|
CL- PREVNAR 13 - HOSPITAL
|
Facility
|
IP
|
$234.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
3350119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.88 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna Commercial |
$198.90
|
| Rate for Payer: First Health Commercial |
$210.60
|
| Rate for Payer: First Health Workers Compensation |
$90.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$210.60
|
| Rate for Payer: GEHA Commercial |
$163.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$210.60
|
| Rate for Payer: Multiplan All |
$212.94
|
| Rate for Payer: OMNI Networks Commercial |
$163.80
|
| Rate for Payer: One Health Plan PPO/POS |
$210.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$222.30
|
| Rate for Payer: Three Rivers Provider Network All |
$175.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$217.62
|
| Rate for Payer: Zelis Auto |
$93.60
|
| Rate for Payer: Zelis Worker's Compensation |
$63.88
|
|
|
CL- Prevnar 13 - Medicare
|
Facility
|
OP
|
$234.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
3350389
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.84 |
| Max. Negotiated Rate |
$288.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$288.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$140.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$288.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$228.91
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna Commercial |
$198.90
|
| Rate for Payer: First Health Commercial |
$210.60
|
| Rate for Payer: First Health Workers Compensation |
$90.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$210.60
|
| Rate for Payer: GEHA Commercial |
$283.79
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$210.60
|
| Rate for Payer: Humana ChoiceCare |
$60.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$233.58
|
| Rate for Payer: Multiplan All |
$212.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$140.40
|
| Rate for Payer: OMNI Networks Commercial |
$163.80
|
| Rate for Payer: One Health Plan PPO/POS |
$210.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$269.70
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$233.58
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$222.30
|
| Rate for Payer: Three Rivers Provider Network All |
$175.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$205.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$233.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$217.62
|
| Rate for Payer: Zelis Auto |
$93.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$117.00
|
| Rate for Payer: Zelis Worker's Compensation |
$63.88
|
|
|
CL- Prevnar 13 - Medicare
|
Facility
|
IP
|
$234.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
3350389
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.88 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna Commercial |
$198.90
|
| Rate for Payer: First Health Commercial |
$210.60
|
| Rate for Payer: First Health Workers Compensation |
$90.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$210.60
|
| Rate for Payer: GEHA Commercial |
$163.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$210.60
|
| Rate for Payer: Multiplan All |
$212.94
|
| Rate for Payer: OMNI Networks Commercial |
$163.80
|
| Rate for Payer: One Health Plan PPO/POS |
$210.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$222.30
|
| Rate for Payer: Three Rivers Provider Network All |
$175.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$217.62
|
| Rate for Payer: Zelis Auto |
$93.60
|
| Rate for Payer: Zelis Worker's Compensation |
$63.88
|
|
|
CL- Prevnar 13 - Non Medicare
|
Facility
|
OP
|
$234.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
3350388
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.84 |
| Max. Negotiated Rate |
$288.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$288.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$140.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$288.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$228.91
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna Commercial |
$198.90
|
| Rate for Payer: First Health Commercial |
$210.60
|
| Rate for Payer: First Health Workers Compensation |
$90.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$210.60
|
| Rate for Payer: GEHA Commercial |
$283.79
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$210.60
|
| Rate for Payer: Humana ChoiceCare |
$60.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$233.58
|
| Rate for Payer: Multiplan All |
$212.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$140.40
|
| Rate for Payer: OMNI Networks Commercial |
$163.80
|
| Rate for Payer: One Health Plan PPO/POS |
$210.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$269.70
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$233.58
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$222.30
|
| Rate for Payer: Three Rivers Provider Network All |
$175.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$205.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$233.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$217.62
|
| Rate for Payer: Zelis Auto |
$93.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$117.00
|
| Rate for Payer: Zelis Worker's Compensation |
$63.88
|
|
|
CL- Prevnar 13 - Non Medicare
|
Facility
|
IP
|
$234.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
3350388
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.88 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna Commercial |
$198.90
|
| Rate for Payer: First Health Commercial |
$210.60
|
