|
FLUTICAS/SALMET 100-50 MCG- PER PUFF
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00378932032
|
| Hospital Charge Code |
3303043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$14.25 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$12.75
|
| Rate for Payer: First Health Commercial |
$13.50
|
| Rate for Payer: First Health Workers Compensation |
$5.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$13.50
|
| Rate for Payer: GEHA Commercial |
$10.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$13.50
|
| Rate for Payer: Multiplan All |
$13.65
|
| Rate for Payer: OMNI Networks Commercial |
$10.50
|
| Rate for Payer: One Health Plan PPO/POS |
$13.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$14.25
|
| Rate for Payer: Three Rivers Provider Network All |
$11.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.95
|
| Rate for Payer: Zelis Auto |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.09
|
|
|
FLUTICAS/SALMET 250-50 MCG/DOSE DPI
|
Facility
|
IP
|
$726.00
|
|
|
Service Code
|
NDC 00173069604
|
| Hospital Charge Code |
3300355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$198.20 |
| Max. Negotiated Rate |
$689.70 |
| Rate for Payer: Cash Price |
$435.60
|
| Rate for Payer: Cigna Commercial |
$617.10
|
| Rate for Payer: First Health Commercial |
$653.40
|
| Rate for Payer: First Health Workers Compensation |
$280.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$653.40
|
| Rate for Payer: GEHA Commercial |
$508.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$653.40
|
| Rate for Payer: Multiplan All |
$660.66
|
| Rate for Payer: OMNI Networks Commercial |
$508.20
|
| Rate for Payer: One Health Plan PPO/POS |
$653.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$689.70
|
| Rate for Payer: Three Rivers Provider Network All |
$544.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$675.18
|
| Rate for Payer: Zelis Auto |
$290.40
|
| Rate for Payer: Zelis Worker's Compensation |
$198.20
|
|
|
FLUTICAS/SALMET 250-50 MCG/DOSE DPI
|
Facility
|
OP
|
$726.00
|
|
|
Service Code
|
NDC 00173069604
|
| Hospital Charge Code |
3300355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$181.50 |
| Max. Negotiated Rate |
$689.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$435.60
|
| Rate for Payer: Cash Price |
$435.60
|
| Rate for Payer: Cigna Commercial |
$617.10
|
| Rate for Payer: First Health Commercial |
$653.40
|
| Rate for Payer: First Health Workers Compensation |
$280.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$653.40
|
| Rate for Payer: GEHA Commercial |
$580.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$653.40
|
| Rate for Payer: Humana ChoiceCare |
$188.76
|
| Rate for Payer: Multiplan All |
$660.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$435.60
|
| Rate for Payer: OMNI Networks Commercial |
$508.20
|
| Rate for Payer: One Health Plan PPO/POS |
$653.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$689.70
|
| Rate for Payer: Three Rivers Provider Network All |
$544.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$638.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$181.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$675.18
|
| Rate for Payer: Zelis Auto |
$290.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$363.00
|
| Rate for Payer: Zelis Worker's Compensation |
$198.20
|
|
|
FLUTICAS/SALMET 250-50 MCG- PER PUFF
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 00378932132
|
| Hospital Charge Code |
3303044
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.19 |
| Max. Negotiated Rate |
$18.05 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: First Health Commercial |
$17.10
|
| Rate for Payer: First Health Workers Compensation |
$7.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$17.10
|
| Rate for Payer: GEHA Commercial |
$13.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17.10
|
| Rate for Payer: Multiplan All |
$17.29
|
| Rate for Payer: OMNI Networks Commercial |
$13.30
|
| Rate for Payer: One Health Plan PPO/POS |
$17.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18.05
|
| Rate for Payer: Three Rivers Provider Network All |
$14.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17.67
|
| Rate for Payer: Zelis Auto |
$7.60
|
| Rate for Payer: Zelis Worker's Compensation |
$5.19
|
|
|
FLUTICAS/SALMET 250-50 MCG- PER PUFF
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 00378932132
|
| Hospital Charge Code |
3303044
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.75 |
| Max. Negotiated Rate |
$18.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$11.40
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: First Health Commercial |
$17.10
|
