|
DEXTROSE 25%- INFANT
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
NDC 00409177510
|
| Hospital Charge Code |
3300234
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$14.47 |
| Max. Negotiated Rate |
$50.35 |
| 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 |
$37.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$47.70
|
| Rate for Payer: Multiplan All |
$48.23
|
| 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: United Payors & United Providers UP&UP |
$49.29
|
| Rate for Payer: Zelis Auto |
$21.20
|
| Rate for Payer: Zelis Worker's Compensation |
$14.47
|
|
|
DEXTROSE 5% / 0.225% NACL 500ML (PEDS)
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 00338007703
|
| Hospital Charge Code |
3300230
|
|
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 5% / 0.225% NACL 500ML (PEDS)
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 00338007703
|
| Hospital Charge Code |
3300230
|
|
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 5% / 0.45% NACL 1000ML
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 00338008504
|
| Hospital Charge Code |
3300231
|
|
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
|
|
|
DEXTROSE 5% / 0.45% NACL 1000ML
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 00338008504
|
| Hospital Charge Code |
3300231
|
|
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
|
|
|
DEXTROSE 5 0.9 NS 1000ML
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 00338008904
|
| Hospital Charge Code |
3300232
|
|
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 5 0.9 NS 1000ML
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 00338008904
|
| Hospital Charge Code |
3300232
|
|
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 50% ADULT
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
NDC 00409751716
|
| Hospital Charge Code |
3300241
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$100.00 |
| Max. Negotiated Rate |
$380.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$240.00
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Cigna Commercial |
$340.00
|
| Rate for Payer: First Health Commercial |
$360.00
|
| Rate for Payer: First Health Workers Compensation |
$154.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$360.00
|
| Rate for Payer: GEHA Commercial |
$320.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$360.00
|
| Rate for Payer: Humana ChoiceCare |
$104.00
|
| Rate for Payer: Multiplan All |
$364.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$240.00
|
| Rate for Payer: OMNI Networks Commercial |
$280.00
|
| Rate for Payer: One Health Plan PPO/POS |
$360.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$380.00
|
| Rate for Payer: Three Rivers Provider Network All |
$300.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$352.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$100.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$372.00
|
| Rate for Payer: Zelis Auto |
$160.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$200.00
|
| Rate for Payer: Zelis Worker's Compensation |
$109.20
|
|
|
DEXTROSE 50% ADULT
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
NDC 00409751716
|
| Hospital Charge Code |
3300241
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$109.20 |
| Max. Negotiated Rate |
$380.00 |
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Cigna Commercial |
$340.00
|
| Rate for Payer: First Health Commercial |
$360.00
|
| Rate for Payer: First Health Workers Compensation |
$154.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$360.00
|
| Rate for Payer: GEHA Commercial |
$280.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$360.00
|
| Rate for Payer: Multiplan All |
$364.00
|
| Rate for Payer: OMNI Networks Commercial |
$280.00
|
| Rate for Payer: One Health Plan PPO/POS |
$360.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$380.00
|
| Rate for Payer: Three Rivers Provider Network All |
$300.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$372.00
|
| Rate for Payer: Zelis Auto |
$160.00
|
| Rate for Payer: Zelis Worker's Compensation |
$109.20
|
|
|
DEXTROSE 5%-LACTATED RINGERS 1000ML
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 00338012504
|
| Hospital Charge Code |
3300228
|
|
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
|
|
|
DEXTROSE 5%-LACTATED RINGERS 1000ML
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 00338012504
|
| Hospital Charge Code |
3300228
|
|
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
|
|
|
DEXTROSE 5% /NACL 0.225% 1000ML IV
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
NDC 00990792409
|
| Hospital Charge Code |
3303110
|
|
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
|
|
|
DEXTROSE 5% /NACL 0.225% 1000ML IV
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
NDC 00990792409
|
| Hospital Charge Code |
3303110
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$14.47 |
