|
DOPamine 400MG/250ML D5W PREMIX
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
3300275
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.75 |
| Max. Negotiated Rate |
$93.10 |
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$83.30
|
| Rate for Payer: First Health Commercial |
$88.20
|
| Rate for Payer: First Health Workers Compensation |
$37.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$88.20
|
| Rate for Payer: GEHA Commercial |
$68.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$88.20
|
| Rate for Payer: Multiplan All |
$89.18
|
| Rate for Payer: OMNI Networks Commercial |
$68.60
|
| Rate for Payer: One Health Plan PPO/POS |
$88.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$93.10
|
| Rate for Payer: Three Rivers Provider Network All |
$73.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$91.14
|
| Rate for Payer: Zelis Auto |
$39.20
|
| Rate for Payer: Zelis Worker's Compensation |
$26.75
|
|
|
DORNASE 10 MG/NS 30 ML IRRIGATION
|
Facility
|
IP
|
$698.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3303136
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$190.55 |
| Max. Negotiated Rate |
$663.10 |
| Rate for Payer: Cash Price |
$418.80
|
| Rate for Payer: Cigna Commercial |
$593.30
|
| Rate for Payer: First Health Commercial |
$628.20
|
| Rate for Payer: First Health Workers Compensation |
$269.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$628.20
|
| Rate for Payer: GEHA Commercial |
$488.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$628.20
|
| Rate for Payer: Multiplan All |
$635.18
|
| Rate for Payer: OMNI Networks Commercial |
$488.60
|
| Rate for Payer: One Health Plan PPO/POS |
$628.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$663.10
|
| Rate for Payer: Three Rivers Provider Network All |
$523.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$649.14
|
| Rate for Payer: Zelis Auto |
$279.20
|
| Rate for Payer: Zelis Worker's Compensation |
$190.55
|
|
|
DORNASE 10 MG/NS 30 ML IRRIGATION
|
Facility
|
OP
|
$698.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3303136
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$174.50 |
| Max. Negotiated Rate |
$663.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$418.80
|
| Rate for Payer: Cash Price |
$418.80
|
| Rate for Payer: Cigna Commercial |
$593.30
|
| Rate for Payer: First Health Commercial |
$628.20
|
| Rate for Payer: First Health Workers Compensation |
$269.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$628.20
|
| Rate for Payer: GEHA Commercial |
$558.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$628.20
|
| Rate for Payer: Humana ChoiceCare |
$181.48
|
| Rate for Payer: Multiplan All |
$635.18
|
| Rate for Payer: New Mexico Health Connections Medicare |
$418.80
|
| Rate for Payer: OMNI Networks Commercial |
$488.60
|
| Rate for Payer: One Health Plan PPO/POS |
$628.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$663.10
|
| Rate for Payer: Three Rivers Provider Network All |
$523.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$614.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$174.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$649.14
|
| Rate for Payer: Zelis Auto |
$279.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$349.00
|
| Rate for Payer: Zelis Worker's Compensation |
$190.55
|
|
|
DORNASE 5 MG/NS 50 ML IRRIGATION
|
Facility
|
OP
|
$698.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3303122
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$174.50 |
| Max. Negotiated Rate |
$663.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$418.80
|
| Rate for Payer: Cash Price |
$418.80
|
| Rate for Payer: Cigna Commercial |
$593.30
|
| Rate for Payer: First Health Commercial |
$628.20
|
| Rate for Payer: First Health Workers Compensation |
$269.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$628.20
|
| Rate for Payer: GEHA Commercial |
$558.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$628.20
|
| Rate for Payer: Humana ChoiceCare |
$181.48
|
| Rate for Payer: Multiplan All |
$635.18
|
| Rate for Payer: New Mexico Health Connections Medicare |
$418.80
|
| Rate for Payer: OMNI Networks Commercial |
$488.60
|
| Rate for Payer: One Health Plan PPO/POS |
$628.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$663.10
|
| Rate for Payer: Three Rivers Provider Network All |
$523.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$614.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$174.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$649.14
|
| Rate for Payer: Zelis Auto |
$279.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$349.00
|
| Rate for Payer: Zelis Worker's Compensation |
$190.55
|
|
|
DORNASE 5 MG/NS 50 ML IRRIGATION
|
Facility
|
IP
|
$698.00
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3303122
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$190.55 |
| Max. Negotiated Rate |
$663.10 |
| Rate for Payer: Cash Price |
$418.80
|
| Rate for Payer: Cigna Commercial |
$593.30
|
| Rate for Payer: First Health Commercial |
$628.20
|
| Rate for Payer: First Health Workers Compensation |
$269.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$628.20
|
| Rate for Payer: GEHA Commercial |