| Rate for Payer: First Health Workers Compensation |
$7.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$17.10
|
| Rate for Payer: GEHA Commercial |
$15.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17.10
|
| Rate for Payer: Humana ChoiceCare |
$4.94
|
| Rate for Payer: Multiplan All |
$17.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.40
|
| Rate for Payer: OMNI Networks Commercial |
$13.30
|
| Rate for Payer: One Health Plan PPO/POS |
$17.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18.05
|
| Rate for Payer: Three Rivers Provider Network All |
$14.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17.67
|
| Rate for Payer: Zelis Auto |
$7.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$9.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.19
|
|
|
FLUTICAS/SALMET 500-50 MCG DPI
|
Facility
|
IP
|
$1,002.00
|
|
|
Service Code
|
NDC 00173069704
|
| Hospital Charge Code |
3300356
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$273.55 |
| Max. Negotiated Rate |
$951.90 |
| Rate for Payer: Cash Price |
$601.20
|
| Rate for Payer: Cigna Commercial |
$851.70
|
| Rate for Payer: First Health Commercial |
$901.80
|
| Rate for Payer: First Health Workers Compensation |
$386.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$901.80
|
| Rate for Payer: GEHA Commercial |
$701.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$901.80
|
| Rate for Payer: Multiplan All |
$911.82
|
| Rate for Payer: OMNI Networks Commercial |
$701.40
|
| Rate for Payer: One Health Plan PPO/POS |
$901.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$951.90
|
| Rate for Payer: Three Rivers Provider Network All |
$751.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$931.86
|
| Rate for Payer: Zelis Auto |
$400.80
|
| Rate for Payer: Zelis Worker's Compensation |
$273.55
|
|
|
FLUTICAS/SALMET 500-50 MCG DPI
|
Facility
|
OP
|
$1,002.00
|
|
|
Service Code
|
NDC 00173069704
|
| Hospital Charge Code |
3300356
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$250.50 |
| Max. Negotiated Rate |
$951.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$601.20
|
| Rate for Payer: Cash Price |
$601.20
|
| Rate for Payer: Cigna Commercial |
$851.70
|
| Rate for Payer: First Health Commercial |
$901.80
|
| Rate for Payer: First Health Workers Compensation |
$386.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$901.80
|
| Rate for Payer: GEHA Commercial |
$801.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$901.80
|
| Rate for Payer: Humana ChoiceCare |
$260.52
|
| Rate for Payer: Multiplan All |
$911.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$601.20
|
| Rate for Payer: OMNI Networks Commercial |
$701.40
|
| Rate for Payer: One Health Plan PPO/POS |
$901.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$951.90
|
| Rate for Payer: Three Rivers Provider Network All |
$751.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$881.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$250.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$931.86
|
| Rate for Payer: Zelis Auto |
$400.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$501.00
|
| Rate for Payer: Zelis Worker's Compensation |
$273.55
|
|
|
FLUTICAS/SALMET 500-50 MCG- PER PUFF
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
NDC 00378932232
|
| Hospital Charge Code |
3303045
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$29.45 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$26.35
|
| Rate for Payer: First Health Commercial |
$27.90
|
| Rate for Payer: First Health Workers Compensation |
$11.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.90
|
| Rate for Payer: GEHA Commercial |
$21.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.90
|
| Rate for Payer: Multiplan All |
$28.21
|
| Rate for Payer: OMNI Networks Commercial |
$21.70
|
| Rate for Payer: One Health Plan PPO/POS |
$27.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$29.45
|
| Rate for Payer: Three Rivers Provider Network All |
$23.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$28.83
|
| Rate for Payer: Zelis Auto |
$12.40
|
| Rate for Payer: Zelis Worker's Compensation |
$8.46
|
|
|
FLUTICAS/SALMET 500-50 MCG- PER PUFF
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
NDC 00378932232
|
| Hospital Charge Code |
3303045
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.75 |
| Max. Negotiated Rate |
$29.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$18.60
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$26.35
|
| Rate for Payer: First Health Commercial |
$27.90
|
| Rate for Payer: First Health Workers Compensation |
$11.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.90
|
| Rate for Payer: GEHA Commercial |