| Max. Negotiated Rate |
$50.35 |
| 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 |
$37.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$47.70
|
| Rate for Payer: Multiplan All |
$48.23
|
| 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: United Payors & United Providers UP&UP |
$49.29
|
| Rate for Payer: Zelis Auto |
$21.20
|
| Rate for Payer: Zelis Worker's Compensation |
$14.47
|
|
|
DEXTROSE 5% WATER 1000ML
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 00338001704
|
| Hospital Charge Code |
3300235
|
|
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 5% WATER 1000ML
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 00338001704
|
| Hospital Charge Code |
3300235
|
|
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 5% WATER 250ML
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
NDC 00338001702
|
| Hospital Charge Code |
3300236
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$11.74 |
| Max. Negotiated Rate |
$40.85 |
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$36.55
|
| Rate for Payer: First Health Commercial |
$38.70
|
| Rate for Payer: First Health Workers Compensation |
$16.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$38.70
|
| Rate for Payer: GEHA Commercial |
$30.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$38.70
|
| Rate for Payer: Multiplan All |
$39.13
|
| Rate for Payer: OMNI Networks Commercial |
$30.10
|
| Rate for Payer: One Health Plan PPO/POS |
$38.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$40.85
|
| Rate for Payer: Three Rivers Provider Network All |
$32.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$39.99
|
| Rate for Payer: Zelis Auto |
$17.20
|
| Rate for Payer: Zelis Worker's Compensation |
$11.74
|
|
|
DEXTROSE 5% WATER 250ML
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
NDC 00338001702
|
| Hospital Charge Code |
3300236
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$10.75 |
| Max. Negotiated Rate |
$40.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$25.80
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$36.55
|
| Rate for Payer: First Health Commercial |
$38.70
|
| Rate for Payer: First Health Workers Compensation |
$16.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$38.70
|
| Rate for Payer: GEHA Commercial |
$34.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$38.70
|
| Rate for Payer: Humana ChoiceCare |
$11.18
|
| Rate for Payer: Multiplan All |
$39.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.80
|
| Rate for Payer: OMNI Networks Commercial |
$30.10
|
| Rate for Payer: One Health Plan PPO/POS |
$38.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$40.85
|
| Rate for Payer: Three Rivers Provider Network All |
$32.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$37.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$39.99
|
| Rate for Payer: Zelis Auto |
$17.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.50
|
| Rate for Payer: Zelis Worker's Compensation |
$11.74
|
|
|
DEXTROSE 5% WATER 500ML
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
NDC 00338001703
|
| Hospital Charge Code |
3300238
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$11.74 |
| Max. Negotiated Rate |
$40.85 |
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$36.55
|
| Rate for Payer: First Health Commercial |
$38.70
|
| Rate for Payer: First Health Workers Compensation |
$16.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$38.70
|
| Rate for Payer: GEHA Commercial |
$30.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$38.70
|
| Rate for Payer: Multiplan All |
$39.13
|
| Rate for Payer: OMNI Networks Commercial |
$30.10
|
| Rate for Payer: One Health Plan PPO/POS |
$38.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$40.85
|
| Rate for Payer: Three Rivers Provider Network All |
$32.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$39.99
|
| Rate for Payer: Zelis Auto |
$17.20
|
| Rate for Payer: Zelis Worker's Compensation |
$11.74
|
|
|
DEXTROSE 5% WATER 500ML
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
NDC 00338001703
|
| Hospital Charge Code |
3300238
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$10.75 |
| Max. Negotiated Rate |
$40.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$25.80
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$36.55
|
| Rate for Payer: First Health Commercial |
$38.70
|
| Rate for Payer: First Health Workers Compensation |
$16.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$38.70
|
| Rate for Payer: GEHA Commercial |
$34.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$38.70
|
| Rate for Payer: Humana ChoiceCare |
$11.18
|
| Rate for Payer: Multiplan All |
$39.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.80
|
| Rate for Payer: OMNI Networks Commercial |
$30.10
|
| Rate for Payer: One Health Plan PPO/POS |