$488.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$628.20
|
| Rate for Payer: Multiplan All |
$635.18
|
| Rate for Payer: OMNI Networks Commercial |
$488.60
|
| Rate for Payer: One Health Plan PPO/POS |
$628.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$663.10
|
| Rate for Payer: Three Rivers Provider Network All |
$523.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$649.14
|
| Rate for Payer: Zelis Auto |
$279.20
|
| Rate for Payer: Zelis Worker's Compensation |
$190.55
|
|
|
DORNASE ALFA 2.5 MG/2.5 ML NEB UD
|
Facility
|
OP
|
$698.00
|
|
|
Service Code
|
CPT J7639
|
| Hospital Charge Code |
3303121
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.68 |
| Max. Negotiated Rate |
$663.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$418.80
|
| Rate for Payer: Cash Price |
$418.80
|
| Rate for Payer: Cash Price |
$418.80
|
| Rate for Payer: Cigna Commercial |
$593.30
|
| Rate for Payer: First Health Commercial |
$628.20
|
| Rate for Payer: First Health Workers Compensation |
$269.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$628.20
|
| Rate for Payer: GEHA Commercial |
$60.68
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$628.20
|
| Rate for Payer: Humana ChoiceCare |
$181.48
|
| Rate for Payer: Multiplan All |
$635.18
|
| Rate for Payer: New Mexico Health Connections Medicare |
$418.80
|
| Rate for Payer: OMNI Networks Commercial |
$488.60
|
| Rate for Payer: One Health Plan PPO/POS |
$628.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$663.10
|
| Rate for Payer: Three Rivers Provider Network All |
$523.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$614.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$174.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$649.14
|
| Rate for Payer: Zelis Auto |
$279.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$349.00
|
| Rate for Payer: Zelis Worker's Compensation |
$190.55
|
|
|
DORNASE ALFA 2.5 MG/2.5 ML NEB UD
|
Facility
|
IP
|
$698.00
|
|
|
Service Code
|
CPT J7639
|
| Hospital Charge Code |
3303121
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$190.55 |
| Max. Negotiated Rate |
$663.10 |
| Rate for Payer: Cash Price |
$418.80
|
| Rate for Payer: Cigna Commercial |
$593.30
|
| Rate for Payer: First Health Commercial |
$628.20
|
| Rate for Payer: First Health Workers Compensation |
$269.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$628.20
|
| Rate for Payer: GEHA Commercial |
$488.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$628.20
|
| Rate for Payer: Multiplan All |
$635.18
|
| Rate for Payer: OMNI Networks Commercial |
$488.60
|
| Rate for Payer: One Health Plan PPO/POS |
$628.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$663.10
|
| Rate for Payer: Three Rivers Provider Network All |
$523.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$649.14
|
| Rate for Payer: Zelis Auto |
$279.20
|
| Rate for Payer: Zelis Worker's Compensation |
$190.55
|
|
|
DORZOLAMIDE HCL OPTH SOLN 2%
|
Facility
|
IP
|
$279.00
|
|
|
Service Code
|
NDC 61314001910
|
| Hospital Charge Code |
3300276
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.17 |
| Max. Negotiated Rate |
$265.05 |
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$237.15
|
| Rate for Payer: First Health Commercial |
$251.10
|
| Rate for Payer: First Health Workers Compensation |
$107.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$251.10
|
| Rate for Payer: GEHA Commercial |
$195.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$251.10
|
| Rate for Payer: Multiplan All |
$253.89
|
| Rate for Payer: OMNI Networks Commercial |
$195.30
|
| Rate for Payer: One Health Plan PPO/POS |
$251.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$265.05
|
| Rate for Payer: Three Rivers Provider Network All |
$209.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$259.47
|
| Rate for Payer: Zelis Auto |
$111.60
|
| Rate for Payer: Zelis Worker's Compensation |
$76.17
|
|
|
DORZOLAMIDE HCL OPTH SOLN 2%
|
Facility
|
OP
|
$279.00
|
|
|
Service Code
|
NDC 61314001910
|
| Hospital Charge Code |
3300276
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.75 |
| Max. Negotiated Rate |
$265.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$237.15
|
| Rate for Payer: First Health Commercial |
$251.10
|
| Rate for Payer: First Health Workers Compensation |
$107.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$251.10
|
| Rate for Payer: GEHA Commercial |
$223.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$251.10
|
| Rate for Payer: Humana ChoiceCare |
$72.54
|
| Rate for Payer: Multiplan All |
$253.89
|
| Rate for Payer: New Mexico Health Connections Medicare |
$167.40
|
| Rate for Payer: OMNI Networks Commercial |
$195.30
|
| Rate for Payer: One Health Plan PPO/POS |
$251.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$265.05
|
| Rate for Payer: Three Rivers Provider Network All |
$209.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$245.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$69.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$259.47
|
| Rate for Payer: Zelis Auto |
$111.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$139.50
|
| Rate for Payer: Zelis Worker's Compensation |
$76.17
|
|
|
DORZOLAMIDE HCL-TIMOLOL OPTH
|
Facility
|
IP
|
$591.00
|
