|
CL- SODIUM BICARB INJ 4.2%- NEUT
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350541
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$22.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$20.40
|
| Rate for Payer: First Health Commercial |
$21.60
|
| Rate for Payer: First Health Workers Compensation |
$9.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$21.60
|
| Rate for Payer: GEHA Commercial |
$19.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$21.60
|
| Rate for Payer: Humana ChoiceCare |
$6.24
|
| Rate for Payer: Multiplan All |
$21.84
|
| Rate for Payer: New Mexico Health Connections Medicare |
$14.40
|
| Rate for Payer: OMNI Networks Commercial |
$16.80
|
| Rate for Payer: One Health Plan PPO/POS |
$21.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$22.80
|
| Rate for Payer: Three Rivers Provider Network All |
$18.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$21.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$22.32
|
| Rate for Payer: Zelis Auto |
$9.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6.55
|
|
|
CL- SODIUM BICARBONATE INJ 8.4% - ADULT
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
NDC 00409663734
|
| Hospital Charge Code |
3350085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$45.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$40.80
|
| Rate for Payer: First Health Commercial |
$43.20
|
| Rate for Payer: First Health Workers Compensation |
$18.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$43.20
|
| Rate for Payer: GEHA Commercial |
$38.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$43.20
|
| Rate for Payer: Humana ChoiceCare |
$12.48
|
| Rate for Payer: Multiplan All |
$43.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$28.80
|
| Rate for Payer: OMNI Networks Commercial |
$33.60
|
| Rate for Payer: One Health Plan PPO/POS |
$43.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$45.60
|
| Rate for Payer: Three Rivers Provider Network All |
$36.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$42.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$44.64
|
| Rate for Payer: Zelis Auto |
$19.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$24.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.10
|
|
|
CL- SODIUM BICARBONATE INJ 8.4% - ADULT
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
NDC 00409663734
|
| Hospital Charge Code |
3350085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.10 |
| Max. Negotiated Rate |
$45.60 |
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$40.80
|
| Rate for Payer: First Health Commercial |
$43.20
|
| Rate for Payer: First Health Workers Compensation |
$18.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$43.20
|
| Rate for Payer: GEHA Commercial |
$33.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$43.20
|
| Rate for Payer: Multiplan All |
$43.68
|
| Rate for Payer: OMNI Networks Commercial |
$33.60
|
| Rate for Payer: One Health Plan PPO/POS |
$43.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$45.60
|
| Rate for Payer: Three Rivers Provider Network All |
$36.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$44.64
|
| Rate for Payer: Zelis Auto |
$19.20
|
| Rate for Payer: Zelis Worker's Compensation |
$13.10
|
|
|
CL- SODIUM BICARBONATE INJ 8.4% - PEDI
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
NDC 71456000101
|
| Hospital Charge Code |
3350083
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.25 |
| Max. Negotiated Rate |
$84.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$75.65
|
| Rate for Payer: First Health Commercial |
$80.10
|
| Rate for Payer: First Health Workers Compensation |
$34.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$80.10
|
| Rate for Payer: GEHA Commercial |
$71.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$80.10
|
| Rate for Payer: Humana ChoiceCare |
$23.14
|
| Rate for Payer: Multiplan All |
$80.99
|
| Rate for Payer: New Mexico Health Connections Medicare |
$53.40
|
| Rate for Payer: OMNI Networks Commercial |
$62.30
|
| Rate for Payer: One Health Plan PPO/POS |
$80.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$84.55
|
| Rate for Payer: Three Rivers Provider Network All |
$66.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$78.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$22.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$82.77
|
| Rate for Payer: Zelis Auto |
$35.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$44.50
|
| Rate for Payer: Zelis Worker's Compensation |
$24.30
|
|
|
CL- SODIUM BICARBONATE INJ 8.4% - PEDI
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
NDC 71456000101
|
| Hospital Charge Code |
3350083
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.30 |
| Max. Negotiated Rate |
$84.55 |
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$75.65
|
| Rate for Payer: First Health Commercial |
$80.10
|
| Rate for Payer: First Health Workers Compensation |
$34.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$80.10
|
| Rate for Payer: GEHA Commercial |
$62.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$80.10
|
| Rate for Payer: Multiplan All |
$80.99
|
| Rate for Payer: OMNI Networks Commercial |
$62.30
|
| Rate for Payer: One Health Plan PPO/POS |
$80.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$84.55
|
| Rate for Payer: Three Rivers Provider Network All |
$66.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$82.77
|
| Rate for Payer: Zelis Auto |
$35.60
|
| Rate for Payer: Zelis Worker's Compensation |
$24.30
|
|
|
CL- SODIUM BICARBONATE INJ 8.4% - VIAL
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 00409662502
|
| Hospital Charge Code |
3350084
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$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 |
$12.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Humana ChoiceCare |
$4.16
|
| 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: 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 |
$4.00
|
| 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- SODIUM BICARBONATE INJ 8.4% - VIAL
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 00409662502
|
| Hospital Charge Code |
3350084
|
|
Hospital Revenue Code
|
250
|
| 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- Sodium Chloride 0.65% Nasal Spray
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 00904386575
|
| Hospital Charge Code |
3350400
|
|
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- Sodium Chloride 0.65% Nasal Spray
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 00904386575
|
| Hospital Charge Code |
3350400
|
|
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- Sodium Chloride 0.9% 1000 mL