$38.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$40.85
|
| Rate for Payer: Three Rivers Provider Network All |
$32.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$37.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$39.99
|
| Rate for Payer: Zelis Auto |
$17.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.50
|
| Rate for Payer: Zelis Worker's Compensation |
$11.74
|
|
|
DEXTROSE 5% WATER 50ML
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 00338001731
|
| Hospital Charge Code |
3300240
|
|
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
|
|
|
DEXTROSE 5% WATER 50ML
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 00338001731
|
| Hospital Charge Code |
3300240
|
|
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
|
|
|
Dextrose Injection 50% (25gm/50ml) VIAL
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
NDC 00409664802
|
| Hospital Charge Code |
3302485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.55 |
| Max. Negotiated Rate |
$22.80 |
| 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 |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$21.60
|
| Rate for Payer: Multiplan All |
$21.84
|
| 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: United Payors & United Providers UP&UP |
$22.32
|
| Rate for Payer: Zelis Auto |
$9.60
|
| Rate for Payer: Zelis Worker's Compensation |
$6.55
|
|
|
Dextrose Injection 50% (25gm/50ml) VIAL
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
NDC 00409664802
|
| Hospital Charge Code |
3302485
|
|
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
|
|
|
dhea sulfate (dheas) REF004020
|
Facility
|
OP
|
$214.00
|
|
|
Service Code
|
CPT 82627
|
| Hospital Charge Code |
2232631
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.90 |
| Max. Negotiated Rate |
$203.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$40.02
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$128.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$40.02
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$31.70
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$22.23
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$181.90
|
| Rate for Payer: First Health Commercial |
$192.60
|
| Rate for Payer: First Health Workers Compensation |
$33.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$192.60
|
| Rate for Payer: GEHA Commercial |
$171.20
|
| Rate for Payer: GEHA Medicare |
$22.23
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$192.60
|
| Rate for Payer: Humana ChoiceCare |
$24.45
|
| Rate for Payer: Humana Medicare Advantage |
$22.23
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$37.35
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$32.35
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$22.23
|
| Rate for Payer: Multiplan All |
$194.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$37.79
|
| Rate for Payer: OMNI Networks Commercial |
$149.80
|
| Rate for Payer: One Health Plan PPO/POS |
$192.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$37.35
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$32.35
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$22.23
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$203.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$44.46
|
| Rate for Payer: Three Rivers Provider Network All |
$160.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$21.79
|
| Rate for Payer: United Healthcare Commercial |
$181.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$32.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.23
|
| Rate for Payer: United Payors & United Providers UP&UP |
$199.02
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$22.23
|
| Rate for Payer: Zelis Auto |
$85.60
|
| Rate for Payer: Zelis Medicare |
$18.90
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$26.68
|
| Rate for Payer: Zelis Worker's Compensation |
$24.01
|
|
|
dhea sulfate (dheas) REF004020
|
Facility
|
IP
|
$214.00
|
|
|
Service Code
|
CPT 82627
|
| Hospital Charge Code |
2232631
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$24.01 |
| Max. Negotiated Rate |
$203.30 |
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$181.90
|
| Rate for Payer: First Health Commercial |
$192.60
|
| Rate for Payer: First Health Workers Compensation |
$33.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$192.60
|
| Rate for Payer: GEHA Commercial |
$149.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$192.60
|
| Rate for Payer: Multiplan All |
$194.74
|
| Rate for Payer: OMNI Networks Commercial |
$149.80
|
| Rate for Payer: One Health Plan PPO/POS |
$192.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$203.30
|
| Rate for Payer: Three Rivers Provider Network All |
$160.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$199.02
|
| Rate for Payer: Zelis Auto |
$85.60
|
| Rate for Payer: Zelis Worker's Compensation |
$24.01
|
|
