|
metroNIDAZOLE 500MG/100ML IV PREMIX
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300597
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$12.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Humana ChoiceCare |
$4.16
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.60
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
metroNIDAZOLE 500MG/100ML IV PREMIX
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300597
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$11.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
METRONIDAZOLE TOPICAL 0.75% CREAM 45 GM
|
Facility
|
OP
|
$553.00
|
|
|
Service Code
|
NDC 66993096045
|
| Hospital Charge Code |
3302868
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$138.25 |
| Max. Negotiated Rate |
$525.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$331.80
|
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cigna Commercial |
$470.05
|
| Rate for Payer: First Health Commercial |
$497.70
|
| Rate for Payer: First Health Workers Compensation |
$213.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$497.70
|
| Rate for Payer: GEHA Commercial |
$442.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$497.70
|
| Rate for Payer: Humana ChoiceCare |
$143.78
|
| Rate for Payer: Multiplan All |
$503.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$331.80
|
| Rate for Payer: OMNI Networks Commercial |
$387.10
|
| Rate for Payer: One Health Plan PPO/POS |
$497.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$525.35
|
| Rate for Payer: Three Rivers Provider Network All |
$414.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$486.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$138.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$514.29
|
| Rate for Payer: Zelis Auto |
$221.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$276.50
|
| Rate for Payer: Zelis Worker's Compensation |
$150.97
|
|
|
METRONIDAZOLE TOPICAL 0.75% CREAM 45 GM
|
Facility
|
IP
|
$553.00
|
|
|
Service Code
|
NDC 66993096045
|
| Hospital Charge Code |
3302868
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$150.97 |
| Max. Negotiated Rate |
$525.35 |
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cigna Commercial |
$470.05
|
| Rate for Payer: First Health Commercial |
$497.70
|
| Rate for Payer: First Health Workers Compensation |
$213.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$497.70
|
| Rate for Payer: GEHA Commercial |
$387.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$497.70
|
| Rate for Payer: Multiplan All |
$503.23
|
| Rate for Payer: OMNI Networks Commercial |
$387.10
|
| Rate for Payer: One Health Plan PPO/POS |
$497.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$525.35
|
| Rate for Payer: Three Rivers Provider Network All |
$414.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$514.29
|
| Rate for Payer: Zelis Auto |
$221.20
|
| Rate for Payer: Zelis Worker's Compensation |
$150.97
|
|
|
MICAFUNGIN 100 MG PWVL
|
Facility
|
OP
|
$513.00
|
|
|
Service Code
|
CPT J2248
|
| Hospital Charge Code |
3302849
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$487.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$307.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1.31
|
| Rate for Payer: Cash Price |
$307.80
|
| Rate for Payer: Cash Price |
$307.80
|
| Rate for Payer: Cigna Commercial |
$436.05
|
| Rate for Payer: First Health Commercial |
$461.70
|
| Rate for Payer: First Health Workers Compensation |
$198.07
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$461.70
|
| Rate for Payer: GEHA Commercial |
$0.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$461.70
|
| Rate for Payer: Humana ChoiceCare |
$133.38
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1.33
|
| Rate for Payer: Multiplan All |
$466.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$307.80
|
| Rate for Payer: OMNI Networks Commercial |
$359.10
|
| Rate for Payer: One Health Plan PPO/POS |
$461.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1.54
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1.33
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$487.35
|
| Rate for Payer: Three Rivers Provider Network All |
$384.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$451.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.33
|
| Rate for Payer: United Payors & United Providers UP&UP |
$477.09
|
| Rate for Payer: Zelis Auto |
$205.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$256.50
|
| Rate for Payer: Zelis Worker's Compensation |
$140.05
|
|
|
MICAFUNGIN 100 MG PWVL
|
Facility
|
IP
|
$513.00
|
|
|
Service Code
|
CPT J2248
|
| Hospital Charge Code |
3302849
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$140.05 |
| Max. Negotiated Rate |
$487.35 |
| Rate for Payer: Cash Price |
$307.80
|
| Rate for Payer: Cigna Commercial |
$436.05
|
| Rate for Payer: First Health Commercial |
$461.70
|
| Rate for Payer: First Health Workers Compensation |
$198.07
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$461.70
|
| Rate for Payer: GEHA Commercial |
$359.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$461.70
|
| Rate for Payer: Multiplan All |
$466.83
|
| Rate for Payer: OMNI Networks Commercial |
$359.10
|
| Rate for Payer: One Health Plan PPO/POS |
$461.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$487.35
|
| Rate for Payer: Three Rivers Provider Network All |
$384.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$477.09