$24.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.90
|
| Rate for Payer: Humana ChoiceCare |
$8.06
|
| Rate for Payer: Multiplan All |
$28.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$18.60
|
| Rate for Payer: OMNI Networks Commercial |
$21.70
|
| Rate for Payer: One Health Plan PPO/POS |
$27.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$29.45
|
| Rate for Payer: Three Rivers Provider Network All |
$23.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$27.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$28.83
|
| Rate for Payer: Zelis Auto |
$12.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.50
|
| Rate for Payer: Zelis Worker's Compensation |
$8.46
|
|
|
FLU VACCINE
|
Facility
|
IP
|
$119.30
|
|
|
Service Code
|
CPT 90656
|
| Hospital Charge Code |
7290656
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.57 |
| Max. Negotiated Rate |
$113.33 |
| Rate for Payer: Cash Price |
$71.58
|
| Rate for Payer: Cigna Commercial |
$101.41
|
| Rate for Payer: First Health Commercial |
$107.37
|
| Rate for Payer: First Health Workers Compensation |
$46.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$107.37
|
| Rate for Payer: GEHA Commercial |
$83.51
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$107.37
|
| Rate for Payer: Multiplan All |
$108.56
|
| Rate for Payer: OMNI Networks Commercial |
$83.51
|
| Rate for Payer: One Health Plan PPO/POS |
$107.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$113.33
|
| Rate for Payer: Three Rivers Provider Network All |
$89.47
|
| Rate for Payer: United Payors & United Providers UP&UP |
$110.95
|
| Rate for Payer: Zelis Auto |
$47.72
|
| Rate for Payer: Zelis Worker's Compensation |
$32.57
|
|
|
FLU VACCINE
|
Facility
|
OP
|
$119.30
|
|
|
Service Code
|
CPT 90656
|
| Hospital Charge Code |
7290656
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.54 |
| Max. Negotiated Rate |
$113.33 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$36.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$71.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$36.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$28.80
|
| Rate for Payer: Cash Price |
$71.58
|
| Rate for Payer: Cash Price |
$71.58
|
| Rate for Payer: Cigna Commercial |
$101.41
|
| Rate for Payer: First Health Commercial |
$107.37
|
| Rate for Payer: First Health Workers Compensation |
$46.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$107.37
|
| Rate for Payer: GEHA Commercial |
$25.54
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$107.37
|
| Rate for Payer: Humana ChoiceCare |
$31.02
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$29.39
|
| Rate for Payer: Multiplan All |
$108.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$71.58
|
| Rate for Payer: OMNI Networks Commercial |
$83.51
|
| Rate for Payer: One Health Plan PPO/POS |
$107.37
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$33.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$29.39
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$113.33
|
| Rate for Payer: Three Rivers Provider Network All |
$89.47
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$104.98
|
| Rate for Payer: United Healthcare Managed Medicaid |
$29.39
|
| Rate for Payer: United Payors & United Providers UP&UP |
$110.95
|
| Rate for Payer: Zelis Auto |
$47.72
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$59.65
|
| Rate for Payer: Zelis Worker's Compensation |
$32.57
|
|
|
FLU VACCINE, 3 YRS & >, I
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT Q2038
|
| Hospital Charge Code |
8590658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$28.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$22.12
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$18.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$22.12
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$17.53
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$25.50
|
| Rate for Payer: First Health Commercial |
$27.00
|
| Rate for Payer: First Health Workers Compensation |
$11.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.00
|
| Rate for Payer: GEHA Commercial |
$24.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.00
|
| Rate for Payer: Humana ChoiceCare |
$7.80
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$17.88
|
| Rate for Payer: Multiplan All |
$27.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$18.00
|
| Rate for Payer: OMNI Networks Commercial |
$21.00
|
| Rate for Payer: One Health Plan PPO/POS |
$27.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$20.65
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$17.88
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$28.50