| Rate for Payer: First Health Workers Compensation |
$90.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$210.60
|
| Rate for Payer: GEHA Commercial |
$163.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$210.60
|
| Rate for Payer: Multiplan All |
$212.94
|
| Rate for Payer: OMNI Networks Commercial |
$163.80
|
| Rate for Payer: One Health Plan PPO/POS |
$210.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$222.30
|
| Rate for Payer: Three Rivers Provider Network All |
$175.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$217.62
|
| Rate for Payer: Zelis Auto |
$93.60
|
| Rate for Payer: Zelis Worker's Compensation |
$63.88
|
|
|
CL- Prevnar 13 - Non Medicare - RHC
|
Facility
|
IP
|
$234.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
3350374
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.88 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna Commercial |
$198.90
|
| Rate for Payer: First Health Commercial |
$210.60
|
| Rate for Payer: First Health Workers Compensation |
$90.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$210.60
|
| Rate for Payer: GEHA Commercial |
$163.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$210.60
|
| Rate for Payer: Multiplan All |
$212.94
|
| Rate for Payer: OMNI Networks Commercial |
$163.80
|
| Rate for Payer: One Health Plan PPO/POS |
$210.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$222.30
|
| Rate for Payer: Three Rivers Provider Network All |
$175.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$217.62
|
| Rate for Payer: Zelis Auto |
$93.60
|
| Rate for Payer: Zelis Worker's Compensation |
$63.88
|
|
|
CL- Prevnar 13 - Non Medicare - RHC
|
Facility
|
OP
|
$234.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
3350374
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.84 |
| Max. Negotiated Rate |
$288.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$288.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$140.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$288.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$228.91
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna Commercial |
$198.90
|
| Rate for Payer: First Health Commercial |
$210.60
|
| Rate for Payer: First Health Workers Compensation |
$90.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$210.60
|
| Rate for Payer: GEHA Commercial |
$283.79
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$210.60
|
| Rate for Payer: Humana ChoiceCare |
$60.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$233.58
|
| Rate for Payer: Multiplan All |
$212.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$140.40
|
| Rate for Payer: OMNI Networks Commercial |
$163.80
|
| Rate for Payer: One Health Plan PPO/POS |
$210.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$269.70
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$233.58
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$222.30
|
| Rate for Payer: Three Rivers Provider Network All |
$175.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$205.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$233.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$217.62
|
| Rate for Payer: Zelis Auto |
$93.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$117.00
|
| Rate for Payer: Zelis Worker's Compensation |
$63.88
|
|
|
CL- PROLIA SUBQ 60MG/1ML
|
Facility
|
IP
|
$5,100.00
|
|
|
Service Code
|
CPT J0897
|
| Hospital Charge Code |
3350428
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,392.30 |
| Max. Negotiated Rate |
$4,845.00 |
| Rate for Payer: Cash Price |
$3,060.00
|
| Rate for Payer: Cigna Commercial |
$4,335.00
|
| Rate for Payer: First Health Commercial |
$4,590.00
|
| Rate for Payer: First Health Workers Compensation |
$1,969.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,590.00
|
| Rate for Payer: GEHA Commercial |
$3,570.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,590.00
|
| Rate for Payer: Multiplan All |
$4,641.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,570.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,590.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,845.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,825.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,743.00
|
| Rate for Payer: Zelis Auto |
$2,040.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,392.30
|
|
|
CL- PROLIA SUBQ 60MG/1ML
|
Facility
|
OP
|
$5,100.00
|
|
|
Service Code
|
CPT J0897
|
| Hospital Charge Code |
3350428
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.48 |
| Max. Negotiated Rate |
$4,845.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$22.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,060.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$22.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$17.48
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$29.38
|
| Rate for Payer: Cash Price |
$3,060.00
|
| Rate for Payer: Cash Price |
$3,060.00
|
| Rate for Payer: Cigna Commercial |
$4,335.00
|
| Rate for Payer: First Health Commercial |
$4,590.00
|
| Rate for Payer: First Health Workers Compensation |
$1,969.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,590.00
|
| Rate for Payer: GEHA Commercial |
$32.32
|
| Rate for Payer: GEHA Medicare |
$29.38
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,590.00
|
| Rate for Payer: Humana ChoiceCare |
$32.32
|
| Rate for Payer: Humana Medicare Advantage |
$29.38
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$49.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$17.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$29.38
|
| Rate for Payer: Multiplan All |
