|
CYTOMEL 25MCG TAB - NF
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 60793011601
|
| Hospital Charge Code |
3301945
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.19 |
| Max. Negotiated Rate |
$18.05 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: First Health Commercial |
$17.10
|
| Rate for Payer: First Health Workers Compensation |
$7.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$17.10
|
| Rate for Payer: GEHA Commercial |
$13.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17.10
|
| Rate for Payer: Multiplan All |
$17.29
|
| Rate for Payer: OMNI Networks Commercial |
$13.30
|
| Rate for Payer: One Health Plan PPO/POS |
$17.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18.05
|
| Rate for Payer: Three Rivers Provider Network All |
$14.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17.67
|
| Rate for Payer: Zelis Auto |
$7.60
|
| Rate for Payer: Zelis Worker's Compensation |
$5.19
|
|
|
CYTOMEL 25MCG TAB - NF
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 60793011601
|
| Hospital Charge Code |
3301945
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.75 |
| Max. Negotiated Rate |
$18.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$11.40
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: First Health Commercial |
$17.10
|
| Rate for Payer: First Health Workers Compensation |
$7.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$17.10
|
| Rate for Payer: GEHA Commercial |
$15.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17.10
|
| Rate for Payer: Humana ChoiceCare |
$4.94
|
| Rate for Payer: Multiplan All |
$17.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.40
|
| Rate for Payer: OMNI Networks Commercial |
$13.30
|
| Rate for Payer: One Health Plan PPO/POS |
$17.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18.05
|
| Rate for Payer: Three Rivers Provider Network All |
$14.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17.67
|
| Rate for Payer: Zelis Auto |
$7.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$9.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.19
|
|
|
CYTOPATHOLOGY SELECTIVE CELL ENHANCEMENT
|
Facility
|
OP
|
$234.00
|
|
|
Service Code
|
CPT 88112
|
| Hospital Charge Code |
2200967
|
|
Hospital Revenue Code
|
311
|
| Min. Negotiated Rate |
$43.12 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$65.64
|
| 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 |
$65.64
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$52.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$50.73
|
| 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 |
$110.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$210.60
|
| Rate for Payer: GEHA Commercial |
$187.20
|
| Rate for Payer: GEHA Medicare |
$50.73
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$210.60
|
| Rate for Payer: Humana ChoiceCare |
$55.80
|
| Rate for Payer: Humana Medicare Advantage |
$50.73
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$85.23
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$53.06
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$50.73
|
| Rate for Payer: Multiplan All |
$212.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$86.24
|
| 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 |
$61.26
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$53.06
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$50.73
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$222.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$101.46
|
| Rate for Payer: Three Rivers Provider Network All |
$175.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$49.72
|
| Rate for Payer: United Healthcare Commercial |
$198.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$53.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.73
|
| Rate for Payer: United Payors & United Providers UP&UP |
$217.62
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$50.73
|
| Rate for Payer: Zelis Auto |
$93.60
|
| Rate for Payer: Zelis Medicare |
$43.12
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$60.88
|
| Rate for Payer: Zelis Worker's Compensation |
$77.80
|
|
|
CYTOPATHOLOGY SELECTIVE CELL ENHANCEMENT
|
Facility
|
IP
|
$234.00
|
|
|
Service Code
|
CPT 88112
|
| Hospital Charge Code |
2200967
|
|
Hospital Revenue Code
|
311
|
| Min. Negotiated Rate |
$77.80 |
| Max. Negotiated Rate |
$222.30 |
| 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 |
$110.03
|
| 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 |
$77.80
|
|
|
CYTOPATHOLOGY SMEAR
|
Facility
|
OP
|
$213.00
|
|
|
Service Code
|
CPT 88108
|
| Hospital Charge Code |
2299066
|
|
Hospital Revenue Code
|
311
|
| Min. Negotiated Rate |