|
|
Service Code
|
NDC 24208048610
|
| Hospital Charge Code |
3300277
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$161.34 |
| Max. Negotiated Rate |
$561.45 |
| Rate for Payer: Cash Price |
$354.60
|
| Rate for Payer: Cigna Commercial |
$502.35
|
| Rate for Payer: First Health Commercial |
$531.90
|
| Rate for Payer: First Health Workers Compensation |
$228.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$531.90
|
| Rate for Payer: GEHA Commercial |
$413.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$531.90
|
| Rate for Payer: Multiplan All |
$537.81
|
| Rate for Payer: OMNI Networks Commercial |
$413.70
|
| Rate for Payer: One Health Plan PPO/POS |
$531.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$561.45
|
| Rate for Payer: Three Rivers Provider Network All |
$443.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$549.63
|
| Rate for Payer: Zelis Auto |
$236.40
|
| Rate for Payer: Zelis Worker's Compensation |
$161.34
|
|
|
DORZOLAMIDE HCL-TIMOLOL OPTH
|
Facility
|
OP
|
$591.00
|
|
|
Service Code
|
NDC 24208048610
|
| Hospital Charge Code |
3300277
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$147.75 |
| Max. Negotiated Rate |
$561.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$354.60
|
| Rate for Payer: Cash Price |
$354.60
|
| Rate for Payer: Cigna Commercial |
$502.35
|
| Rate for Payer: First Health Commercial |
$531.90
|
| Rate for Payer: First Health Workers Compensation |
$228.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$531.90
|
| Rate for Payer: GEHA Commercial |
$472.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$531.90
|
| Rate for Payer: Humana ChoiceCare |
$153.66
|
| Rate for Payer: Multiplan All |
$537.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$354.60
|
| Rate for Payer: OMNI Networks Commercial |
$413.70
|
| Rate for Payer: One Health Plan PPO/POS |
$531.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$561.45
|
| Rate for Payer: Three Rivers Provider Network All |
$443.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$520.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$147.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$549.63
|
| Rate for Payer: Zelis Auto |
$236.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$295.50
|
| Rate for Payer: Zelis Worker's Compensation |
$161.34
|
|
|
DOUBLE TRANSFER TOE-HAND
|
Facility
|
OP
|
$6,807.00
|
|
|
Service Code
|
CPT 26554
|
| Hospital Charge Code |
6126554
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,701.75 |
| Max. Negotiated Rate |
$6,466.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,084.20
|
| Rate for Payer: Cash Price |
$4,084.20
|
| Rate for Payer: Cigna Commercial |
$5,785.95
|
| Rate for Payer: First Health Commercial |
$6,126.30
|
| Rate for Payer: First Health Workers Compensation |
$2,628.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,126.30
|
| Rate for Payer: GEHA Commercial |
$5,445.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,126.30
|
| Rate for Payer: Humana ChoiceCare |
$1,769.82
|
| Rate for Payer: Multiplan All |
$6,194.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,084.20
|
| Rate for Payer: OMNI Networks Commercial |
$4,764.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6,126.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,466.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5,105.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,990.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,701.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,330.51
|
| Rate for Payer: Zelis Auto |
$2,722.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,403.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1,858.31
|
|
|
DOUBLE TRANSFER TOE-HAND
|
Facility
|
IP
|
$6,807.00
|
|
|
Service Code
|
CPT 26554
|
| Hospital Charge Code |
6126554
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,858.31 |
| Max. Negotiated Rate |
$6,466.65 |
| Rate for Payer: Cash Price |
$4,084.20
|
| Rate for Payer: Cigna Commercial |
$5,785.95
|
| Rate for Payer: First Health Commercial |
$6,126.30
|
| Rate for Payer: First Health Workers Compensation |
$2,628.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,126.30
|
| Rate for Payer: GEHA Commercial |
$4,764.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,126.30
|
| Rate for Payer: Multiplan All |
$6,194.37
|
| Rate for Payer: OMNI Networks Commercial |
$4,764.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6,126.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,466.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5,105.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,330.51
|
| Rate for Payer: Zelis Auto |
$2,722.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1,858.31
|
|
|
DOXAZOSIN MESYLATE TAB 1MG
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 51079095720
|
| Hospital Charge Code |
3300278
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
DOXAZOSIN MESYLATE TAB 1MG
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 51079095720
|
| Hospital Charge Code |
3300278
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| 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: 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 |
$9.60
|
