|
AMIODARONE 150MG/3ML VIAL
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
CPT J0282
|
| Hospital Charge Code |
3300039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.47 |
| 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: 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 |
$0.47
|
| 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
|
|
|
AMIODARONE 150MG/3ML VIAL
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
CPT J0282
|
| Hospital Charge Code |
3300039
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
AMIODARONE 360MG/200ML D5W PREMIX
|
Facility
|
OP
|
$338.00
|
|
|
Service Code
|
CPT J0282
|
| Hospital Charge Code |
3300040
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$321.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$202.80
|
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Cigna Commercial |
$287.30
|
| Rate for Payer: First Health Commercial |
$304.20
|
| Rate for Payer: First Health Workers Compensation |
$130.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$304.20
|
| Rate for Payer: GEHA Commercial |
$0.47
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$304.20
|
| Rate for Payer: Humana ChoiceCare |
$87.88
|
| Rate for Payer: Multiplan All |
$307.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$202.80
|
| Rate for Payer: OMNI Networks Commercial |
$236.60
|
| Rate for Payer: One Health Plan PPO/POS |
$304.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$321.10
|
| Rate for Payer: Three Rivers Provider Network All |
$253.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$297.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$84.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$314.34
|
| Rate for Payer: Zelis Auto |
$135.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$169.00
|
| Rate for Payer: Zelis Worker's Compensation |
$92.27
|
|
|
AMIODARONE 360MG/200ML D5W PREMIX
|
Facility
|
IP
|
$338.00
|
|
|
Service Code
|
CPT J0282
|
| Hospital Charge Code |
3300040
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.27 |
| Max. Negotiated Rate |
$321.10 |
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Cigna Commercial |
$287.30
|
| Rate for Payer: First Health Commercial |
$304.20
|
| Rate for Payer: First Health Workers Compensation |
$130.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$304.20
|
| Rate for Payer: GEHA Commercial |
$236.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$304.20
|
| Rate for Payer: Multiplan All |
$307.58
|
| Rate for Payer: OMNI Networks Commercial |
$236.60
|
| Rate for Payer: One Health Plan PPO/POS |
$304.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$321.10
|
| Rate for Payer: Three Rivers Provider Network All |
$253.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$314.34
|
| Rate for Payer: Zelis Auto |
$135.20
|
| Rate for Payer: Zelis Worker's Compensation |
$92.27
|
|
|
AMIODARONE HCL 200 MG TAB
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 68084037111
|
| Hospital Charge Code |
3300041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$6.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
AMIODARONE HCL 200 MG TAB
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 68084037111
|
| Hospital Charge Code |
3300041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$7.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Humana ChoiceCare |
$2.34
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5.40
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.50
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
amiodarone REF706705
|
Facility
|
IP
|
$251.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
2200685
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$22.12 |
| Max. Negotiated Rate |
$238.45 |
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cigna Commercial |
$213.35
|
| Rate for Payer: First Health Commercial |
$225.90
|
| Rate for Payer: First Health Workers Compensation |
$31.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$225.90
|
| Rate for Payer: GEHA Commercial |
$175.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$225.90
|
| Rate for Payer: Multiplan All |
$228.41
|
| Rate for Payer: OMNI Networks Commercial |
$175.70
|
| Rate for Payer: One Health Plan PPO/POS |
$225.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$238.45
|
| Rate for Payer: Three Rivers Provider Network All |
$188.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$233.43
|
| Rate for Payer: Zelis Auto |
$100.40
|
| Rate for Payer: Zelis Worker's Compensation |
$22.12
|
|
|
amiodarone REF706705
|
Facility
|
OP
|
$251.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
2200685
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.84 |
| Max. Negotiated Rate |
$238.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$33.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$150.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$33.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$26.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$18.64
|
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cash Price |
$150.60
|
| Rate for Payer: Cigna Commercial |
$213.35
|
| Rate for Payer: First Health Commercial |
$225.90
|
| Rate for Payer: First Health Workers Compensation |
$31.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$225.90
|
| Rate for Payer: GEHA Commercial |
$200.80
|
| Rate for Payer: GEHA Medicare |
$18.64
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$225.90
|
| Rate for Payer: Humana ChoiceCare |
$20.50
|
| Rate for Payer: Humana Medicare Advantage |
$18.64
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$31.32
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$27.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$18.64
|
| Rate for Payer: Multiplan All |
$228.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.69