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
CPT J7030
|
| Hospital Charge Code |
3350426
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$14.45
|
| Rate for Payer: First Health Commercial |
$15.30
|
| Rate for Payer: First Health Workers Compensation |
$6.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15.30
|
| Rate for Payer: GEHA Commercial |
$11.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15.30
|
| Rate for Payer: Multiplan All |
$15.47
|
| Rate for Payer: OMNI Networks Commercial |
$11.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16.15
|
| Rate for Payer: Three Rivers Provider Network All |
$12.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15.81
|
| Rate for Payer: Zelis Auto |
$6.80
|
| Rate for Payer: Zelis Worker's Compensation |
$4.64
|
|
|
CL- Sodium Chloride 0.9% 1000 mL
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
CPT J7030
|
| Hospital Charge Code |
3350426
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$14.45
|
| Rate for Payer: First Health Commercial |
$15.30
|
| Rate for Payer: First Health Workers Compensation |
$6.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15.30
|
| Rate for Payer: GEHA Commercial |
$2.15
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15.30
|
| Rate for Payer: Humana ChoiceCare |
$4.42
|
| Rate for Payer: Multiplan All |
$15.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10.20
|
| Rate for Payer: OMNI Networks Commercial |
$11.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16.15
|
| Rate for Payer: Three Rivers Provider Network All |
$12.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15.81
|
| Rate for Payer: Zelis Auto |
$6.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.50
|
| Rate for Payer: Zelis Worker's Compensation |
$4.64
|
|
|
CL- SODIUM CHLORIDE 0.9% INHALATION
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00487930103
|
| Hospital Charge Code |
3350122
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
CL- SODIUM CHLORIDE 0.9% INHALATION
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00487930103
|
| Hospital Charge Code |
3350122
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
CL- SODIUM CHLORIDE INJ 0.9% - 20ML VIAL
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 00409488820
|
| Hospital Charge Code |
3350111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$7.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
CL- SODIUM CHLORIDE INJ 0.9% - 20ML VIAL
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 00409488820
|
| Hospital Charge Code |
3350111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$8.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Humana ChoiceCare |
$2.86
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.60
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
CL- SOLU-MEDROL 40MG INJ; IV
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT J2919
|
| Hospital Charge Code |
3350225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$0.21
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$0.23
|
| Rate for Payer: GEHA Medicare |
$0.21
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Humana ChoiceCare |
$0.23
|
| Rate for Payer: Humana Medicare Advantage |
$0.21
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$0.35
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$0.21
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.36
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$0.21
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$0.42
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.21
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.21
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$0.21
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Medicare |
$0.18
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.25
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
CL- SOLU-MEDROL 40MG INJ; IV
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT J2919
|
| Hospital Charge Code |
3350225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.56 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$32.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
CL- SUMAtriptan SUCCINATE INJ 6MG/0.5ML
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
3350412
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.93 |
| Max. Negotiated Rate |
$69.35 |
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$62.05
|
| Rate for Payer: First Health Commercial |
$65.70
|
| Rate for Payer: First Health Workers Compensation |
$28.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$65.70
|
| Rate for Payer: GEHA Commercial |
$51.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$65.70
|
| Rate for Payer: Multiplan All |
$66.43
|
| Rate for Payer: OMNI Networks Commercial |
$51.10
|
| Rate for Payer: One Health Plan PPO/POS |
$65.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$69.35
|
| Rate for Payer: Three Rivers Provider Network All |
$54.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$67.89
|
| Rate for Payer: Zelis Auto |
$29.20
|
| Rate for Payer: Zelis Worker's Compensation |
$19.93
|
|
|
CL- SUMAtriptan SUCCINATE INJ 6MG/0.5ML
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
3350412
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.25 |
| Max. Negotiated Rate |
$69.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$43.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$62.05
|
| Rate for Payer: First Health Commercial |
$65.70
|
| Rate for Payer: First Health Workers Compensation |
$28.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$65.70
|
| Rate for Payer: GEHA Commercial |
$58.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$65.70
|
| Rate for Payer: Humana ChoiceCare |
$18.98
|
| Rate for Payer: Multiplan All |
$66.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$43.80
|
| Rate for Payer: OMNI Networks Commercial |
$51.10
|
| Rate for Payer: One Health Plan PPO/POS |
$65.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$69.35
|
| Rate for Payer: Three Rivers Provider Network All |
$54.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$64.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$18.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$67.89
|
| Rate for Payer: Zelis Auto |
$29.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$36.50
|
| Rate for Payer: Zelis Worker's Compensation |
$19.93
|
|
|
CL- SUPARTZ 25MG/2.5ML
|
Facility
|
OP
|
$508.00
|
|
|
Service Code
|
CPT J7321
|
| Hospital Charge Code |
3350087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.67 |
| Max. Negotiated Rate |
$482.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$133.81
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$304.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$133.81