$4,641.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$49.95
|
| Rate for Payer: OMNI Networks Commercial |
$3,570.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,590.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$20.59
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$17.84
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$29.38
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,845.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$58.76
|
| Rate for Payer: Three Rivers Provider Network All |
$3,825.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$28.79
|
| Rate for Payer: United Healthcare Managed Medicaid |
$17.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.38
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,743.00
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$29.38
|
| Rate for Payer: Zelis Auto |
$2,040.00
|
| Rate for Payer: Zelis Medicare |
$24.97
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$35.26
|
| Rate for Payer: Zelis Worker's Compensation |
$1,392.30
|
|
|
CL- PROLIA SUBQ 60MG/1ML - PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J0897
|
| Hospital Charge Code |
3350230
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$58.76 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$22.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$22.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$17.48
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$29.38
|
| Rate for Payer: Cash Price |
$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 |
$32.32
|
| Rate for Payer: GEHA Medicare |
$29.38
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$32.32
|
| Rate for Payer: Humana Medicare Advantage |
$29.38
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$49.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$17.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$29.38
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$49.95
|
| 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 |
$20.59
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$17.84
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$29.38
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$58.76
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$28.79
|
| Rate for Payer: United Healthcare Managed Medicaid |
$17.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.38
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$29.38
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Medicare |
$24.97
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$35.26
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- PROLIA SUBQ 60MG/1ML - PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J0897
|
| Hospital Charge Code |
3350230
|
|
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- Promethazine HCL 6.25mg/5ml
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60432060816
|
| Hospital Charge Code |
3350396
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
CL- Promethazine HCL 6.25mg/5ml
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60432060816
|
| Hospital Charge Code |
3350396
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
CL- PROMETHAZINE HCL INJ 25MG/ML
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
CPT J2550
|
| Hospital Charge Code |
3350078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$14.25 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$12.75
|
| Rate for Payer: First Health Commercial |
$13.50
|
| Rate for Payer: First Health Workers Compensation |
$5.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$13.50
|
| Rate for Payer: GEHA Commercial |
$10.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$13.50
|
| Rate for Payer: Multiplan All |
$13.65
|
| Rate for Payer: OMNI Networks Commercial |
$10.50
|
| Rate for Payer: One Health Plan PPO/POS |
$13.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$14.25
|
| Rate for Payer: Three Rivers Provider Network All |
$11.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.95
|
| Rate for Payer: Zelis Auto |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.09
|
|
|
CL- PROMETHAZINE HCL INJ 25MG/ML
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
CPT J2550
|
| Hospital Charge Code |
3350078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$14.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$12.75
|
| Rate for Payer: First Health Commercial |
$13.50
|
| Rate for Payer: First Health Workers Compensation |
$5.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$13.50
|
| Rate for Payer: GEHA Commercial |
$3.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$13.50
|
| Rate for Payer: Humana ChoiceCare |
$3.90
|
| Rate for Payer: Multiplan All |
$13.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.00
|
| Rate for Payer: OMNI Networks Commercial |
$10.50
|
| Rate for Payer: One Health Plan PPO/POS |
$13.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$14.25
|
| Rate for Payer: Three Rivers Provider Network All |
$11.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.95
|
| Rate for Payer: Zelis Auto |
$6.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.50
|
| Rate for Payer: Zelis Worker's Compensation |
$4.09
|
|
|
CL- Proparacaine 0.5% Opth.
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 61314001601
|
| Hospital Charge Code |
3350397
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$4.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Humana ChoiceCare |
$1.30
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.00
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
CL- Proparacaine 0.5% Opth.
