|
DEXAMETHASONE 20MG/5ML VIAL **MDV
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
CPT J1100
|
| Hospital Charge Code |
3301139
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
DEXAMETHASONE 20MG/5ML VIAL **MDV
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
CPT J1100
|
| Hospital Charge Code |
3301139
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| 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: 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 |
$0.10
|
| 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
|
|
|
DEXAMETHASONE ELIXIR 0.5MG/5ML
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
CPT J8540
|
| Hospital Charge Code |
3300223
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$0.02
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Humana ChoiceCare |
$3.12
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.20
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
DEXAMETHASONE ELIXIR 0.5MG/5ML
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
CPT J8540
|
| Hospital Charge Code |
3300223
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$8.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
DEXAMETHASONE INJ 4MG/ML
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
CPT J1100
|
| Hospital Charge Code |
3300224
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$0.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Humana ChoiceCare |
$1.82
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.20
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
DEXAMETHASONE INJ 4MG/ML
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
CPT J1100
|
| Hospital Charge Code |
3300224
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$4.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
DEXAMETHASONE INJ 4MG/ML**PEDIATRIC DOSE
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
CPT J1100
|
| Hospital Charge Code |
3301143
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
DEXAMETHASONE INJ 4MG/ML**PEDIATRIC DOSE
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
CPT J1100
|
| Hospital Charge Code |
3301143
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| 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: 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 |
$0.10
|
| 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
|
|
|
dexamethasone REF500118
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
CPT 80375
|
| Hospital Charge Code |
2200041
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$256.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$162.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$229.50
|
| Rate for Payer: First Health Commercial |
$243.00
|
| Rate for Payer: First Health Workers Compensation |
$27.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$243.00
|
| Rate for Payer: GEHA Commercial |
$216.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$243.00
|
| Rate for Payer: Humana ChoiceCare |
$70.20
|
| Rate for Payer: Multiplan All |
$245.70
|
| Rate for Payer: New Mexico Health Connections Medicare |
$162.00
|
| Rate for Payer: OMNI Networks Commercial |
$189.00
|
| Rate for Payer: One Health Plan PPO/POS |
$243.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$256.50
|
| Rate for Payer: Three Rivers Provider Network All |
$202.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$237.60
|
| Rate for Payer: United Healthcare Commercial |
$229.50
|
| Rate for Payer: United Healthcare Managed Medicaid |
$67.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$251.10
|
| Rate for Payer: Zelis Auto |
$108.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$135.00
|
| Rate for Payer: Zelis Worker's Compensation |
$19.29
|
|
|
dexamethasone REF500118
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
CPT 80375
|
| Hospital Charge Code |
2200041
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$256.50 |
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$229.50
|
| Rate for Payer: First Health Commercial |
$243.00
|
| Rate for Payer: First Health Workers Compensation |
$27.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$243.00
|
| Rate for Payer: GEHA Commercial |
$189.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$243.00
|
| Rate for Payer: Multiplan All |
$245.70
|
| Rate for Payer: OMNI Networks Commercial |
$189.00
|
| Rate for Payer: One Health Plan PPO/POS |
$243.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$256.50
|
| Rate for Payer: Three Rivers Provider Network All |
$202.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$251.10
|
| Rate for Payer: Zelis Auto |
$108.00
|
| Rate for Payer: Zelis Worker's Compensation |
$19.29
|
|
|
DEXAMETHASONE TAB 4MG
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
CPT J8540
|
| Hospital Charge Code |
3300225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$0.02
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Humana ChoiceCare |
$2.60
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.00
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
DEXAMETHASONE TAB 4MG
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
CPT J8540
|
| Hospital Charge Code |
3300225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$7.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
DEXMEDETOMIDINE 1000 MCG/NS 250 mL IVPB
|
Facility
|
OP
|
$538.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3303010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$134.50 |
| Max. Negotiated Rate |
$511.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$322.80
|
| Rate for Payer: Cash Price |
$322.80
