|
CL- PAMIDRONATE 30 MG
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
CPT J2430
|
| Hospital Charge Code |
3350346
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.38 |
| Max. Negotiated Rate |
$46.55 |
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$41.65
|
| Rate for Payer: First Health Commercial |
$44.10
|
| Rate for Payer: First Health Workers Compensation |
$18.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$44.10
|
| Rate for Payer: GEHA Commercial |
$34.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$44.10
|
| Rate for Payer: Multiplan All |
$44.59
|
| Rate for Payer: OMNI Networks Commercial |
$34.30
|
| Rate for Payer: One Health Plan PPO/POS |
$44.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$46.55
|
| Rate for Payer: Three Rivers Provider Network All |
$36.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$45.57
|
| Rate for Payer: Zelis Auto |
$19.60
|
| Rate for Payer: Zelis Worker's Compensation |
$13.38
|
|
|
CL- PEMBROLIZUMAB 1 MG
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
CPT J9271
|
| Hospital Charge Code |
3350321
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.95 |
| Max. Negotiated Rate |
$142.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$68.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$90.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$68.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$54.29
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$60.29
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$127.50
|
| Rate for Payer: First Health Commercial |
$135.00
|
| Rate for Payer: First Health Workers Compensation |
$57.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$135.00
|
| Rate for Payer: GEHA Commercial |
$66.32
|
| Rate for Payer: GEHA Medicare |
$60.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$135.00
|
| Rate for Payer: Humana ChoiceCare |
$66.32
|
| Rate for Payer: Humana Medicare Advantage |
$60.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$101.29
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$55.40
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$60.29
|
| Rate for Payer: Multiplan All |
$136.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$102.49
|
| Rate for Payer: OMNI Networks Commercial |
$105.00
|
| Rate for Payer: One Health Plan PPO/POS |
$135.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$63.97
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$55.40
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$60.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$142.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$120.58
|
| Rate for Payer: Three Rivers Provider Network All |
$112.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$59.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$55.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$139.50
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$60.29
|
| Rate for Payer: Zelis Auto |
$60.00
|
| Rate for Payer: Zelis Medicare |
$51.25
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$72.35
|
| Rate for Payer: Zelis Worker's Compensation |
$40.95
|
|
|
CL- PEMBROLIZUMAB 1 MG
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
CPT J9271
|
| Hospital Charge Code |
3350321
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.95 |
| Max. Negotiated Rate |
$142.50 |
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$127.50
|
| Rate for Payer: First Health Commercial |
$135.00
|
| Rate for Payer: First Health Workers Compensation |
$57.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$135.00
|
| Rate for Payer: GEHA Commercial |
$105.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$135.00
|
| Rate for Payer: Multiplan All |
$136.50
|
| Rate for Payer: OMNI Networks Commercial |
$105.00
|
| Rate for Payer: One Health Plan PPO/POS |
$135.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$142.50
|
| Rate for Payer: Three Rivers Provider Network All |
$112.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$139.50
|
| Rate for Payer: Zelis Auto |
$60.00
|
| Rate for Payer: Zelis Worker's Compensation |
$40.95
|
|
|
CL- PENICILLIN G 1,200,000 UNIT/2ML - IM
|
Facility
|
OP
|
$1,490.00
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
3350073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.32 |
| Max. Negotiated Rate |
$1,415.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$11.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$894.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$11.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$9.32
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$30.01
|
| Rate for Payer: Cash Price |
$894.00
|
| Rate for Payer: Cash Price |
$894.00
|
| Rate for Payer: Cigna Commercial |
$1,266.50
|
| Rate for Payer: First Health Commercial |
$1,341.00
|
| Rate for Payer: First Health Workers Compensation |
$575.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,341.00
|
| Rate for Payer: GEHA Commercial |
$33.01
|
| Rate for Payer: GEHA Medicare |
$30.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,341.00
|
| Rate for Payer: Humana ChoiceCare |
$33.01
|
| Rate for Payer: Humana Medicare Advantage |
$30.01
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$50.42
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$9.51
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$30.01
|
| Rate for Payer: Multiplan All |
$1,355.90
|
| Rate for Payer: New Mexico Health Connections Medicare |
$51.02
|
| Rate for Payer: OMNI Networks Commercial |
$1,043.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,341.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$10.98
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$9.51
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$30.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,415.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$60.02
|
| Rate for Payer: Three Rivers Provider Network All |
$1,117.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$29.41