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 61314001601
|
| Hospital Charge Code |
3350397
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
CL- Provenge (50 million cells)
|
Facility
|
IP
|
$134,244.00
|
|
|
Service Code
|
CPT Q2043
|
| Hospital Charge Code |
3350430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36,648.61 |
| Max. Negotiated Rate |
$127,531.80 |
| Rate for Payer: Cash Price |
$80,546.40
|
| Rate for Payer: Cigna Commercial |
$114,107.40
|
| Rate for Payer: First Health Commercial |
$120,819.60
|
| Rate for Payer: First Health Workers Compensation |
$51,831.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$120,819.60
|
| Rate for Payer: GEHA Commercial |
$93,970.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$120,819.60
|
| Rate for Payer: Multiplan All |
$122,162.04
|
| Rate for Payer: OMNI Networks Commercial |
$93,970.80
|
| Rate for Payer: One Health Plan PPO/POS |
$120,819.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$127,531.80
|
| Rate for Payer: Three Rivers Provider Network All |
$100,683.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$124,846.92
|
| Rate for Payer: Zelis Auto |
$53,697.60
|
| Rate for Payer: Zelis Worker's Compensation |
$36,648.61
|
|
|
CL- Provenge (50 million cells)
|
Facility
|
OP
|
$134,244.00
|
|
|
Service Code
|
CPT Q2043
|
| Hospital Charge Code |
3350430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36,648.61 |
| Max. Negotiated Rate |
$127,531.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$53,820.12
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$80,546.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$53,820.12
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$42,636.30
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$55,272.32
|
| Rate for Payer: Cash Price |
$80,546.40
|
| Rate for Payer: Cash Price |
$80,546.40
|
| Rate for Payer: Cigna Commercial |
$114,107.40
|
| Rate for Payer: First Health Commercial |
$120,819.60
|
| Rate for Payer: First Health Workers Compensation |
$51,831.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$120,819.60
|
| Rate for Payer: GEHA Commercial |
$60,799.55
|
| Rate for Payer: GEHA Medicare |
$55,272.32
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$120,819.60
|
| Rate for Payer: Humana ChoiceCare |
$60,799.55
|
| Rate for Payer: Humana Medicare Advantage |
$55,272.32
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$92,857.50
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$43,504.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$55,272.32
|
| Rate for Payer: Multiplan All |
$122,162.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$93,962.94
|
| Rate for Payer: OMNI Networks Commercial |
$93,970.80
|
| Rate for Payer: One Health Plan PPO/POS |
$120,819.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$50,232.11
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$43,504.60
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$55,272.32
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$127,531.80
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$110,544.64
|
| Rate for Payer: Three Rivers Provider Network All |
$100,683.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$54,166.87
|
| Rate for Payer: United Healthcare Managed Medicaid |
$43,504.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$55,272.32
|
| Rate for Payer: United Payors & United Providers UP&UP |
$124,846.92
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$55,272.32
|
| Rate for Payer: Zelis Auto |
$53,697.60
|
| Rate for Payer: Zelis Medicare |
$46,981.47
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$66,326.78
|
| Rate for Payer: Zelis Worker's Compensation |
$36,648.61
|
|
|
CL- RACEPINEPHRINE 2.25% NEB
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350493
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
CL- RACEPINEPHRINE 2.25% NEB
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350493
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$6.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Humana ChoiceCare |
$2.08
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.80
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
CL- RANITIDINE 25 MG/ML
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
CPT J2780
|
| Hospital Charge Code |
3350353
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.75 |
| Max. Negotiated Rate |
$14.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$12.75
|
| Rate for Payer: First Health Commercial |
$13.50
|
| Rate for Payer: First Health Workers Compensation |
$5.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$13.50
|
| Rate for Payer: GEHA Commercial |
$12.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$13.50
|
| Rate for Payer: Humana ChoiceCare |
$3.90
|
| Rate for Payer: Multiplan All |
$13.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.00
|
| Rate for Payer: OMNI Networks Commercial |
$10.50
|
| Rate for Payer: One Health Plan PPO/POS |
$13.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$14.25
|
| Rate for Payer: Three Rivers Provider Network All |
$11.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.95
|
| Rate for Payer: Zelis Auto |
$6.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.50
|
| Rate for Payer: Zelis Worker's Compensation |
$4.09
|
|
|
CL- RANITIDINE 25 MG/ML
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
CPT J2780
|
| Hospital Charge Code |
3350353
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$14.25 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$12.75
|
| Rate for Payer: First Health Commercial |
$13.50
|
| Rate for Payer: First Health Workers Compensation |
$5.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$13.50
|
| Rate for Payer: GEHA Commercial |
$10.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$13.50
|
| Rate for Payer: Multiplan All |
$13.65
|
| Rate for Payer: OMNI Networks Commercial |
$10.50
|
| Rate for Payer: One Health Plan PPO/POS |
$13.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$14.25
|
| Rate for Payer: Three Rivers Provider Network All |
$11.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.95
|
| Rate for Payer: Zelis Auto |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.09
|
|
|
CL- REPATHA 140MG/1ML (PT OWN)
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350229
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.00
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.01
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.01
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- REPATHA 140MG/1ML (PT OWN)
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350229
|
|
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
|
|