|
| Rate for Payer: Zelis Auto |
$205.20
|
| Rate for Payer: Zelis Worker's Compensation |
$140.05
|
|
|
MICAFUNGIN 50 MG VIAL
|
Facility
|
IP
|
$208.48
|
|
|
Service Code
|
CPT J2248
|
| Hospital Charge Code |
3303178
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.92 |
| Max. Negotiated Rate |
$198.06 |
| Rate for Payer: Cash Price |
$125.09
|
| Rate for Payer: Cigna Commercial |
$177.21
|
| Rate for Payer: First Health Commercial |
$187.63
|
| Rate for Payer: First Health Workers Compensation |
$80.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$187.63
|
| Rate for Payer: GEHA Commercial |
$145.94
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$187.63
|
| Rate for Payer: Multiplan All |
$189.72
|
| Rate for Payer: OMNI Networks Commercial |
$145.94
|
| Rate for Payer: One Health Plan PPO/POS |
$187.63
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$198.06
|
| Rate for Payer: Three Rivers Provider Network All |
$156.36
|
| Rate for Payer: United Payors & United Providers UP&UP |
$193.89
|
| Rate for Payer: Zelis Auto |
$83.39
|
| Rate for Payer: Zelis Worker's Compensation |
$56.92
|
|
|
MICAFUNGIN 50 MG VIAL
|
Facility
|
OP
|
$208.48
|
|
|
Service Code
|
CPT J2248
|
| Hospital Charge Code |
3303178
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$198.06 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$125.09
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1.31
|
| Rate for Payer: Cash Price |
$125.09
|
| Rate for Payer: Cash Price |
$125.09
|
| Rate for Payer: Cigna Commercial |
$177.21
|
| Rate for Payer: First Health Commercial |
$187.63
|
| Rate for Payer: First Health Workers Compensation |
$80.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$187.63
|
| Rate for Payer: GEHA Commercial |
$0.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$187.63
|
| Rate for Payer: Humana ChoiceCare |
$54.20
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1.33
|
| Rate for Payer: Multiplan All |
$189.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$125.09
|
| Rate for Payer: OMNI Networks Commercial |
$145.94
|
| Rate for Payer: One Health Plan PPO/POS |
$187.63
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1.54
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1.33
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$198.06
|
| Rate for Payer: Three Rivers Provider Network All |
$156.36
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$183.46
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.33
|
| Rate for Payer: United Payors & United Providers UP&UP |
$193.89
|
| Rate for Payer: Zelis Auto |
$83.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$104.24
|
| Rate for Payer: Zelis Worker's Compensation |
$56.92
|
|
|
MICONAZOLE CREAM 2%
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 00472073556
|
| Hospital Charge Code |
3301826
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Humana ChoiceCare |
$5.46
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.60
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
MICONAZOLE CREAM 2%
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 00472073556
|
| Hospital Charge Code |
3301826
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
MICONAZOLE NITRATE POWDER 2%
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
NDC 00316023225
|
| Hospital Charge Code |
3300599
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.37 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$32.30
|
| Rate for Payer: First Health Commercial |
$34.20
|
| Rate for Payer: First Health Workers Compensation |
$14.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$34.20
|
| Rate for Payer: GEHA Commercial |
$26.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$34.20
|
| Rate for Payer: Multiplan All |
$34.58
|
| Rate for Payer: OMNI Networks Commercial |
$26.60
|
| Rate for Payer: One Health Plan PPO/POS |
$34.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$36.10
|
| Rate for Payer: Three Rivers Provider Network All |
$28.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$35.34
|
| Rate for Payer: Zelis Auto |
$15.20
|
| Rate for Payer: Zelis Worker's Compensation |
$10.37
|
|
|
MICONAZOLE NITRATE POWDER 2%
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
NDC 00316023225
|
| Hospital Charge Code |
3300599
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$32.30
|
| Rate for Payer: First Health Commercial |
$34.20
|
| Rate for Payer: First Health Workers Compensation |
$14.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$34.20
|
| Rate for Payer: GEHA Commercial |
$30.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$34.20
|
| Rate for Payer: Humana ChoiceCare |
$9.88
|
| Rate for Payer: Multiplan All |
$34.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.80
|
| Rate for Payer: OMNI Networks Commercial |
$26.60
|
| Rate for Payer: One Health Plan PPO/POS |
$34.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$36.10
|
| Rate for Payer: Three Rivers Provider Network All |
$28.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$33.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$35.34
|
| Rate for Payer: Zelis Auto |
$15.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$19.00
|
| Rate for Payer: Zelis Worker's Compensation |
$10.37
|
|
|
MICONAZOLE POWDER
|
Facility
|
OP
|
$329.00
|
|
|
Service Code
|
NDC 70000032301
|
| Hospital Charge Code |
3300602
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.25 |