|
| Rate for Payer: Cigna Commercial |
$457.30
|
| Rate for Payer: First Health Commercial |
$484.20
|
| Rate for Payer: First Health Workers Compensation |
$207.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$484.20
|
| Rate for Payer: GEHA Commercial |
$430.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$484.20
|
| Rate for Payer: Humana ChoiceCare |
$139.88
|
| Rate for Payer: Multiplan All |
$489.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$322.80
|
| Rate for Payer: OMNI Networks Commercial |
$376.60
|
| Rate for Payer: One Health Plan PPO/POS |
$484.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$511.10
|
| Rate for Payer: Three Rivers Provider Network All |
$403.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$473.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$134.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$500.34
|
| Rate for Payer: Zelis Auto |
$215.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$269.00
|
| Rate for Payer: Zelis Worker's Compensation |
$146.87
|
|
|
DEXMEDETOMIDINE 1000 MCG/NS 250 mL IVPB
|
Facility
|
IP
|
$538.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3303010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$146.87 |
| Max. Negotiated Rate |
$511.10 |
| Rate for Payer: Cash Price |
$322.80
|
| Rate for Payer: Cigna Commercial |
$457.30
|
| Rate for Payer: First Health Commercial |
$484.20
|
| Rate for Payer: First Health Workers Compensation |
$207.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$484.20
|
| Rate for Payer: GEHA Commercial |
$376.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$484.20
|
| Rate for Payer: Multiplan All |
$489.58
|
| Rate for Payer: OMNI Networks Commercial |
$376.60
|
| Rate for Payer: One Health Plan PPO/POS |
$484.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$511.10
|
| Rate for Payer: Three Rivers Provider Network All |
$403.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$500.34
|
| Rate for Payer: Zelis Auto |
$215.20
|
| Rate for Payer: Zelis Worker's Compensation |
$146.87
|
|
|
DEXMEDETOMIDINE 200 MCG/2 ML INJ
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
NDC 42023014625
|
| Hospital Charge Code |
3303009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$119.00
|
| Rate for Payer: First Health Commercial |
$126.00
|
| Rate for Payer: First Health Workers Compensation |
$54.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$126.00
|
| Rate for Payer: GEHA Commercial |
$98.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$126.00
|
| Rate for Payer: Multiplan All |
$127.40
|
| Rate for Payer: OMNI Networks Commercial |
$98.00
|
| Rate for Payer: One Health Plan PPO/POS |
$126.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$133.00
|
| Rate for Payer: Three Rivers Provider Network All |
$105.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$130.20
|
| Rate for Payer: Zelis Auto |
$56.00
|
| Rate for Payer: Zelis Worker's Compensation |
$38.22
|
|
|
DEXMEDETOMIDINE 200 MCG/2 ML INJ
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
NDC 42023014625
|
| Hospital Charge Code |
3303009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$119.00
|
| Rate for Payer: First Health Commercial |
$126.00
|
| Rate for Payer: First Health Workers Compensation |
$54.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$126.00
|
| Rate for Payer: GEHA Commercial |
$112.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$126.00
|
| Rate for Payer: Humana ChoiceCare |
$36.40
|
| Rate for Payer: Multiplan All |
$127.40
|
| Rate for Payer: New Mexico Health Connections Medicare |
$84.00
|
| Rate for Payer: OMNI Networks Commercial |
$98.00
|
| Rate for Payer: One Health Plan PPO/POS |
$126.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$133.00
|
| Rate for Payer: Three Rivers Provider Network All |
$105.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$123.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$35.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$130.20
|
| Rate for Payer: Zelis Auto |
$56.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$70.00
|
| Rate for Payer: Zelis Worker's Compensation |
$38.22
|
|
|
DEXMEDETOMIDINE 400 MCG/100 mL PREMIX IV
|
Facility
|
OP
|
$538.00
|
|
|
Service Code
|
NDC 42023018701
|
| Hospital Charge Code |
3302894
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$134.50 |
| Max. Negotiated Rate |
$511.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$322.80
|
| Rate for Payer: Cash Price |
$322.80
|
| Rate for Payer: Cigna Commercial |
$457.30
|
| Rate for Payer: First Health Commercial |
$484.20
|
| Rate for Payer: First Health Workers Compensation |
$207.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$484.20
|
| Rate for Payer: GEHA Commercial |
$430.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$484.20
|
| Rate for Payer: Humana ChoiceCare |
$139.88
|
| Rate for Payer: Multiplan All |
$489.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$322.80
|
| Rate for Payer: OMNI Networks Commercial |
$376.60
|
| Rate for Payer: One Health Plan PPO/POS |
$484.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$511.10
|
| Rate for Payer: Three Rivers Provider Network All |
$403.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$473.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$134.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$500.34
|
| Rate for Payer: Zelis Auto |
$215.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$269.00
|
| Rate for Payer: Zelis Worker's Compensation |
$146.87
|
|
|
DEXMEDETOMIDINE 400 MCG/100 mL PREMIX IV
