|
CL- GEMCITABINE 1 GM/26.3 ML INJ PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
3350534
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$8.22 |
| 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 |
$0.01
|
| 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 |
$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 |
$3.44
|
| 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 |
$6.64
|
| 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 |
$7.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$6.64
|
| 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 |
$6.64
|
| 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 PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
3350534
|
|
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- GEMCITABINE 200 MG/10 ML
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
3350307
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$11.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
CL- GEMCITABINE 200 MG/10 ML
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
3350307
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$15.20 |
| 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 |
$9.60
|
| 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 |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$3.44
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Humana ChoiceCare |
$4.16
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$6.64
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.60
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| 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 |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.64
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
CL- GEMCITABINE HCL 1 GRAM INJ
|
Facility
|
IP
|
$260.00
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
3350533
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.98 |
| Max. Negotiated Rate |
$247.00 |
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cigna Commercial |
$221.00
|
| Rate for Payer: First Health Commercial |
$234.00
|
| Rate for Payer: First Health Workers Compensation |
$100.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$234.00
|
| Rate for Payer: GEHA Commercial |
$182.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$234.00
|
| Rate for Payer: Multiplan All |
$236.60
|
| Rate for Payer: OMNI Networks Commercial |
$182.00
|
| Rate for Payer: One Health Plan PPO/POS |
$234.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$247.00
|
| Rate for Payer: Three Rivers Provider Network All |
$195.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$241.80
|
| Rate for Payer: Zelis Auto |
$104.00
|
| Rate for Payer: Zelis Worker's Compensation |
$70.98
|
|
|
CL- GEMCITABINE HCL 1 GRAM INJ
|
Facility
|
OP
|
$260.00
|
|
|
Service Code
|
CPT J9201
|
| Hospital Charge Code |
3350533
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$247.00 |
| 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 |
$156.00
|
| 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 |
$156.00
|
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cigna Commercial |
$221.00
|
| Rate for Payer: First Health Commercial |
$234.00
|
| Rate for Payer: First Health Workers Compensation |
$100.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$234.00
|
| Rate for Payer: GEHA Commercial |
$3.44
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$234.00
|
| Rate for Payer: Humana ChoiceCare |
$67.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$6.64
|
| Rate for Payer: Multiplan All |
$236.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$156.00
|
| Rate for Payer: OMNI Networks Commercial |
$182.00
|
| Rate for Payer: One Health Plan PPO/POS |
$234.00
|
| 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 |
$247.00
|
| Rate for Payer: Three Rivers Provider Network All |
$195.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$228.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.64
|
| Rate for Payer: United Payors & United Providers UP&UP |
$241.80
|
| Rate for Payer: Zelis Auto |
$104.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$130.00
|
| Rate for Payer: Zelis Worker's Compensation |
$70.98
|
|
|
CL- GENTAMICIN 240 MG/6 ML IM INJ
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
CPT J1580
|
| Hospital Charge Code |
3350495
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.57 |
| Max. Negotiated Rate |
$85.50 |
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna Commercial |
$76.50
|
| Rate for Payer: First Health Commercial |
$81.00
|
| Rate for Payer: First Health Workers Compensation |
$34.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.00
|
| Rate for Payer: GEHA Commercial |
$63.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.00
|
| Rate for Payer: Multiplan All |
$81.90
|
| Rate for Payer: OMNI Networks Commercial |
$63.00
|
| Rate for Payer: One Health Plan PPO/POS |
$81.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$85.50
|
| Rate for Payer: Three Rivers Provider Network All |
$67.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$83.70
|
| Rate for Payer: Zelis Auto |
$36.00
|
| Rate for Payer: Zelis Worker's Compensation |
$24.57
|
|
|
CL- GENTAMICIN 240 MG/6 ML IM INJ
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
CPT J1580
|
| Hospital Charge Code |
3350495
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$85.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna Commercial |
$76.50
|
| Rate for Payer: First Health Commercial |
$81.00
|
| Rate for Payer: First Health Workers Compensation |
$34.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.00
|
| Rate for Payer: GEHA Commercial |
$2.43
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.00
|
| Rate for Payer: Humana ChoiceCare |
$23.40
|
| Rate for Payer: Multiplan All |
$81.90
|
| Rate for Payer: New Mexico Health Connections Medicare |
$54.00
|
| Rate for Payer: OMNI Networks Commercial |
$63.00
|
| Rate for Payer: One Health Plan PPO/POS |
$81.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$85.50
|
| Rate for Payer: Three Rivers Provider Network All |
$67.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$79.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$22.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$83.70
|
| Rate for Payer: Zelis Auto |
$36.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$45.00
|
| Rate for Payer: Zelis Worker's Compensation |
$24.57
|
|
|
CL- GENTAMICIN 800 MG/20 ML VIAL
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
CPT J1580
|
| Hospital Charge Code |
3350496
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.13 |