|
| Rate for Payer: Three Rivers Provider Network All |
$22.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$26.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$17.88
|
| Rate for Payer: United Payors & United Providers UP&UP |
$27.90
|
| Rate for Payer: Zelis Auto |
$12.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.19
|
|
|
FLU VACCINE, 3 YRS & >, I
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT Q2038
|
| Hospital Charge Code |
8590658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.19 |
| Max. Negotiated Rate |
$28.50 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$25.50
|
| Rate for Payer: First Health Commercial |
$27.00
|
| Rate for Payer: First Health Workers Compensation |
$11.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.00
|
| Rate for Payer: GEHA Commercial |
$21.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.00
|
| Rate for Payer: Multiplan All |
$27.30
|
| Rate for Payer: OMNI Networks Commercial |
$21.00
|
| Rate for Payer: One Health Plan PPO/POS |
$27.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$28.50
|
| Rate for Payer: Three Rivers Provider Network All |
$22.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$27.90
|
| Rate for Payer: Zelis Auto |
$12.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.19
|
|
|
FLU VACCINE, 3 YRS, IM
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
CPT 90657
|
| Hospital Charge Code |
8590657
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.65 |
| Max. Negotiated Rate |
$37.05 |
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$33.15
|
| Rate for Payer: First Health Commercial |
$35.10
|
| Rate for Payer: First Health Workers Compensation |
$15.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$35.10
|
| Rate for Payer: GEHA Commercial |
$27.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$35.10
|
| Rate for Payer: Multiplan All |
$35.49
|
| Rate for Payer: OMNI Networks Commercial |
$27.30
|
| Rate for Payer: One Health Plan PPO/POS |
$35.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$37.05
|
| Rate for Payer: Three Rivers Provider Network All |
$29.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$36.27
|
| Rate for Payer: Zelis Auto |
$15.60
|
| Rate for Payer: Zelis Worker's Compensation |
$10.65
|
|
|
FLU VACCINE, 3 YRS, IM
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
CPT 90657
|
| Hospital Charge Code |
8590657
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.77 |
| Max. Negotiated Rate |
$37.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$11.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$23.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$11.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$8.77
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$33.15
|
| Rate for Payer: First Health Commercial |
$35.10
|
| Rate for Payer: First Health Workers Compensation |
$15.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$35.10
|
| Rate for Payer: GEHA Commercial |
$12.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$35.10
|
| Rate for Payer: Humana ChoiceCare |
$10.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$8.95
|
| Rate for Payer: Multiplan All |
$35.49
|
| Rate for Payer: New Mexico Health Connections Medicare |
$23.40
|
| Rate for Payer: OMNI Networks Commercial |
$27.30
|
| Rate for Payer: One Health Plan PPO/POS |
$35.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$10.33
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$8.95
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$37.05
|
| Rate for Payer: Three Rivers Provider Network All |
$29.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$34.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.95
|
| Rate for Payer: United Payors & United Providers UP&UP |
$36.27
|
| Rate for Payer: Zelis Auto |
$15.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$19.50
|
| Rate for Payer: Zelis Worker's Compensation |
$10.65
|
|
|
fluvoxaMINE 50MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 62559015901
|
| Hospital Charge Code |
3301468
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
fluvoxaMINE 50MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 62559015901
|
| Hospital Charge Code |
3301468
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
FLUVOXAMINE MALEATE 25MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 62559015801
|
| Hospital Charge Code |
3305002
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
FLUVOXAMINE MALEATE 25MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 62559015801
|
| Hospital Charge Code |
3305002
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
FL VOIDING URETHROGRAM
|
Facility