$31.68 |
| Max. Negotiated Rate |
$202.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$63.02
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$127.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$63.02
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$49.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$37.27
|
| Rate for Payer: Cash Price |
$127.80
|
| Rate for Payer: Cash Price |
$127.80
|
| Rate for Payer: Cigna Commercial |
$181.05
|
| Rate for Payer: First Health Commercial |
$191.70
|
| Rate for Payer: First Health Workers Compensation |
$81.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$191.70
|
| Rate for Payer: GEHA Commercial |
$170.40
|
| Rate for Payer: GEHA Medicare |
$37.27
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$191.70
|
| Rate for Payer: Humana ChoiceCare |
$41.00
|
| Rate for Payer: Humana Medicare Advantage |
$37.27
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$62.61
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$50.94
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$37.27
|
| Rate for Payer: Multiplan All |
$193.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$63.36
|
| Rate for Payer: OMNI Networks Commercial |
$149.10
|
| Rate for Payer: One Health Plan PPO/POS |
$191.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$58.81
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$50.94
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$37.27
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$202.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$74.54
|
| Rate for Payer: Three Rivers Provider Network All |
$159.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$36.52
|
| Rate for Payer: United Healthcare Commercial |
$181.05
|
| Rate for Payer: United Healthcare Managed Medicaid |
$50.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37.27
|
| Rate for Payer: United Payors & United Providers UP&UP |
$198.09
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$37.27
|
| Rate for Payer: Zelis Auto |
$85.20
|
| Rate for Payer: Zelis Medicare |
$31.68
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$44.72
|
| Rate for Payer: Zelis Worker's Compensation |
$57.60
|
|
|
CYTOPATHOLOGY SMEAR
|
Facility
|
IP
|
$213.00
|
|
|
Service Code
|
CPT 88108
|
| Hospital Charge Code |
2299066
|
|
Hospital Revenue Code
|
311
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$202.35 |
| Rate for Payer: Cash Price |
$127.80
|
| Rate for Payer: Cash Price |
$127.80
|
| Rate for Payer: Cigna Commercial |
$181.05
|
| Rate for Payer: First Health Commercial |
$191.70
|
| Rate for Payer: First Health Workers Compensation |
$81.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$191.70
|
| Rate for Payer: GEHA Commercial |
$149.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$191.70
|
| Rate for Payer: Multiplan All |
$193.83
|
| Rate for Payer: OMNI Networks Commercial |
$149.10
|
| Rate for Payer: One Health Plan PPO/POS |
$191.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$202.35
|
| Rate for Payer: Three Rivers Provider Network All |
$159.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$198.09
|
| Rate for Payer: Zelis Auto |
$85.20
|
| Rate for Payer: Zelis Worker's Compensation |
$57.60
|
|
|
D5LR - 1000ML
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 00409793309
|
| Hospital Charge Code |
3300229
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
D5LR - 1000ML
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 00409793309
|
| Hospital Charge Code |
3300229
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Humana ChoiceCare |
$5.46
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.60
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
D5 & NACL 0.45% W/ KCL 10MEQ/L PREMIXED
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 00338066904
|
| Hospital Charge Code |
3300472
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$25.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$22.95
|
| Rate for Payer: First Health Commercial |
$24.30
|
| Rate for Payer: First Health Workers Compensation |
$10.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$24.30
|
| Rate for Payer: GEHA Commercial |
$21.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$24.30
|
| Rate for Payer: Humana ChoiceCare |
$7.02
|
| Rate for Payer: Multiplan All |
$24.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$16.20
|
| Rate for Payer: OMNI Networks Commercial |
$18.90
|
| Rate for Payer: One Health Plan PPO/POS |
$24.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$25.65
|
| Rate for Payer: Three Rivers Provider Network All |
$20.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$23.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$25.11