| Max. Negotiated Rate |
$312.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$197.40
|
| Rate for Payer: Cash Price |
$197.40
|
| Rate for Payer: Cigna Commercial |
$279.65
|
| Rate for Payer: First Health Commercial |
$296.10
|
| Rate for Payer: First Health Workers Compensation |
$127.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$296.10
|
| Rate for Payer: GEHA Commercial |
$263.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$296.10
|
| Rate for Payer: Humana ChoiceCare |
$85.54
|
| Rate for Payer: Multiplan All |
$299.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$197.40
|
| Rate for Payer: OMNI Networks Commercial |
$230.30
|
| Rate for Payer: One Health Plan PPO/POS |
$296.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$312.55
|
| Rate for Payer: Three Rivers Provider Network All |
$246.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$289.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$82.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$305.97
|
| Rate for Payer: Zelis Auto |
$131.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$164.50
|
| Rate for Payer: Zelis Worker's Compensation |
$89.82
|
|
|
MICONAZOLE POWDER
|
Facility
|
IP
|
$329.00
|
|
|
Service Code
|
NDC 70000032301
|
| Hospital Charge Code |
3300602
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$312.55 |
| Rate for Payer: Cash Price |
$197.40
|
| Rate for Payer: Cigna Commercial |
$279.65
|
| Rate for Payer: First Health Commercial |
$296.10
|
| Rate for Payer: First Health Workers Compensation |
$127.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$296.10
|
| Rate for Payer: GEHA Commercial |
$230.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$296.10
|
| Rate for Payer: Multiplan All |
$299.39
|
| Rate for Payer: OMNI Networks Commercial |
$230.30
|
| Rate for Payer: One Health Plan PPO/POS |
$296.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$312.55
|
| Rate for Payer: Three Rivers Provider Network All |
$246.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$305.97
|
| Rate for Payer: Zelis Auto |
$131.60
|
| Rate for Payer: Zelis Worker's Compensation |
$89.82
|
|
|
MICONAZOLE VAGINAL CREAM 2%
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
NDC 51672203506
|
| Hospital Charge Code |
3300600
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.74 |
| Max. Negotiated Rate |
$51.30 |
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$45.90
|
| Rate for Payer: First Health Commercial |
$48.60
|
| Rate for Payer: First Health Workers Compensation |
$20.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$48.60
|
| Rate for Payer: GEHA Commercial |
$37.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$48.60
|
| Rate for Payer: Multiplan All |
$49.14
|
| Rate for Payer: OMNI Networks Commercial |
$37.80
|
| Rate for Payer: One Health Plan PPO/POS |
$48.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$51.30
|
| Rate for Payer: Three Rivers Provider Network All |
$40.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$50.22
|
| Rate for Payer: Zelis Auto |
$21.60
|
| Rate for Payer: Zelis Worker's Compensation |
$14.74
|
|
|
MICONAZOLE VAGINAL CREAM 2%
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
NDC 51672203506
|
| Hospital Charge Code |
3300600
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$51.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$45.90
|
| Rate for Payer: First Health Commercial |
$48.60
|
| Rate for Payer: First Health Workers Compensation |
$20.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$48.60
|
| Rate for Payer: GEHA Commercial |
$43.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$48.60
|
| Rate for Payer: Humana ChoiceCare |
$14.04
|
| Rate for Payer: Multiplan All |
$49.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$32.40
|
| Rate for Payer: OMNI Networks Commercial |
$37.80
|
| Rate for Payer: One Health Plan PPO/POS |
$48.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$51.30
|
| Rate for Payer: Three Rivers Provider Network All |
$40.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$47.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$50.22
|
| Rate for Payer: Zelis Auto |
$21.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$27.00
|
| Rate for Payer: Zelis Worker's Compensation |
$14.74
|
|
|
MICONAZOLE VAGINAL SUPP 200MG
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
NDC 00472173803
|
| Hospital Charge Code |
3300601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.75 |
| Max. Negotiated Rate |
$82.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$52.20
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$73.95
|
| Rate for Payer: First Health Commercial |
$78.30
|
| Rate for Payer: First Health Workers Compensation |
$33.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$78.30
|
| Rate for Payer: GEHA Commercial |
$69.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$78.30
|
| Rate for Payer: Humana ChoiceCare |
$22.62
|
| Rate for Payer: Multiplan All |
$79.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$52.20
|
| Rate for Payer: OMNI Networks Commercial |
$60.90
|
| Rate for Payer: One Health Plan PPO/POS |
$78.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$82.65
|
| Rate for Payer: Three Rivers Provider Network All |
$65.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$76.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$80.91
|
| Rate for Payer: Zelis Auto |