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$106.01
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cigna Commercial |
$431.80
|
| Rate for Payer: First Health Commercial |
$457.20
|
| Rate for Payer: First Health Workers Compensation |
$196.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$457.20
|
| Rate for Payer: GEHA Commercial |
$78.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$457.20
|
| Rate for Payer: Humana ChoiceCare |
$132.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$108.17
|
| Rate for Payer: Multiplan All |
$462.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$304.80
|
| Rate for Payer: OMNI Networks Commercial |
$355.60
|
| Rate for Payer: One Health Plan PPO/POS |
$457.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$124.89
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$108.17
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$482.60
|
| Rate for Payer: Three Rivers Provider Network All |
$381.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$447.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$108.17
|
| Rate for Payer: United Payors & United Providers UP&UP |
$472.44
|
| Rate for Payer: Zelis Auto |
$203.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$254.00
|
| Rate for Payer: Zelis Worker's Compensation |
$138.68
|
|
|
CL- SUPARTZ 25MG/2.5ML
|
Facility
|
IP
|
$508.00
|
|
|
Service Code
|
CPT J7321
|
| Hospital Charge Code |
3350087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$138.68 |
| Max. Negotiated Rate |
$482.60 |
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cigna Commercial |
$431.80
|
| Rate for Payer: First Health Commercial |
$457.20
|
| Rate for Payer: First Health Workers Compensation |
$196.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$457.20
|
| Rate for Payer: GEHA Commercial |
$355.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$457.20
|
| Rate for Payer: Multiplan All |
$462.28
|
| Rate for Payer: OMNI Networks Commercial |
$355.60
|
| Rate for Payer: One Health Plan PPO/POS |
$457.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$482.60
|
| Rate for Payer: Three Rivers Provider Network All |
$381.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$472.44
|
| Rate for Payer: Zelis Auto |
$203.20
|
| Rate for Payer: Zelis Worker's Compensation |
$138.68
|
|
|
CL- SUPARTZ 25MG/2.5ML - PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J7321
|
| Hospital Charge Code |
3350232
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$133.81 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$133.81
|
| 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 |
$133.81
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$106.01
|
| 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 |
$78.67
|
| 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 |
$108.17
|
| 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 |
$124.89
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$108.17
|
| 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 |
$108.17
|
| 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- SUPARTZ 25MG/2.5ML - PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J7321
|
| Hospital Charge Code |
3350232
|
|
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- SYNAGIS 50 MG/ 0.5 ML
|
Facility
|
OP
|
$5,096.00
|
|
|
Service Code
|
CPT 90378
|
| Hospital Charge Code |
3350240
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$611.89 |
| Max. Negotiated Rate |
$4,841.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,754.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,057.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,754.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,390.30
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$719.87
|
| Rate for Payer: Cash Price |
$3,057.60
|
| Rate for Payer: Cash Price |
$3,057.60
|
| Rate for Payer: Cigna Commercial |
$4,331.60
|
| Rate for Payer: First Health Commercial |
$4,586.40
|
| Rate for Payer: First Health Workers Compensation |
$1,967.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,586.40
|
| Rate for Payer: GEHA Commercial |
$4,076.80
|
| Rate for Payer: GEHA Medicare |
$719.87
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,586.40
|
| Rate for Payer: Humana ChoiceCare |
$791.86
|
| Rate for Payer: Humana Medicare Advantage |
$719.87
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,209.38
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,418.61
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$719.87
|
| Rate for Payer: Multiplan All |
$4,637.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,223.78
|
| Rate for Payer: OMNI Networks Commercial |
$3,567.20
|
| Rate for Payer: One Health Plan PPO/POS |
$4,586.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,637.99
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,418.61
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$719.87
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,841.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,439.74
|
| Rate for Payer: Three Rivers Provider Network All |
$3,822.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$705.47
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,418.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$719.87
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,739.28
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$719.87
|
| Rate for Payer: Zelis Auto |
$2,038.40
|
| Rate for Payer: Zelis Medicare |
$611.89
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$863.84
|
| Rate for Payer: Zelis Worker's Compensation |
$1,391.21
|
|
|
CL- SYNAGIS 50 MG/ 0.5 ML
|
Facility
|
IP
|
$5,096.00
|
|
|
Service Code
|
CPT 90378
|
| Hospital Charge Code |
3350240
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,391.21 |
| Max. Negotiated Rate |
$4,841.20 |
| Rate for Payer: Cash Price |
$3,057.60
|
| Rate for Payer: Cigna Commercial |
$4,331.60
|
| Rate for Payer: First Health Commercial |
$4,586.40
|
| Rate for Payer: First Health Workers Compensation |
$1,967.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,586.40
|
| Rate for Payer: GEHA Commercial |
$3,567.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,586.40
|
| Rate for Payer: Multiplan All |
$4,637.36
|
| Rate for Payer: OMNI Networks Commercial |
$3,567.20
|
| Rate for Payer: One Health Plan PPO/POS |
$4,586.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,841.20
|
| Rate for Payer: Three Rivers Provider Network All |
$3,822.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,739.28
|
| Rate for Payer: Zelis Auto |
$2,038.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1,391.21
|
|