|
| Rate for Payer: OMNI Networks Commercial |
$175.70
|
| Rate for Payer: One Health Plan PPO/POS |
$225.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$31.32
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$27.12
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$18.64
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$238.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$37.28
|
| Rate for Payer: Three Rivers Provider Network All |
$188.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.27
|
| Rate for Payer: United Healthcare Commercial |
$213.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$27.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: United Payors & United Providers UP&UP |
$233.43
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$18.64
|
| Rate for Payer: Zelis Auto |
$100.40
|
| Rate for Payer: Zelis Medicare |
$15.84
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.37
|
| Rate for Payer: Zelis Worker's Compensation |
$22.12
|
|
|
AMITRIPTYLINE HCL 100 MG TABLET
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 51079056320
|
| Hospital Charge Code |
3302836
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Humana ChoiceCare |
$1.82
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.20
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
AMITRIPTYLINE HCL 100 MG TABLET
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 51079056320
|
| Hospital Charge Code |
3302836
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$4.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
AMITRIPTYLINE HCL 10MG TAB
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 51079013120
|
| Hospital Charge Code |
3300042
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$4.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Humana ChoiceCare |
$1.30
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.00
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
AMITRIPTYLINE HCL 10MG TAB
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 51079013120
|
| Hospital Charge Code |
3300042
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
AMITRIPTYLINE HCL 25MG TAB
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 60687043311
|
| Hospital Charge Code |
3300043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Humana ChoiceCare |
$1.82
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.20
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
AMITRIPTYLINE HCL 25MG TAB
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 60687043311
|
| Hospital Charge Code |
3300043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$4.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
amitriptyline REF007476
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
2299260
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$120.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$76.20
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$107.95
|
| Rate for Payer: First Health Commercial |
$114.30
|
| Rate for Payer: First Health Workers Compensation |
$27.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$114.30
|
| Rate for Payer: GEHA Commercial |
$101.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$114.30
|
| Rate for Payer: Humana ChoiceCare |
$33.02
|
| Rate for Payer: Multiplan All |
$115.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$76.20
|
| Rate for Payer: OMNI Networks Commercial |
$88.90
|
| Rate for Payer: One Health Plan PPO/POS |
$114.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$120.65
|
| Rate for Payer: Three Rivers Provider Network All |
$95.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$111.76
|
| Rate for Payer: United Healthcare Commercial |
$107.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$118.11
|
| Rate for Payer: Zelis Auto |
$50.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$63.50
|
| Rate for Payer: Zelis Worker's Compensation |
$19.29
|
|
|
amitriptyline REF007476
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
2299260
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$120.65 |
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$107.95
|
| Rate for Payer: First Health Commercial |
$114.30
|
| Rate for Payer: First Health Workers Compensation |
$27.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$114.30
|
| Rate for Payer: GEHA Commercial |
$88.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$114.30
|
| Rate for Payer: Multiplan All |
$115.57
|
| Rate for Payer: OMNI Networks Commercial |
$88.90
|
| Rate for Payer: One Health Plan PPO/POS |
$114.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$120.65
|
| Rate for Payer: Three Rivers Provider Network All |
$95.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$118.11
|
| Rate for Payer: Zelis Auto |
$50.80
|
| Rate for Payer: Zelis Worker's Compensation |
$19.29
|
|
|
AmLODIPine BESYLATE 5MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904637061
|
| Hospital Charge Code |
3300045
|
|
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
|
|
|
AmLODIPine BESYLATE 5MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904637061
|
| Hospital Charge Code |
3300045
|
|
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
|
|
|
AMMONIA AROMATIC INHALATION
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 67777251001
|
| Hospital Charge Code |
3300046
|
|
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
|
|
|
AMMONIA AROMATIC INHALATION
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 67777251001
|
| Hospital Charge Code |
3300046
|
|
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
|
|
|
AMMONIA BLOOD (Vitros)
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
CPT 82140
|
| Hospital Charge Code |
2232215
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.74 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$163.20