|
| Rate for Payer: Zelis Auto |
$10.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$13.50
|
| Rate for Payer: Zelis Worker's Compensation |
$7.37
|
|
|
D5 & NACL 0.45% W/ KCL 10MEQ/L PREMIXED
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
NDC 00338066904
|
| Hospital Charge Code |
90009903
|
|
Hospital Revenue Code
|
258
|
| 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
|
|
|
D5 & NACL 0.45% W/ KCL 10MEQ/L PREMIXED
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
NDC 00338066904
|
| Hospital Charge Code |
90009903
|
|
Hospital Revenue Code
|
258
|
| 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
|
|
|
D5 & NACL 0.45% W/ KCL 10MEQ/L PREMIXED
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 00338066904
|
| Hospital Charge Code |
3300472
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$7.37 |
| Max. Negotiated Rate |
$25.65 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$22.95
|
| Rate for Payer: First Health Commercial |
$24.30
|
| Rate for Payer: First Health Workers Compensation |
$10.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$24.30
|
| Rate for Payer: GEHA Commercial |
$18.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$24.30
|
| Rate for Payer: Multiplan All |
$24.57
|
| Rate for Payer: OMNI Networks Commercial |
$18.90
|
| Rate for Payer: One Health Plan PPO/POS |
$24.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$25.65
|
| Rate for Payer: Three Rivers Provider Network All |
$20.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$25.11
|
| Rate for Payer: Zelis Auto |
$10.80
|
| Rate for Payer: Zelis Worker's Compensation |
$7.37
|
|
|
D5 & NACL 0.45% W/ KCL 20MEQ/L PREMIXED
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 00338067104
|
| Hospital Charge Code |
3300473
|
|
Hospital Revenue Code
|
258
|
| 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
|
|
|
D5 & NACL 0.45% W/ KCL 20MEQ/L PREMIXED
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 00338067104
|
| Hospital Charge Code |
3300473
|
|
Hospital Revenue Code
|
258
|
| 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
|
|
|
D5 & NACL 0.45% W/ KCL 30MEQ/L PREMIXED
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
NDC 00338067304
|
| Hospital Charge Code |
3300476
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$20.40
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cigna Commercial |
$28.90
|
| Rate for Payer: First Health Commercial |
$30.60
|
| Rate for Payer: First Health Workers Compensation |
$13.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$30.60
|
| Rate for Payer: GEHA Commercial |
$27.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$30.60
|
| Rate for Payer: Humana ChoiceCare |
$8.84
|
| Rate for Payer: Multiplan All |
$30.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$20.40
|
| Rate for Payer: OMNI Networks Commercial |
$23.80
|
| Rate for Payer: One Health Plan PPO/POS |
$30.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$32.30
|
| Rate for Payer: Three Rivers Provider Network All |
$25.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$29.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$31.62
|
| Rate for Payer: Zelis Auto |
$13.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.28
|
|
|
D5 & NACL 0.45% W/ KCL 30MEQ/L PREMIXED
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
NDC 00338067304
|
| Hospital Charge Code |
3300476
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$9.28 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cigna Commercial |
$28.90
|
| Rate for Payer: First Health Commercial |
$30.60
|
| Rate for Payer: First Health Workers Compensation |
$13.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$30.60
|
| Rate for Payer: GEHA Commercial |
$23.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$30.60
|
| Rate for Payer: Multiplan All |
$30.94
|
| Rate for Payer: OMNI Networks Commercial |
$23.80
|
| Rate for Payer: One Health Plan PPO/POS |
$30.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$32.30
|
| Rate for Payer: Three Rivers Provider Network All |
$25.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$31.62
|
| Rate for Payer: Zelis Auto |
$13.60
|
| Rate for Payer: Zelis Worker's Compensation |
$9.28
|
|
|
D5 & NACL 0.45% W/ KCL 40MEQ/L PREMIXED
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
NDC 00338067504
|
| Hospital Charge Code |
3300477
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$9.28 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cigna Commercial |
$28.90
|
| Rate for Payer: First Health Commercial |
$30.60
|
| Rate for Payer: First Health Workers Compensation |