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,385.70
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$30.01
|
| Rate for Payer: Zelis Auto |
$596.00
|
| Rate for Payer: Zelis Medicare |
$25.51
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$36.01
|
| Rate for Payer: Zelis Worker's Compensation |
$406.77
|
|
|
CL- PENICILLIN G 1,200,000 UNIT/2ML - IM
|
Facility
|
IP
|
$1,490.00
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
3350073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$406.77 |
| Max. Negotiated Rate |
$1,415.50 |
| Rate for Payer: Cash Price |
$894.00
|
| Rate for Payer: Cigna Commercial |
$1,266.50
|
| Rate for Payer: First Health Commercial |
$1,341.00
|
| Rate for Payer: First Health Workers Compensation |
$575.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,341.00
|
| Rate for Payer: GEHA Commercial |
$1,043.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,341.00
|
| Rate for Payer: Multiplan All |
$1,355.90
|
| Rate for Payer: OMNI Networks Commercial |
$1,043.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,341.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,415.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,117.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,385.70
|
| Rate for Payer: Zelis Auto |
$596.00
|
| Rate for Payer: Zelis Worker's Compensation |
$406.77
|
|
|
CL- PENICILLIN G 600,000 UNIT/1ML - IM
|
Facility
|
OP
|
$590.00
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
3350401
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.32 |
| Max. Negotiated Rate |
$560.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$11.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$354.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$11.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$9.32
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$30.01
|
| Rate for Payer: Cash Price |
$354.00
|
| Rate for Payer: Cash Price |
$354.00
|
| Rate for Payer: Cigna Commercial |
$501.50
|
| Rate for Payer: First Health Commercial |
$531.00
|
| Rate for Payer: First Health Workers Compensation |
$227.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$531.00
|
| Rate for Payer: GEHA Commercial |
$33.01
|
| Rate for Payer: GEHA Medicare |
$30.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$531.00
|
| Rate for Payer: Humana ChoiceCare |
$33.01
|
| Rate for Payer: Humana Medicare Advantage |
$30.01
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$50.42
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$9.51
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$30.01
|
| Rate for Payer: Multiplan All |
$536.90
|
| Rate for Payer: New Mexico Health Connections Medicare |
$51.02
|
| Rate for Payer: OMNI Networks Commercial |
$413.00
|
| Rate for Payer: One Health Plan PPO/POS |
$531.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$10.98
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$9.51
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$30.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$560.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$60.02
|
| Rate for Payer: Three Rivers Provider Network All |
$442.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$29.41
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$548.70
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$30.01
|
| Rate for Payer: Zelis Auto |
$236.00
|
| Rate for Payer: Zelis Medicare |
$25.51
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$36.01
|
| Rate for Payer: Zelis Worker's Compensation |
$161.07
|
|
|
CL- PENICILLIN G 600,000 UNIT/1ML - IM
|
Facility
|
IP
|
$590.00
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
3350401
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$161.07 |
| Max. Negotiated Rate |
$560.50 |
| Rate for Payer: Cash Price |
$354.00
|
| Rate for Payer: Cigna Commercial |
$501.50
|
| Rate for Payer: First Health Commercial |
$531.00
|
| Rate for Payer: First Health Workers Compensation |
$227.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$531.00
|
| Rate for Payer: GEHA Commercial |
$413.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$531.00
|
| Rate for Payer: Multiplan All |
$536.90
|
| Rate for Payer: OMNI Networks Commercial |
$413.00
|
| Rate for Payer: One Health Plan PPO/POS |
$531.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$560.50
|
| Rate for Payer: Three Rivers Provider Network All |
$442.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$548.70
|
| Rate for Payer: Zelis Auto |
$236.00
|
| Rate for Payer: Zelis Worker's Compensation |
$161.07
|
|
|
CL- PERTUZUMAB 1 MG
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
CPT J9306
|
| Hospital Charge Code |
3350347
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$15.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$15.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$12.14
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$17.02
|
| 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 |
$18.72
|
| Rate for Payer: GEHA Medicare |
$17.02
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Humana ChoiceCare |
$18.72
|
| Rate for Payer: Humana Medicare Advantage |
$17.02
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$28.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$12.39
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$17.02
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$28.93
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$14.31
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$12.39
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$17.02
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$34.04
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.02
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$17.02
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Medicare |
$14.47
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.42
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
CL- PERTUZUMAB 1 MG
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
CPT J9306
|
| Hospital Charge Code |
3350347
