Health Commercial |
$267.30
|
| Rate for Payer: First Health Workers Compensation |
$114.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$267.30
|
| Rate for Payer: GEHA Commercial |
$7.40
|
| Rate for Payer: GEHA Medicare |
$6.73
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$267.30
|
| Rate for Payer: Humana ChoiceCare |
$7.40
|
| Rate for Payer: Humana Medicare Advantage |
$6.73
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$11.31
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$111.97
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6.73
|
| Rate for Payer: Multiplan All |
$270.27
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.44
|
| Rate for Payer: OMNI Networks Commercial |
$207.90
|
| Rate for Payer: One Health Plan PPO/POS |
$267.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$129.29
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$111.97
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6.73
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$282.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$13.46
|
| Rate for Payer: Three Rivers Provider Network All |
$222.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$111.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.73
|
| Rate for Payer: United Payors & United Providers UP&UP |
$276.21
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6.73
|
| Rate for Payer: Zelis Auto |
$118.80
|
| Rate for Payer: Zelis Medicare |
$5.72
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.08
|
| Rate for Payer: Zelis Worker's Compensation |
$81.08
|
|
|
CL- FULVESTRANT 25 MG
|
Facility
|
IP
|
$297.00
|
|
|
Service Code
|
CPT J9395
|
| Hospital Charge Code |
3350302
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.08 |
| Max. Negotiated Rate |
$282.15 |
| Rate for Payer: Cash Price |
$178.20
|
| Rate for Payer: Cigna Commercial |
$252.45
|
| Rate for Payer: First Health Commercial |
$267.30
|
| Rate for Payer: First Health Workers Compensation |
$114.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$267.30
|
| Rate for Payer: GEHA Commercial |
$207.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$267.30
|
| Rate for Payer: Multiplan All |
$270.27
|
| Rate for Payer: OMNI Networks Commercial |
$207.90
|
| Rate for Payer: One Health Plan PPO/POS |
$267.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$282.15
|
| Rate for Payer: Three Rivers Provider Network All |
$222.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$276.21
|
| Rate for Payer: Zelis Auto |
$118.80
|
| Rate for Payer: Zelis Worker's Compensation |
$81.08
|
|
|
CL- FUROSEMIDE 20MG/2ML INJ
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
CPT J1940
|
| Hospital Charge Code |
3302748
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$7.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
CL- FUROSEMIDE 20MG/2ML INJ
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
CPT J1940
|
| Hospital Charge Code |
3302748
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$8.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Humana ChoiceCare |
$2.86
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.60
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
CL- GARDASIL 9 **HOSPITAL
|
Facility
|
OP
|
$1,020.00
|
|
|
Service Code
|
CPT 90651
|
| Hospital Charge Code |
3350248
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$257.71 |
| Max. Negotiated Rate |
$969.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$325.31
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$612.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$325.31
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$257.71
|
| Rate for Payer: Cash Price |
$612.00
|
| Rate for Payer: Cash Price |
$612.00
|
| Rate for Payer: Cigna Commercial |
$867.00
|
| Rate for Payer: First Health Commercial |
$918.00
|
| Rate for Payer: First Health Workers Compensation |
$393.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$918.00
|
| Rate for Payer: GEHA Commercial |
$816.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$918.00
|
| Rate for Payer: Humana ChoiceCare |
$265.20
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$262.95
|
| Rate for Payer: Multiplan All |
$928.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$612.00
|
| Rate for Payer: OMNI Networks Commercial |
$714.00
|
| Rate for Payer: One Health Plan PPO/POS |
$918.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$303.62
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$262.95
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$969.00
|
| Rate for Payer: Three Rivers Provider Network All |
$765.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$897.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$262.95
|
| Rate for Payer: United Payors & United Providers UP&UP |
$948.60
|
| Rate for Payer: Zelis Auto |
$408.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$510.00
|
| Rate for Payer: Zelis Worker's Compensation |
$278.46
|
|
|
CL- GARDASIL 9 **HOSPITAL
|
Facility
|
IP
|
$1,020.00
|
|
|
Service Code
|
CPT 90651
|
| Hospital Charge Code |
3350248
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$278.46 |
| Max. Negotiated Rate |
$969.00 |
| Rate for Payer: Cash Price |
$612.00
|
| Rate for Payer: Cigna Commercial |
$867.00
|
| Rate for Payer: First Health Commercial |
$918.00
|
| Rate for Payer: First Health Workers Compensation |
$393.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$918.00
|
| Rate for Payer: GEHA Commercial |
$714.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$918.00
|
| Rate for Payer: Multiplan All |
$928.20
|
| Rate for Payer: OMNI Networks Commercial |
$714.00
|
| Rate for Payer: One Health Plan PPO/POS |
$918.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$969.00
|
| Rate for Payer: Three Rivers Provider Network All |
$765.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$948.60
|
| Rate for Payer: Zelis Auto |
$408.00
|
| Rate for Payer: Zelis Worker's Compensation |
$278.46
|
|
|
CL- GARDASIL 9 **PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90651
|
| Hospital Charge Code |
3350274
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$325.31 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$325.31
|
| 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 |
$325.31
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$257.71
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$262.95
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$303.62
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$262.95
|
| 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 |
$262.95
|
| 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- GARDASIL 9 **PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90651
|
| Hospital Charge Code |
3350274
|
|
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- GARDISIL - PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
3350165
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$238.98 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$238.98
|
| 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 |
$238.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$189.32
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$193.18