$13.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$30.60
|
| Rate for Payer: GEHA Commercial |
$23.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$30.60
|
| Rate for Payer: Multiplan All |
$30.94
|
| Rate for Payer: OMNI Networks Commercial |
$23.80
|
| Rate for Payer: One Health Plan PPO/POS |
$30.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$32.30
|
| Rate for Payer: Three Rivers Provider Network All |
$25.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$31.62
|
| Rate for Payer: Zelis Auto |
$13.60
|
| Rate for Payer: Zelis Worker's Compensation |
$9.28
|
|
|
D5 & NACL 0.45% W/ KCL 40MEQ/L PREMIXED
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
NDC 00338067504
|
| Hospital Charge Code |
3300477
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$20.40
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cigna Commercial |
$28.90
|
| Rate for Payer: First Health Commercial |
$30.60
|
| Rate for Payer: First Health Workers Compensation |
$13.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$30.60
|
| Rate for Payer: GEHA Commercial |
$27.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$30.60
|
| Rate for Payer: Humana ChoiceCare |
$8.84
|
| Rate for Payer: Multiplan All |
$30.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$20.40
|
| Rate for Payer: OMNI Networks Commercial |
$23.80
|
| Rate for Payer: One Health Plan PPO/POS |
$30.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$32.30
|
| Rate for Payer: Three Rivers Provider Network All |
$25.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$29.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$31.62
|
| Rate for Payer: Zelis Auto |
$13.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.28
|
|
|
D5 & NACL 0.9% W/ KCL 20MEQ/L PREMIXED
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
NDC 00338080304
|
| Hospital Charge Code |
3300474
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$20.40
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cigna Commercial |
$28.90
|
| Rate for Payer: First Health Commercial |
$30.60
|
| Rate for Payer: First Health Workers Compensation |
$13.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$30.60
|
| Rate for Payer: GEHA Commercial |
$27.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$30.60
|
| Rate for Payer: Humana ChoiceCare |
$8.84
|
| Rate for Payer: Multiplan All |
$30.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$20.40
|
| Rate for Payer: OMNI Networks Commercial |
$23.80
|
| Rate for Payer: One Health Plan PPO/POS |
$30.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$32.30
|
| Rate for Payer: Three Rivers Provider Network All |
$25.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$29.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$31.62
|
| Rate for Payer: Zelis Auto |
$13.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.28
|
|
|
D5 & NACL 0.9% W/ KCL 20MEQ/L PREMIXED
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
NDC 00338080304
|
| Hospital Charge Code |
3300474
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$9.28 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cigna Commercial |
$28.90
|
| Rate for Payer: First Health Commercial |
$30.60
|
| Rate for Payer: First Health Workers Compensation |
$13.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$30.60
|
| Rate for Payer: GEHA Commercial |
$23.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$30.60
|
| Rate for Payer: Multiplan All |
$30.94
|
| Rate for Payer: OMNI Networks Commercial |
$23.80
|
| Rate for Payer: One Health Plan PPO/POS |
$30.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$32.30
|
| Rate for Payer: Three Rivers Provider Network All |
$25.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$31.62
|
| Rate for Payer: Zelis Auto |
$13.60
|
| Rate for Payer: Zelis Worker's Compensation |
$9.28
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
NDC 00597035556
|
| Hospital Charge Code |
3302902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$59.85 |
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$53.55
|
| Rate for Payer: First Health Commercial |
$56.70
|
| Rate for Payer: First Health Workers Compensation |
$24.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$56.70
|
| Rate for Payer: GEHA Commercial |
$44.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$56.70
|
| Rate for Payer: Multiplan All |
$57.33
|
| Rate for Payer: OMNI Networks Commercial |
$44.10
|
| Rate for Payer: One Health Plan PPO/POS |
$56.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$59.85
|
| Rate for Payer: Three Rivers Provider Network All |
$47.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$58.59
|