|
Facility
|
IP
|
$538.00
|
|
|
Service Code
|
NDC 42023018701
|
| Hospital Charge Code |
3302894
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$146.87 |
| Max. Negotiated Rate |
$511.10 |
| Rate for Payer: Cash Price |
$322.80
|
| Rate for Payer: Cigna Commercial |
$457.30
|
| Rate for Payer: First Health Commercial |
$484.20
|
| Rate for Payer: First Health Workers Compensation |
$207.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$484.20
|
| Rate for Payer: GEHA Commercial |
$376.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$484.20
|
| Rate for Payer: Multiplan All |
$489.58
|
| Rate for Payer: OMNI Networks Commercial |
$376.60
|
| Rate for Payer: One Health Plan PPO/POS |
$484.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$511.10
|
| Rate for Payer: Three Rivers Provider Network All |
$403.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$500.34
|
| Rate for Payer: Zelis Auto |
$215.20
|
| Rate for Payer: Zelis Worker's Compensation |
$146.87
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN TAB 30-600M
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 63824005634
|
| Hospital Charge Code |
3300227
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$7.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Humana ChoiceCare |
$2.34
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5.40
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.50
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN TAB 30-600M
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 63824005634
|
| Hospital Charge Code |
3300227
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$6.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
DEXTROSE 10%/0.45% NACL 1000 ML
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 00264762200
|
| Hospital Charge Code |
3303218
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$17.10 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$15.30
|
| Rate for Payer: First Health Commercial |
$16.20
|
| Rate for Payer: First Health Workers Compensation |
$6.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$16.20
|
| Rate for Payer: GEHA Commercial |
$12.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$16.20
|
| Rate for Payer: Multiplan All |
$16.38
|
| Rate for Payer: OMNI Networks Commercial |
$12.60
|
| Rate for Payer: One Health Plan PPO/POS |
$16.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$17.10
|
| Rate for Payer: Three Rivers Provider Network All |
$13.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$16.74
|
| Rate for Payer: Zelis Auto |
$7.20
|
| Rate for Payer: Zelis Worker's Compensation |
$4.91
|
|
|
DEXTROSE 10%/0.45% NACL 1000 ML
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 00264762200
|
| Hospital Charge Code |
3303218
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$17.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$15.30
|
| Rate for Payer: First Health Commercial |
$16.20
|
| Rate for Payer: First Health Workers Compensation |
$6.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$16.20
|
| Rate for Payer: GEHA Commercial |
$14.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$16.20
|
| Rate for Payer: Humana ChoiceCare |
$4.68
|
| Rate for Payer: Multiplan All |
$16.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10.80
|
| Rate for Payer: OMNI Networks Commercial |
$12.60
|
| Rate for Payer: One Health Plan PPO/POS |
$16.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$17.10
|
| Rate for Payer: Three Rivers Provider Network All |
$13.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$15.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$16.74
|
| Rate for Payer: Zelis Auto |
$7.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$9.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.91
|
|
|
DEXTROSE 10% WATER IV 1000 ML
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 00990793009
|
| Hospital Charge Code |
3300233
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$16.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Humana ChoiceCare |
$5.20
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.00
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
|
DEXTROSE 10% WATER IV 1000 ML
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 00990793009
|
| Hospital Charge Code |
3300233
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$14.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
|
DEXTROSE 25%- INFANT
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
NDC 00409177510
|
| Hospital Charge Code |
3300234
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$50.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$45.05
|
| Rate for Payer: First Health Commercial |
$47.70
|
| Rate for Payer: First Health Workers Compensation |
$20.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$47.70
|
| Rate for Payer: GEHA Commercial |
$42.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$47.70
|
| Rate for Payer: Humana ChoiceCare |
$13.78
|
| Rate for Payer: Multiplan All |
$48.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.80
|
| Rate for Payer: OMNI Networks Commercial |
$37.10
|
| Rate for Payer: One Health Plan PPO/POS |
$47.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$50.35
|
| Rate for Payer: Three Rivers Provider Network All |
$39.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$46.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$49.29
|
| Rate for Payer: Zelis Auto |
$21.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$26.50
|
| Rate for Payer: Zelis Worker's Compensation |
$14.47
|
|