| Max. Negotiated Rate |
$150.10 |
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cigna Commercial |
$134.30
|
| Rate for Payer: First Health Commercial |
$142.20
|
| Rate for Payer: First Health Workers Compensation |
$61.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$142.20
|
| Rate for Payer: GEHA Commercial |
$110.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$142.20
|
| Rate for Payer: Multiplan All |
$143.78
|
| Rate for Payer: OMNI Networks Commercial |
$110.60
|
| Rate for Payer: One Health Plan PPO/POS |
$142.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$150.10
|
| Rate for Payer: Three Rivers Provider Network All |
$118.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$146.94
|
| Rate for Payer: Zelis Auto |
$63.20
|
| Rate for Payer: Zelis Worker's Compensation |
$43.13
|
|
|
CL- GENTAMICIN 800 MG/20 ML VIAL
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
CPT J1580
|
| Hospital Charge Code |
3350496
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$150.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$94.80
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cigna Commercial |
$134.30
|
| Rate for Payer: First Health Commercial |
$142.20
|
| Rate for Payer: First Health Workers Compensation |
$61.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$142.20
|
| Rate for Payer: GEHA Commercial |
$2.43
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$142.20
|
| Rate for Payer: Humana ChoiceCare |
$41.08
|
| Rate for Payer: Multiplan All |
$143.78
|
| Rate for Payer: New Mexico Health Connections Medicare |
$94.80
|
| Rate for Payer: OMNI Networks Commercial |
$110.60
|
| Rate for Payer: One Health Plan PPO/POS |
$142.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$150.10
|
| Rate for Payer: Three Rivers Provider Network All |
$118.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$139.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$39.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$146.94
|
| Rate for Payer: Zelis Auto |
$63.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$79.00
|
| Rate for Payer: Zelis Worker's Compensation |
$43.13
|
|
|
CL- GENTAMICIN SULF. 20MG/2ML
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
CPT J1580
|
| Hospital Charge Code |
3350102
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$25.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
CL- GENTAMICIN SULF. 20MG/2ML
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
CPT J1580
|
| Hospital Charge Code |
3350102
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22.20
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$2.43
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Humana ChoiceCare |
$9.62
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.20
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$32.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$18.50
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
CL- GENTAMICIN SULFATE INJ 80MG/2ML
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
CPT J1580
|
| Hospital Charge Code |
3350103
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$21.25
|
| Rate for Payer: First Health Commercial |
$22.50
|
| Rate for Payer: First Health Workers Compensation |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22.50
|
| Rate for Payer: GEHA Commercial |
$2.43
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22.50
|
| Rate for Payer: Humana ChoiceCare |
$6.50
|
| Rate for Payer: Multiplan All |
$22.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$15.00
|
| Rate for Payer: OMNI Networks Commercial |
$17.50
|
| Rate for Payer: One Health Plan PPO/POS |
$22.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$23.75
|
| Rate for Payer: Three Rivers Provider Network All |
$18.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$22.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23.25
|
| Rate for Payer: Zelis Auto |
$10.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12.50
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
|
CL- GENTAMICIN SULFATE INJ 80MG/2ML
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
CPT J1580
|
| Hospital Charge Code |
3350103
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.83 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$21.25
|
| Rate for Payer: First Health Commercial |
$22.50
|
| Rate for Payer: First Health Workers Compensation |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22.50
|
| Rate for Payer: GEHA Commercial |
$17.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22.50
|
| Rate for Payer: Multiplan All |
$22.75
|
| Rate for Payer: OMNI Networks Commercial |
$17.50
|
| Rate for Payer: One Health Plan PPO/POS |
$22.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$23.75
|
| Rate for Payer: Three Rivers Provider Network All |
$18.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23.25
|
| Rate for Payer: Zelis Auto |
$10.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
|
CL- GENTIAN VIOLET 1%
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 00395100392
|
| Hospital Charge Code |
3350116
|
|
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- GENTIAN VIOLET 1%
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 00395100392
|
| Hospital Charge Code |
3350116
|
|
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- GI COCKTAIL
|
Facility
|
IP
|
$502.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$137.05 |
| Max. Negotiated Rate |
$476.90 |
| Rate for Payer: Cash Price |
$301.20
|
| Rate for Payer: Cigna Commercial |
$426.70
|
| Rate for Payer: First Health Commercial |
$451.80
|
| Rate for Payer: First Health Workers Compensation |
$193.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$451.80
|
| Rate for Payer: GEHA Commercial |
$351.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$451.80
|
| Rate for Payer: Multiplan All |
$456.82
|
| Rate for Payer: OMNI Networks Commercial |
$351.40
|
| Rate for Payer: One Health Plan PPO/POS |
$451.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$476.90
|
| Rate for Payer: Three Rivers Provider Network All |
$376.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$466.86
|
| Rate for Payer: Zelis Auto |
$200.80
|
| Rate for Payer: Zelis Worker's Compensation |
$137.05
|
|
|
CL- GI COCKTAIL
|
Facility
|
OP
|
$502.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$125.50 |
| Max. Negotiated Rate |
$476.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$301.20
|
| Rate for Payer: Cash Price |
$301.20
|
| Rate for Payer: Cigna Commercial |
$426.70
|
| Rate for Payer: First Health Commercial |
$451.80
|