| Rate for Payer: Zelis Auto |
$25.20
|
| Rate for Payer: Zelis Worker's Compensation |
$17.20
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
NDC 00597035556
|
| Hospital Charge Code |
3302902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$59.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$37.80
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$53.55
|
| Rate for Payer: First Health Commercial |
$56.70
|
| Rate for Payer: First Health Workers Compensation |
$24.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$56.70
|
| Rate for Payer: GEHA Commercial |
$50.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$56.70
|
| Rate for Payer: Humana ChoiceCare |
$16.38
|
| Rate for Payer: Multiplan All |
$57.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$37.80
|
| Rate for Payer: OMNI Networks Commercial |
$44.10
|
| Rate for Payer: One Health Plan PPO/POS |
$56.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$59.85
|
| Rate for Payer: Three Rivers Provider Network All |
$47.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$55.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$15.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$58.59
|
| Rate for Payer: Zelis Auto |
$25.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$31.50
|
| Rate for Payer: Zelis Worker's Compensation |
$17.20
|
|
|
DAKIN'S SOLN 0.25% (HALF STRENGTH)
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
NDC 39328006325
|
| Hospital Charge Code |
3300217
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.93 |
| Max. Negotiated Rate |
$79.80 |
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$71.40
|
| Rate for Payer: First Health Commercial |
$75.60
|
| Rate for Payer: First Health Workers Compensation |
$32.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$75.60
|
| Rate for Payer: GEHA Commercial |
$58.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$75.60
|
| Rate for Payer: Multiplan All |
$76.44
|
| Rate for Payer: OMNI Networks Commercial |
$58.80
|
| Rate for Payer: One Health Plan PPO/POS |
$75.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$79.80
|
| Rate for Payer: Three Rivers Provider Network All |
$63.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$78.12
|
| Rate for Payer: Zelis Auto |
$33.60
|
| Rate for Payer: Zelis Worker's Compensation |
$22.93
|
|
|
DAKIN'S SOLN 0.25% (HALF STRENGTH)
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
NDC 39328006325
|
| Hospital Charge Code |
3300217
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$79.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$71.40
|
| Rate for Payer: First Health Commercial |
$75.60
|
| Rate for Payer: First Health Workers Compensation |
$32.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$75.60
|
| Rate for Payer: GEHA Commercial |
$67.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$75.60
|
| Rate for Payer: Humana ChoiceCare |
$21.84
|
| Rate for Payer: Multiplan All |
$76.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$50.40
|
| Rate for Payer: OMNI Networks Commercial |
$58.80
|
| Rate for Payer: One Health Plan PPO/POS |
$75.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$79.80
|
| Rate for Payer: Three Rivers Provider Network All |
$63.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$73.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$78.12
|
| Rate for Payer: Zelis Auto |
$33.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$42.00
|
| Rate for Payer: Zelis Worker's Compensation |
$22.93
|
|
|
DAKIN'S SOLUTION 0.5%
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
NDC 39328006250
|
| Hospital Charge Code |
3300218
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$79.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$71.40
|
| Rate for Payer: First Health Commercial |
$75.60
|
| Rate for Payer: First Health Workers Compensation |
$32.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$75.60
|
| Rate for Payer: GEHA Commercial |
$67.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$75.60
|
| Rate for Payer: Humana ChoiceCare |
$21.84
|
| Rate for Payer: Multiplan All |
$76.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$50.40
|
| Rate for Payer: OMNI Networks Commercial |
$58.80
|
| Rate for Payer: One Health Plan PPO/POS |
$75.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$79.80
|
| Rate for Payer: Three Rivers Provider Network All |
$63.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$73.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$78.12
|
| Rate for Payer: Zelis Auto |
$33.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$42.00
|
| Rate for Payer: Zelis Worker's Compensation |
$22.93
|
|