$34.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$43.50
|
| Rate for Payer: Zelis Worker's Compensation |
$23.75
|
|
|
MICONAZOLE VAGINAL SUPP 200MG
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
NDC 00472173803
|
| Hospital Charge Code |
3300601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.75 |
| Max. Negotiated Rate |
$82.65 |
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$73.95
|
| Rate for Payer: First Health Commercial |
$78.30
|
| Rate for Payer: First Health Workers Compensation |
$33.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$78.30
|
| Rate for Payer: GEHA Commercial |
$60.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$78.30
|
| Rate for Payer: Multiplan All |
$79.17
|
| Rate for Payer: OMNI Networks Commercial |
$60.90
|
| Rate for Payer: One Health Plan PPO/POS |
$78.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$82.65
|
| Rate for Payer: Three Rivers Provider Network All |
$65.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$80.91
|
| Rate for Payer: Zelis Auto |
$34.80
|
| Rate for Payer: Zelis Worker's Compensation |
$23.75
|
|
|
MICROALBUMIN URINE 24H (Vitros)
|
Facility
|
IP
|
$205.00
|
|
|
Service Code
|
CPT 82043
|
| Hospital Charge Code |
2232247
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.23 |
| Max. Negotiated Rate |
$194.75 |
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cigna Commercial |
$174.25
|
| Rate for Payer: First Health Commercial |
$184.50
|
| Rate for Payer: First Health Workers Compensation |
$10.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$184.50
|
| Rate for Payer: GEHA Commercial |
$143.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$184.50
|
| Rate for Payer: Multiplan All |
$186.55
|
| Rate for Payer: OMNI Networks Commercial |
$143.50
|
| Rate for Payer: One Health Plan PPO/POS |
$184.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$194.75
|
| Rate for Payer: Three Rivers Provider Network All |
$153.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$190.65
|
| Rate for Payer: Zelis Auto |
$82.00
|
| Rate for Payer: Zelis Worker's Compensation |
$7.23
|
|
|
MICROALBUMIN URINE 24H (Vitros)
|
Facility
|
OP
|
$205.00
|
|
|
Service Code
|
CPT 82043
|
| Hospital Charge Code |
2232247
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$194.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$10.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$123.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$10.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$8.25
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.78
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cigna Commercial |
$174.25
|
| Rate for Payer: First Health Commercial |
$184.50
|
| Rate for Payer: First Health Workers Compensation |
$10.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$184.50
|
| Rate for Payer: GEHA Commercial |
$164.00
|
| Rate for Payer: GEHA Medicare |
$5.78
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$184.50
|
| Rate for Payer: Humana ChoiceCare |
$6.36
|
| Rate for Payer: Humana Medicare Advantage |
$5.78
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$9.71
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$8.41
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.78
|
| Rate for Payer: Multiplan All |
$186.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.83
|
| Rate for Payer: OMNI Networks Commercial |
$143.50
|
| Rate for Payer: One Health Plan PPO/POS |
$184.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$9.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$8.41
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.78
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$194.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11.56
|
| Rate for Payer: Three Rivers Provider Network All |
$153.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.66
|
| Rate for Payer: United Healthcare Commercial |
$174.25
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.78
|
| Rate for Payer: United Payors & United Providers UP&UP |
$190.65
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.78
|
| Rate for Payer: Zelis Auto |
$82.00
|
| Rate for Payer: Zelis Medicare |
$4.91
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.94
|
| Rate for Payer: Zelis Worker's Compensation |
$7.23
|
|
|
MICROALBUMIN URINE (Vitros)
|
Facility
|
OP
|
$205.00
|
|
|
Service Code
|
CPT 82043
|
| Hospital Charge Code |
2232246
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$194.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$10.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$123.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$10.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$8.25
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.78
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cigna Commercial |
$174.25
|
| Rate for Payer: First Health Commercial |
$184.50
|
| Rate for Payer: First Health Workers Compensation |
$10.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$184.50
|
| Rate for Payer: GEHA Commercial |
$164.00
|
| Rate for Payer: GEHA Medicare |
$5.78
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$184.50
|
| Rate for Payer: Humana ChoiceCare |
$6.36
|
| Rate for Payer: Humana Medicare Advantage |
$5.78
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$9.71
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$8.41
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.78