|
|
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- PHENOL SWABS 89%
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
NDC 00884629730
|
| Hospital Charge Code |
3350074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$25.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
CL- PHENOL SWABS 89%
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
NDC 00884629730
|
| Hospital Charge Code |
3350074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.25 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22.20
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$29.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Humana ChoiceCare |
$9.62
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.20
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$32.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$18.50
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
CL- Phenylephrine Nasal Spray 0.5%
|
Facility
|
IP
|
$41.00
|
|
|
Service Code
|
NDC 00225080547
|
| Hospital Charge Code |
3350398
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$28.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
CL- Phenylephrine Nasal Spray 0.5%
|
Facility
|
OP
|
$41.00
|
|
|
Service Code
|
NDC 00225080547
|
| Hospital Charge Code |
3350398
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$32.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Humana ChoiceCare |
$10.66
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.60
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$36.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.50
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
CL- Phenylephrine Nasal Spray 1%
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 70000013201
|
| Hospital Charge Code |
3350399
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$17.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$15.30
|
| Rate for Payer: First Health Commercial |
$16.20
|
| Rate for Payer: First Health Workers Compensation |
$6.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$16.20
|
| Rate for Payer: GEHA Commercial |
$14.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$16.20
|
| Rate for Payer: Humana ChoiceCare |
$4.68
|
| Rate for Payer: Multiplan All |
$16.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10.80
|
| Rate for Payer: OMNI Networks Commercial |
$12.60
|
| Rate for Payer: One Health Plan PPO/POS |
$16.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$17.10
|
| Rate for Payer: Three Rivers Provider Network All |
$13.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$15.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$16.74
|
| Rate for Payer: Zelis Auto |
$7.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$9.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.91
|
|
|
CL- Phenylephrine Nasal Spray 1%
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 70000013201
|
| Hospital Charge Code |
3350399
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$17.10 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$15.30
|
| Rate for Payer: First Health Commercial |
$16.20
|
| Rate for Payer: First Health Workers Compensation |
$6.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$16.20
|
| Rate for Payer: GEHA Commercial |
$12.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$16.20
|
| Rate for Payer: Multiplan All |
$16.38
|
| Rate for Payer: OMNI Networks Commercial |
$12.60
|
| Rate for Payer: One Health Plan PPO/POS |
$16.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$17.10
|
| Rate for Payer: Three Rivers Provider Network All |
$13.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$16.74
|
| Rate for Payer: Zelis Auto |
$7.20
|
| Rate for Payer: Zelis Worker's Compensation |
$4.91
|
|
|
CL- PNEUMOCOCCAL 15 CONJ-MEDICARE- AWV
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90671
|
| Hospital Charge Code |
3350505
|
|
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- PNEUMOCOCCAL 15 CONJ-MEDICARE- AWV
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90671
|
| Hospital Charge Code |
3350505
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$287.26 |
| 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 |
$287.26
|
| 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- PNEUMOCOCCAL 15 CONJ-MEDICARE- RHC
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90671
|
| Hospital Charge Code |
3350506
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$287.26 |
| 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 |
$287.26
|
| 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- PNEUMOCOCCAL 15 CONJ-MEDICARE- RHC
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90671
|
| Hospital Charge Code |
3350506
|
|
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- PNEUMOCOCCAL 15 CONJ-NON MEDICARE
|
Facility
|
IP
|
$1,075.00
|
|
|
Service Code
|
CPT 90671
|
| Hospital Charge Code |
3350507
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$293.48 |
| Max. Negotiated Rate |
$1,021.25 |
| Rate for Payer: Cash Price |
$645.00
|
| Rate for Payer: Cigna Commercial |
$913.75
|
| Rate for Payer: First Health Commercial |
$967.50
|
| Rate for Payer: First Health Workers Compensation |
$415.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$967.50
|
| Rate for Payer: GEHA Commercial |
$752.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$967.50
|
| Rate for Payer: Multiplan All |
$978.25
|
| Rate for Payer: OMNI Networks Commercial |
$752.50
|
| Rate for Payer: One Health Plan PPO/POS |
$967.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,021.25
|
| Rate for Payer: Three Rivers Provider Network All |
$806.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$999.75
|
| Rate for Payer: Zelis Auto |
$430.00
|
| Rate for Payer: Zelis Worker's Compensation |
$293.48
|
|
|
CL- PNEUMOCOCCAL 15 CONJ-NON MEDICARE
|
Facility
|
OP
|
$1,075.00
|
|
|
Service Code
|
CPT 90671
|
| Hospital Charge Code |
3350507
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$268.75 |
| Max. Negotiated Rate |
$1,021.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$645.00