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$223.05
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$193.18
|
| 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 |
$193.18
|
| 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- GARDISIL - PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
3350165
|
|
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- GARDISIL - VFC
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
3350166
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$238.98 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$238.98
|
| 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 |
$238.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$189.32
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$193.18
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$223.05
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$193.18
|
| 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 |
$193.18
|
| 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- GARDISIL - VFC
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
3350166
|
|
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- GEL-ONE **PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J7326
|
| Hospital Charge Code |
3350246
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$1,058.52 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$842.14
|
| 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 |
$842.14
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$667.15
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$529.26
|
| 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 |
$582.19
|
| Rate for Payer: GEHA Medicare |
$529.26
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$582.19
|
| Rate for Payer: Humana Medicare Advantage |
$529.26
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$889.16
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$680.73
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$529.26
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$899.74
|
| 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 |
$786.00
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$680.73
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$529.26
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,058.52
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$518.67
|
| Rate for Payer: United Healthcare Managed Medicaid |
$680.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$529.26
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$529.26
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Medicare |
$449.87
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$635.11
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- GEL-ONE **PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J7326
|
| Hospital Charge Code |
3350246
|
|
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- GELSYN 16.8MG
|
Facility
|
IP
|
$1,435.00
|
|
|
Service Code
|
CPT J7328
|
| Hospital Charge Code |
3350214
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$391.75 |
| Max. Negotiated Rate |
$1,363.25 |
| Rate for Payer: Cash Price |
$861.00
|
| Rate for Payer: Cigna Commercial |
$1,219.75
|
| Rate for Payer: First Health Commercial |
$1,291.50
|
| Rate for Payer: First Health Workers Compensation |
$554.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,291.50
|
| Rate for Payer: GEHA Commercial |
$1,004.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,291.50
|
| Rate for Payer: Multiplan All |
$1,305.85
|
| Rate for Payer: OMNI Networks Commercial |
$1,004.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,291.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,363.25
|
| Rate for Payer: Three Rivers Provider Network All |
$1,076.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,334.55
|
| Rate for Payer: Zelis Auto |
$574.00
|
| Rate for Payer: Zelis Worker's Compensation |
$391.75
|
|
|
CL- GELSYN 16.8MG
|
Facility
|
OP
|
$1,435.00
|
|
|
Service Code
|
CPT J7328
|
| Hospital Charge Code |
3350214
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$1,363.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$861.00
|
| Rate for Payer: Cash Price |
$861.00
|
| Rate for Payer: Cash Price |
$861.00
|
| Rate for Payer: Cigna Commercial |
$1,219.75
|
| Rate for Payer: First Health Commercial |
$1,291.50
|
| Rate for Payer: First Health Workers Compensation |
$554.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,291.50
|
| Rate for Payer: GEHA Commercial |
$0.77
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,291.50
|
| Rate for Payer: Humana ChoiceCare |
$373.10
|
| Rate for Payer: Multiplan All |
$1,305.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$861.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,004.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,291.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,363.25
|
| Rate for Payer: Three Rivers Provider Network All |
$1,076.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,262.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$358.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,334.55
|
| Rate for Payer: Zelis Auto |
$574.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$717.50
|
| Rate for Payer: Zelis Worker's Compensation |
$391.75
|
|
|
CL- GELSYN 16.8MG - PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J7328
|
| Hospital Charge Code |
3350237
|
|
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- GELSYN 16.8MG - PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J7328
|
| Hospital Charge Code |
3350237
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.77
|
| 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- GEMCITABINE 1 GM/26.3 ML INJ
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
3350487
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$8.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$100.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$8.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$6.51
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$64.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$3.44
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Humana ChoiceCare |
$43.68
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$6.64
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$100.80
|
| Rate for Payer: OMNI Networks Commercial |
$117.60
|
| Rate for Payer: One Health Plan PPO/POS |
$151.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$7.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$6.64
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$147.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.64
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$84.00
|
| Rate for Payer: Zelis Worker's Compensation |
$45.86
|
|
|
CL- GEMCITABINE 1 GM/26.3 ML INJ
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
3350487
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.86 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$64.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$117.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: OMNI Networks Commercial |
$117.60
|
| Rate for Payer: One Health Plan PPO/POS |
$151.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Worker's Compensation |
$45.86
|
|