|
OP
|
$1,239.00
|
|
|
Service Code
|
CPT 74455
|
| Hospital Charge Code |
2400064
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.43 |
| Max. Negotiated Rate |
$1,177.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$257.43
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$743.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$257.43
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$203.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$229.52
|
| Rate for Payer: Cash Price |
$743.40
|
| Rate for Payer: Cash Price |
$743.40
|
| Rate for Payer: Cigna Commercial |
$1,053.15
|
| Rate for Payer: First Health Commercial |
$1,115.10
|
| Rate for Payer: First Health Workers Compensation |
$126.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,115.10
|
| Rate for Payer: GEHA Commercial |
$991.20
|
| Rate for Payer: GEHA Medicare |
$229.52
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,115.10
|
| Rate for Payer: Humana ChoiceCare |
$252.47
|
| Rate for Payer: Humana Medicare Advantage |
$229.52
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$385.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$208.09
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$229.52
|
| Rate for Payer: Multiplan All |
$1,127.49
|
| Rate for Payer: New Mexico Health Connections Medicare |
$390.18
|
| Rate for Payer: OMNI Networks Commercial |
$867.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,115.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$240.27
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$208.09
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$229.52
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,177.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$459.04
|
| Rate for Payer: Three Rivers Provider Network All |
$929.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$224.93
|
| Rate for Payer: United Healthcare Commercial |
$1,053.15
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$229.52
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,152.27
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$229.52
|
| Rate for Payer: Zelis Auto |
$495.60
|
| Rate for Payer: Zelis Medicare |
$195.09
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$275.42
|
| Rate for Payer: Zelis Worker's Compensation |
$89.43
|
|
|
FL VOIDING URETHROGRAM
|
Facility
|
IP
|
$1,239.00
|
|
|
Service Code
|
CPT 74455
|
| Hospital Charge Code |
2400064
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.43 |
| Max. Negotiated Rate |
$1,177.05 |
| Rate for Payer: Cash Price |
$743.40
|
| Rate for Payer: Cash Price |
$743.40
|
| Rate for Payer: Cigna Commercial |
$1,053.15
|
| Rate for Payer: First Health Commercial |
$1,115.10
|
| Rate for Payer: First Health Workers Compensation |
$126.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,115.10
|
| Rate for Payer: GEHA Commercial |
$867.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,115.10
|
| Rate for Payer: Multiplan All |
$1,127.49
|
| Rate for Payer: OMNI Networks Commercial |
$867.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,115.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,177.05
|
| Rate for Payer: Three Rivers Provider Network All |
$929.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,152.27
|
| Rate for Payer: Zelis Auto |
$495.60
|
| Rate for Payer: Zelis Worker's Compensation |
$89.43
|
|
|
folate (folic acid) REF002014
|
Facility
|
OP
|
$195.00
|
|
|
Service Code
|
CPT 82746
|
| Hospital Charge Code |
2200792
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.49 |
| Max. Negotiated Rate |
$185.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$117.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$20.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.70
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$165.75
|
| Rate for Payer: First Health Commercial |
$175.50
|
| Rate for Payer: First Health Workers Compensation |
$27.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$175.50
|
| Rate for Payer: GEHA Commercial |
$156.00
|
| Rate for Payer: GEHA Medicare |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$175.50
|
| Rate for Payer: Humana ChoiceCare |
$16.17
|
| Rate for Payer: Humana Medicare Advantage |
$14.70
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$24.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.39
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.70
|
| Rate for Payer: Multiplan All |
$177.45
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.99
|
| Rate for Payer: OMNI Networks Commercial |
$136.50
|
| Rate for Payer: One Health Plan PPO/POS |
$175.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$24.70