| Rate for Payer: First Health Workers Compensation |
$193.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$451.80
|
| Rate for Payer: GEHA Commercial |
$401.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$451.80
|
| Rate for Payer: Humana ChoiceCare |
$130.52
|
| Rate for Payer: Multiplan All |
$456.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$301.20
|
| Rate for Payer: OMNI Networks Commercial |
$351.40
|
| Rate for Payer: One Health Plan PPO/POS |
$451.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$476.90
|
| Rate for Payer: Three Rivers Provider Network All |
$376.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$441.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$125.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$466.86
|
| Rate for Payer: Zelis Auto |
$200.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$251.00
|
| Rate for Payer: Zelis Worker's Compensation |
$137.05
|
|
|
CL- GOLIMUMAB 1 MG
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
CPT J1602
|
| Hospital Charge Code |
3350359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.56 |
| Max. Negotiated Rate |
$64.60 |
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cigna Commercial |
$57.80
|
| Rate for Payer: First Health Commercial |
$61.20
|
| Rate for Payer: First Health Workers Compensation |
$26.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$61.20
|
| Rate for Payer: GEHA Commercial |
$47.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$61.20
|
| Rate for Payer: Multiplan All |
$61.88
|
| Rate for Payer: OMNI Networks Commercial |
$47.60
|
| Rate for Payer: One Health Plan PPO/POS |
$61.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$64.60
|
| Rate for Payer: Three Rivers Provider Network All |
$51.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$63.24
|
| Rate for Payer: Zelis Auto |
$27.20
|
| Rate for Payer: Zelis Worker's Compensation |
$18.56
|
|
|
CL- GOLIMUMAB 1 MG
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
CPT J1602
|
| Hospital Charge Code |
3350359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.38 |
| Max. Negotiated Rate |
$64.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$36.30
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$40.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$36.30
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$28.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$11.04
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cigna Commercial |
$57.80
|
| Rate for Payer: First Health Commercial |
$61.20
|
| Rate for Payer: First Health Workers Compensation |
$26.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$61.20
|
| Rate for Payer: GEHA Commercial |
$12.14
|
| Rate for Payer: GEHA Medicare |
$11.04
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$61.20
|
| Rate for Payer: Humana ChoiceCare |
$12.14
|
| Rate for Payer: Humana Medicare Advantage |
$11.04
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$18.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$29.34
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$11.04
|
| Rate for Payer: Multiplan All |
$61.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$18.77
|
| Rate for Payer: OMNI Networks Commercial |
$47.60
|
| Rate for Payer: One Health Plan PPO/POS |
$61.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$33.88
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$29.34
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$11.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$64.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$22.08
|
| Rate for Payer: Three Rivers Provider Network All |
$51.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.82
|
| Rate for Payer: United Healthcare Managed Medicaid |
$29.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$63.24
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$11.04
|
| Rate for Payer: Zelis Auto |
$27.20
|
| Rate for Payer: Zelis Medicare |
$9.38
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$13.25
|
| Rate for Payer: Zelis Worker's Compensation |
$18.56
|
|
|
CL- GRANISETRON HCL 100 MCG
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
CPT J1626
|
| Hospital Charge Code |
3350310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$0.85
|
| Rate for Payer: First Health Commercial |
$0.90
|
| Rate for Payer: First Health Workers Compensation |
$0.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.90
|
| Rate for Payer: GEHA Commercial |
$0.21
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.90
|
| Rate for Payer: Humana ChoiceCare |
$0.26
|
| Rate for Payer: Multiplan All |
$0.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.60
|
| Rate for Payer: OMNI Networks Commercial |
$0.70
|
| Rate for Payer: One Health Plan PPO/POS |
$0.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.95
|
| Rate for Payer: Three Rivers Provider Network All |
$0.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.93
|
| Rate for Payer: Zelis Auto |
$0.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.27
|
|
|
CL- GRANISETRON HCL 100 MCG
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
CPT J1626
|
| Hospital Charge Code |
3350310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$0.85
|
| Rate for Payer: First Health Commercial |
$0.90
|
| Rate for Payer: First Health Workers Compensation |
$0.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.90
|
| Rate for Payer: GEHA Commercial |
$0.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.90
|
| Rate for Payer: Multiplan All |
$0.91
|
| Rate for Payer: OMNI Networks Commercial |
$0.70
|
| Rate for Payer: One Health Plan PPO/POS |
$0.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.95
|
| Rate for Payer: Three Rivers Provider Network All |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.93
|
| Rate for Payer: Zelis Auto |
$0.40
|
| Rate for Payer: Zelis Worker's Compensation |
$0.27
|
|
|
CL- HALDOL 50MG/ML INJECTION- PT OWN MED
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J1631
|
| Hospital Charge Code |
3350221
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$4.84 |
| 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 |
$4.84
|
| 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- HALDOL 50MG/ML INJECTION- PT OWN MED
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J1631
|
| Hospital Charge Code |
3350221
|
|
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- HALDOL 5MG/ML INJECTION - PT OWN MED
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J1630
|
| Hospital Charge Code |
3350218
|
|
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
|
|