|
| Rate for Payer: First Health Commercial |
$172.80
|
| Rate for Payer: First Health Workers Compensation |
$27.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$172.80
|
| Rate for Payer: GEHA Commercial |
$134.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$172.80
|
| Rate for Payer: Multiplan All |
$174.72
|
| Rate for Payer: OMNI Networks Commercial |
$134.40
|
| Rate for Payer: One Health Plan PPO/POS |
$172.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$182.40
|
| Rate for Payer: Three Rivers Provider Network All |
$144.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$178.56
|
| Rate for Payer: Zelis Auto |
$76.80
|
| Rate for Payer: Zelis Worker's Compensation |
$19.74
|
|
|
AMMONIA BLOOD (Vitros)
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
CPT 82140
|
| Hospital Charge Code |
2232215
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$115.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.57
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$163.20
|
| Rate for Payer: First Health Commercial |
$172.80
|
| Rate for Payer: First Health Workers Compensation |
$27.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$172.80
|
| Rate for Payer: GEHA Commercial |
$153.60
|
| Rate for Payer: GEHA Medicare |
$14.57
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$172.80
|
| Rate for Payer: Humana ChoiceCare |
$16.03
|
| Rate for Payer: Humana Medicare Advantage |
$14.57
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$24.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.19
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.57
|
| Rate for Payer: Multiplan All |
$174.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.77
|
| Rate for Payer: OMNI Networks Commercial |
$134.40
|
| Rate for Payer: One Health Plan PPO/POS |
$172.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$24.47
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.19
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.57
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$182.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.14
|
| Rate for Payer: Three Rivers Provider Network All |
$144.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.28
|
| Rate for Payer: United Healthcare Commercial |
$163.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.57
|
| Rate for Payer: United Payors & United Providers UP&UP |
$178.56
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.57
|
| Rate for Payer: Zelis Auto |
$76.80
|
| Rate for Payer: Zelis Medicare |
$12.38
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.48
|
| Rate for Payer: Zelis Worker's Compensation |
$19.74
|
|
|
AMMONIUM URINE
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
CPT 82140
|
| Hospital Charge Code |
2299376
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$115.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$20.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.57
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$163.20
|
| Rate for Payer: First Health Commercial |
$172.80
|
| Rate for Payer: First Health Workers Compensation |
$27.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$172.80
|
| Rate for Payer: GEHA Commercial |
$153.60
|
| Rate for Payer: GEHA Medicare |
$14.57
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$172.80
|
| Rate for Payer: Humana ChoiceCare |
$16.03
|
| Rate for Payer: Humana Medicare Advantage |
$14.57
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$24.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.19
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.57
|
| Rate for Payer: Multiplan All |
$174.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.77
|
| Rate for Payer: OMNI Networks Commercial |
$134.40
|
| Rate for Payer: One Health Plan PPO/POS |
$172.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$24.47
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.19
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.57
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$182.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.14
|
| Rate for Payer: Three Rivers Provider Network All |
$144.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.28
|
| Rate for Payer: United Healthcare Commercial |
$163.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.57
|
| Rate for Payer: United Payors & United Providers UP&UP |
$178.56
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.57
|
| Rate for Payer: Zelis Auto |
$76.80
|
| Rate for Payer: Zelis Medicare |
$12.38
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.48
|
| Rate for Payer: Zelis Worker's Compensation |
$19.74
|
|
|
AMMONIUM URINE
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
CPT 82140
|
| Hospital Charge Code |
2299376
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.74 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$163.20
|
| Rate for Payer: First Health Commercial |
$172.80
|
| Rate for Payer: First Health Workers Compensation |
$27.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$172.80
|
| Rate for Payer: GEHA Commercial |
$134.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$172.80
|
| Rate for Payer: Multiplan All |
$174.72
|
| Rate for Payer: OMNI Networks Commercial |
$134.40
|
| Rate for Payer: One Health Plan PPO/POS |
$172.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$182.40
|
| Rate for Payer: Three Rivers Provider Network All |
$144.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$178.56
|
| Rate for Payer: Zelis Auto |
$76.80
|
| Rate for Payer: Zelis Worker's Compensation |
$19.74
|
|
|
AMOXICILLIN 125MG/5ML SUSP PER 5ML DOSE
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 00781604146
|
| Hospital Charge Code |
3300051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