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.39
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$185.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.40
|
| Rate for Payer: Three Rivers Provider Network All |
$146.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.41
|
| Rate for Payer: United Healthcare Commercial |
$165.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.70
|
| Rate for Payer: United Payors & United Providers UP&UP |
$181.35
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.70
|
| Rate for Payer: Zelis Auto |
$78.00
|
| Rate for Payer: Zelis Medicare |
$12.49
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.64
|
| Rate for Payer: Zelis Worker's Compensation |
$19.47
|
|
|
folate (folic acid) REF002014
|
Facility
|
IP
|
$195.00
|
|
|
Service Code
|
CPT 82746
|
| Hospital Charge Code |
2200792
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.47 |
| Max. Negotiated Rate |
$185.25 |
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$165.75
|
| Rate for Payer: First Health Commercial |
$175.50
|
| Rate for Payer: First Health Workers Compensation |
$27.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$175.50
|
| Rate for Payer: GEHA Commercial |
$136.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$175.50
|
| Rate for Payer: Multiplan All |
$177.45
|
| Rate for Payer: OMNI Networks Commercial |
$136.50
|
| Rate for Payer: One Health Plan PPO/POS |
$175.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$185.25
|
| Rate for Payer: Three Rivers Provider Network All |
$146.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$181.35
|
| Rate for Payer: Zelis Auto |
$78.00
|
| Rate for Payer: Zelis Worker's Compensation |
$19.47
|
|
|
FOLIC ACID
|
Facility
|
OP
|
$195.00
|
|
|
Service Code
|
CPT 82746
|
| Hospital Charge Code |
2232746
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.49 |
| Max. Negotiated Rate |
$185.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$117.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$20.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.70
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$165.75
|
| Rate for Payer: First Health Commercial |
$175.50
|
| Rate for Payer: First Health Workers Compensation |
$27.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$175.50
|
| Rate for Payer: GEHA Commercial |
$156.00
|
| Rate for Payer: GEHA Medicare |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$175.50
|
| Rate for Payer: Humana ChoiceCare |
$16.17
|
| Rate for Payer: Humana Medicare Advantage |
$14.70
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$24.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.39
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.70
|
| Rate for Payer: Multiplan All |
$177.45
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.99
|
| Rate for Payer: OMNI Networks Commercial |
$136.50
|
| Rate for Payer: One Health Plan PPO/POS |
$175.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$24.70
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.39
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$185.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.40
|
| Rate for Payer: Three Rivers Provider Network All |
$146.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.41
|
| Rate for Payer: United Healthcare Commercial |
$165.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.70
|
| Rate for Payer: United Payors & United Providers UP&UP |
$181.35
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.70
|
| Rate for Payer: Zelis Auto |
$78.00
|
| Rate for Payer: Zelis Medicare |
$12.49
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.64
|
| Rate for Payer: Zelis Worker's Compensation |
$19.47
|
|
|
FOLIC ACID
|
Facility
|
IP
|
$195.00
|
|
|
Service Code
|
CPT 82746
|
| Hospital Charge Code |
2232746
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.47 |
| Max. Negotiated Rate |
$185.25 |
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$165.75
|
| Rate for Payer: First Health Commercial |
$175.50
|
| Rate for Payer: First Health Workers Compensation |
$27.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$175.50
|
| Rate for Payer: GEHA Commercial |
$136.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$175.50
|
| Rate for Payer: Multiplan All |
$177.45
|
| Rate for Payer: OMNI Networks Commercial |
$136.50
|
| Rate for Payer: One Health Plan PPO/POS |
$175.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$185.25
|
| Rate for Payer: Three Rivers Provider Network All |
$146.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$181.35
|
| Rate for Payer: Zelis Auto |
$78.00
|
| Rate for Payer: Zelis Worker's Compensation |
$19.47
|
|