|
| Rate for Payer: Cash Price |
$645.00
|
| Rate for Payer: Cash Price |
$645.00
|
| Rate for Payer: Cigna Commercial |
$913.75
|
| Rate for Payer: First Health Commercial |
$967.50
|
| Rate for Payer: First Health Workers Compensation |
$415.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$967.50
|
| Rate for Payer: GEHA Commercial |
$287.26
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$967.50
|
| Rate for Payer: Humana ChoiceCare |
$279.50
|
| Rate for Payer: Multiplan All |
$978.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$645.00
|
| Rate for Payer: OMNI Networks Commercial |
$752.50
|
| Rate for Payer: One Health Plan PPO/POS |
$967.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,021.25
|
| Rate for Payer: Three Rivers Provider Network All |
$806.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$946.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$268.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$999.75
|
| Rate for Payer: Zelis Auto |
$430.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$537.50
|
| Rate for Payer: Zelis Worker's Compensation |
$293.48
|
|
|
CL- PNEUMOCOCCAL15 CONJ-NON MEDICARE-RHC
|
Facility
|
IP
|
$1,075.00
|
|
|
Service Code
|
CPT 90671
|
| Hospital Charge Code |
3350508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$293.48 |
| Max. Negotiated Rate |
$1,021.25 |
| Rate for Payer: Cash Price |
$645.00
|
| Rate for Payer: Cigna Commercial |
$913.75
|
| Rate for Payer: First Health Commercial |
$967.50
|
| Rate for Payer: First Health Workers Compensation |
$415.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$967.50
|
| Rate for Payer: GEHA Commercial |
$752.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$967.50
|
| Rate for Payer: Multiplan All |
$978.25
|
| Rate for Payer: OMNI Networks Commercial |
$752.50
|
| Rate for Payer: One Health Plan PPO/POS |
$967.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,021.25
|
| Rate for Payer: Three Rivers Provider Network All |
$806.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$999.75
|
| Rate for Payer: Zelis Auto |
$430.00
|
| Rate for Payer: Zelis Worker's Compensation |
$293.48
|
|
|
CL- PNEUMOCOCCAL15 CONJ-NON MEDICARE-RHC
|
Facility
|
OP
|
$1,075.00
|
|
|
Service Code
|
CPT 90671
|
| Hospital Charge Code |
3350508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$268.75 |
| Max. Negotiated Rate |
$1,021.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$645.00
|
| Rate for Payer: Cash Price |
$645.00
|
| Rate for Payer: Cash Price |
$645.00
|
| Rate for Payer: Cigna Commercial |
$913.75
|
| Rate for Payer: First Health Commercial |
$967.50
|
| Rate for Payer: First Health Workers Compensation |
$415.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$967.50
|
| Rate for Payer: GEHA Commercial |
$287.26
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$967.50
|
| Rate for Payer: Humana ChoiceCare |
$279.50
|
| Rate for Payer: Multiplan All |
$978.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$645.00
|
| Rate for Payer: OMNI Networks Commercial |
$752.50
|
| Rate for Payer: One Health Plan PPO/POS |
$967.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,021.25
|
| Rate for Payer: Three Rivers Provider Network All |
$806.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$946.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$268.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$999.75
|
| Rate for Payer: Zelis Auto |
$430.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$537.50
|
| Rate for Payer: Zelis Worker's Compensation |
$293.48
|
|
|
CL- PNEUMOCOCCAL 15- VALENT CONJUGATE
|
Facility
|
OP
|
$1,075.00
|
|
|
Service Code
|
CPT 90671
|
| Hospital Charge Code |
3350504
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$268.75 |
| Max. Negotiated Rate |
$1,021.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$645.00
|
| Rate for Payer: Cash Price |
$645.00
|
| Rate for Payer: Cash Price |
$645.00
|
| Rate for Payer: Cigna Commercial |
$913.75
|
| Rate for Payer: First Health Commercial |
$967.50
|
| Rate for Payer: First Health Workers Compensation |
$415.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$967.50
|
| Rate for Payer: GEHA Commercial |
$287.26
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$967.50
|
| Rate for Payer: Humana ChoiceCare |
$279.50
|
| Rate for Payer: Multiplan All |
$978.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$645.00
|
| Rate for Payer: OMNI Networks Commercial |
$752.50
|
| Rate for Payer: One Health Plan PPO/POS |
$967.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,021.25
|
| Rate for Payer: Three Rivers Provider Network All |
$806.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$946.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$268.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$999.75
|
| Rate for Payer: Zelis Auto |
$430.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$537.50
|
| Rate for Payer: Zelis Worker's Compensation |
$293.48
|
|
|
CL- PNEUMOCOCCAL 15- VALENT CONJUGATE
|
Facility
|
IP
|
$1,075.00
|
|
|
Service Code
|
CPT 90671
|
| Hospital Charge Code |
3350504
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$293.48 |
| Max. Negotiated Rate |
$1,021.25 |
| Rate for Payer: Cash Price |
$645.00
|
| Rate for Payer: Cigna Commercial |
$913.75
|
| Rate for Payer: First Health Commercial |
$967.50
|
| Rate for Payer: First Health Workers Compensation |
$415.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$967.50
|
| Rate for Payer: GEHA Commercial |
$752.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$967.50
|
| Rate for Payer: Multiplan All |
$978.25
|
| Rate for Payer: OMNI Networks Commercial |
$752.50
|
| Rate for Payer: One Health Plan PPO/POS |
$967.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,021.25
|
| Rate for Payer: Three Rivers Provider Network All |
$806.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$999.75
|
| Rate for Payer: Zelis Auto |
$430.00
|
| Rate for Payer: Zelis Worker's Compensation |
$293.48
|
|