| 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
|
|
|
DOXAZOSIN MESYLATE TAB 2MG
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 00904552361
|
| Hospital Charge Code |
3300279
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| 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: 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 |
$9.60
|
| 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
|
|
|
DOXAZOSIN MESYLATE TAB 2MG
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 00904552361
|
| Hospital Charge Code |
3300279
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
DOXEPIN HCL 75MG CAP
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 54868255200
|
| Hospital Charge Code |
3300280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: First Health Commercial |
$12.60
|
| Rate for Payer: First Health Workers Compensation |
$5.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12.60
|
| Rate for Payer: GEHA Commercial |
$11.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12.60
|
| Rate for Payer: Humana ChoiceCare |
$3.64
|
| Rate for Payer: Multiplan All |
$12.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.40
|
| Rate for Payer: OMNI Networks Commercial |
$9.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.02
|
| Rate for Payer: Zelis Auto |
$5.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.82
|
|
|
DOXEPIN HCL 75MG CAP
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 54868255200
|
| Hospital Charge Code |
3300280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: First Health Commercial |
$12.60
|
| Rate for Payer: First Health Workers Compensation |
$5.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12.60
|
| Rate for Payer: GEHA Commercial |
$9.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12.60
|
| Rate for Payer: Multiplan All |
$12.74
|
| Rate for Payer: OMNI Networks Commercial |
$9.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.02
|
| Rate for Payer: Zelis Auto |
$5.60
|
| Rate for Payer: Zelis Worker's Compensation |
$3.82
|
|
|
DOXEPIN HCL CONC 10MG/ML
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00093961212
|
| Hospital Charge Code |
3300281
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
DOXEPIN HCL CONC 10MG/ML
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00093961212
|
| Hospital Charge Code |
3300281
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Humana ChoiceCare |
$1.56
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.60
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
DOXYCYCLINE HYCLATE 100MG FOR IVPB
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
NDC 68382091010
|
| Hospital Charge Code |
3300282
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.49 |
| Max. Negotiated Rate |
$123.50 |
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$110.50
|
| Rate for Payer: First Health Commercial |
$117.00
|
| Rate for Payer: First Health Workers Compensation |
$50.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$117.00
|
| Rate for Payer: GEHA Commercial |
$91.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$117.00
|
| Rate for Payer: Multiplan All |
$118.30
|
| Rate for Payer: OMNI Networks Commercial |
$91.00
|
| Rate for Payer: One Health Plan PPO/POS |
$117.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$123.50
|
| Rate for Payer: Three Rivers Provider Network All |
$97.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$120.90
|
| Rate for Payer: Zelis Auto |
$52.00
|
| Rate for Payer: Zelis Worker's Compensation |
$35.49
|
|
|
DOXYCYCLINE HYCLATE 100MG FOR IVPB
|
Facility
|
OP
|
$130.00
|
|
|
Service Code
|
NDC 68382091010
|
| Hospital Charge Code |
3300282
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.50 |
| Max. Negotiated Rate |
$123.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$78.00
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$110.50
|
| Rate for Payer: First Health Commercial |
$117.00
|
| Rate for Payer: First Health Workers Compensation |
$50.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$117.00
|
| Rate for Payer: GEHA Commercial |
$104.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$117.00
|
| Rate for Payer: Humana ChoiceCare |
$33.80
|
| Rate for Payer: Multiplan All |
$118.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$78.00
|
| Rate for Payer: OMNI Networks Commercial |
$91.00
|
| Rate for Payer: One Health Plan PPO/POS |
$117.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$123.50
|
| Rate for Payer: Three Rivers Provider Network All |
$97.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$114.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$32.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$120.90
|
| Rate for Payer: Zelis Auto |
$52.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$65.00
|
| Rate for Payer: Zelis Worker's Compensation |
$35.49
|
|
|
DOXYCYCLINE MONOHYDRATE 100MG CAP
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 68180065208
|
| Hospital Charge Code |
3300283
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
DOXYCYCLINE MONOHYDRATE 100MG CAP
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 68180065208
|
| Hospital Charge Code |
3300283
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