|
| Rate for Payer: Multiplan All |
$186.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.83
|
| Rate for Payer: OMNI Networks Commercial |
$143.50
|
| Rate for Payer: One Health Plan PPO/POS |
$184.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$9.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$8.41
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.78
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$194.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11.56
|
| Rate for Payer: Three Rivers Provider Network All |
$153.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.66
|
| Rate for Payer: United Healthcare Commercial |
$174.25
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.78
|
| Rate for Payer: United Payors & United Providers UP&UP |
$190.65
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.78
|
| Rate for Payer: Zelis Auto |
$82.00
|
| Rate for Payer: Zelis Medicare |
$4.91
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.94
|
| Rate for Payer: Zelis Worker's Compensation |
$7.23
|
|
|
MICROALBUMIN URINE (Vitros)
|
Facility
|
IP
|
$205.00
|
|
|
Service Code
|
CPT 82043
|
| Hospital Charge Code |
2232246
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.23 |
| Max. Negotiated Rate |
$194.75 |
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cigna Commercial |
$174.25
|
| Rate for Payer: First Health Commercial |
$184.50
|
| Rate for Payer: First Health Workers Compensation |
$10.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$184.50
|
| Rate for Payer: GEHA Commercial |
$143.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$184.50
|
| Rate for Payer: Multiplan All |
$186.55
|
| Rate for Payer: OMNI Networks Commercial |
$143.50
|
| Rate for Payer: One Health Plan PPO/POS |
$184.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$194.75
|
| Rate for Payer: Three Rivers Provider Network All |
$153.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$190.65
|
| Rate for Payer: Zelis Auto |
$82.00
|
| Rate for Payer: Zelis Worker's Compensation |
$7.23
|
|
|
MICROFIBRILLAR COLLAGEN POWDER
|
Facility
|
OP
|
$585.00
|
|
|
Service Code
|
NDC 53276101002
|
| Hospital Charge Code |
3300603
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$146.25 |
| Max. Negotiated Rate |
$555.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$351.00
|
| Rate for Payer: Cash Price |
$351.00
|
| Rate for Payer: Cigna Commercial |
$497.25
|
| Rate for Payer: First Health Commercial |
$526.50
|
| Rate for Payer: First Health Workers Compensation |
$225.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$526.50
|
| Rate for Payer: GEHA Commercial |
$468.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$526.50
|
| Rate for Payer: Humana ChoiceCare |
$152.10
|
| Rate for Payer: Multiplan All |
$532.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$351.00
|
| Rate for Payer: OMNI Networks Commercial |
$409.50
|
| Rate for Payer: One Health Plan PPO/POS |
$526.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$555.75
|
| Rate for Payer: Three Rivers Provider Network All |
$438.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$514.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$146.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$544.05
|
| Rate for Payer: Zelis Auto |
$234.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$292.50
|
| Rate for Payer: Zelis Worker's Compensation |
$159.71
|
|
|
MICROFIBRILLAR COLLAGEN POWDER
|
Facility
|
IP
|
$585.00
|
|
|
Service Code
|
NDC 53276101002
|
| Hospital Charge Code |
3300603
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$159.71 |
| Max. Negotiated Rate |
$555.75 |
| Rate for Payer: Cash Price |
$351.00
|
| Rate for Payer: Cigna Commercial |
$497.25
|
| Rate for Payer: First Health Commercial |
$526.50
|
| Rate for Payer: First Health Workers Compensation |
$225.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$526.50
|
| Rate for Payer: GEHA Commercial |
$409.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$526.50
|
| Rate for Payer: Multiplan All |
$532.35
|
| Rate for Payer: OMNI Networks Commercial |
$409.50
|
| Rate for Payer: One Health Plan PPO/POS |
$526.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$555.75
|
| Rate for Payer: Three Rivers Provider Network All |
$438.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$544.05
|
| Rate for Payer: Zelis Auto |
$234.00
|
| Rate for Payer: Zelis Worker's Compensation |
$159.71
|
|
|
microsporidia stain REF828795
|
Facility
|
IP
|
$310.00
|
|
|
Service Code
|
CPT 87015
|
| Hospital Charge Code |
2200422
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.72 |
| Max. Negotiated Rate |
$294.50 |
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$263.50
|
| Rate for Payer: First Health Commercial |
$279.00
|
| Rate for Payer: First Health Workers Compensation |
$12.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$279.00
|
| Rate for Payer: GEHA Commercial |
$217.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$279.00
|
| Rate for Payer: Multiplan All |
$282.10
|
| Rate for Payer: OMNI Networks Commercial |
$217.00
|
| Rate for Payer: One Health Plan PPO/POS |
$279.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$294.50
|
| Rate for Payer: Three Rivers Provider Network All |
$232.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$288.30
|
| Rate for Payer: Zelis Auto |
$124.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.72
|
|
