|
MIDAZOLAM HCL 5 MG/1 ML INJ
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
CPT J2250
|
| Hospital Charge Code |
3300605
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
MIDAZOLAM HCL 5 MG/1 ML INJ
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
CPT J2250
|
| Hospital Charge Code |
3300605
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| 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: 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 |
$0.17
|
| 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
|
|
|
MIDAZOLAM HCL INJ 2MG/2ML
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
CPT J2250
|
| Hospital Charge Code |
3300604
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| 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: 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 |
$0.17
|
| 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
|
|
|
MIDAZOLAM HCL INJ 2MG/2ML
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
CPT J2250
|
| Hospital Charge Code |
3300604
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
MIDAZOLAM HCL SYRUP 10MG/5ML
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
NDC 68094076459
|
| Hospital Charge Code |
3300606
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$34.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$30.60
|
| Rate for Payer: First Health Commercial |
$32.40
|
| Rate for Payer: First Health Workers Compensation |
$13.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$32.40
|
| Rate for Payer: GEHA Commercial |
$28.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$32.40
|
| Rate for Payer: Humana ChoiceCare |
$9.36
|
| Rate for Payer: Multiplan All |
$32.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$21.60
|
| Rate for Payer: OMNI Networks Commercial |
$25.20
|
| Rate for Payer: One Health Plan PPO/POS |
$32.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$34.20
|
| Rate for Payer: Three Rivers Provider Network All |
$27.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$31.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$33.48
|
| Rate for Payer: Zelis Auto |
$14.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$18.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.83
|
|
|
MIDAZOLAM HCL SYRUP 10MG/5ML
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
NDC 68094076459
|
| Hospital Charge Code |
3300606
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.83 |
| Max. Negotiated Rate |
$34.20 |
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$30.60
|
| Rate for Payer: First Health Commercial |
$32.40
|
| Rate for Payer: First Health Workers Compensation |
$13.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$32.40
|
| Rate for Payer: GEHA Commercial |
$25.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$32.40
|
| Rate for Payer: Multiplan All |
$32.76
|
| Rate for Payer: OMNI Networks Commercial |
$25.20
|
| Rate for Payer: One Health Plan PPO/POS |
$32.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$34.20
|
| Rate for Payer: Three Rivers Provider Network All |
$27.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$33.48
|
| Rate for Payer: Zelis Auto |
$14.40
|
| Rate for Payer: Zelis Worker's Compensation |
$9.83
|
|
|
MIDAZOLAM (VERSED) SYRUP 5MG/2.5ML
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
NDC 68094076262
|
| Hospital Charge Code |
3302352
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.47 |
| Max. Negotiated Rate |
$39.90 |
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$35.70
|
| Rate for Payer: First Health Commercial |
$37.80
|
| Rate for Payer: First Health Workers Compensation |
$16.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$37.80
|
| Rate for Payer: GEHA Commercial |
$29.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$37.80
|
| Rate for Payer: Multiplan All |
$38.22
|
| Rate for Payer: OMNI Networks Commercial |
$29.40
|
| Rate for Payer: One Health Plan PPO/POS |
$37.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$39.90
|
| Rate for Payer: Three Rivers Provider Network All |
$31.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$39.06
|
| Rate for Payer: Zelis Auto |
$16.80
|
| Rate for Payer: Zelis Worker's Compensation |
$11.47
|
|
|
MIDAZOLAM (VERSED) SYRUP 5MG/2.5ML
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
NDC 68094076262
|
| Hospital Charge Code |
3302352
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$39.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$35.70
|
| Rate for Payer: First Health Commercial |
$37.80
|
| Rate for Payer: First Health Workers Compensation |
$16.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$37.80
|
| Rate for Payer: GEHA Commercial |
$33.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$37.80
|
| Rate for Payer: Humana ChoiceCare |
$10.92
|
| Rate for Payer: Multiplan All |
$38.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.20
|
| Rate for Payer: OMNI Networks Commercial |
$29.40
|
| Rate for Payer: One Health Plan PPO/POS |
$37.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$39.90
|
| Rate for Payer: Three Rivers Provider Network All |
$31.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$36.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$39.06
|
| Rate for Payer: Zelis Auto |
$16.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.00
|
| Rate for Payer: Zelis Worker's Compensation |
$11.47
|
|
|
MIDFACE FLAP W/PRSRV OF VASC PEDCL
|
Facility
|
OP
|
$2,061.00
|
|
|
Service Code
|
CPT 15730
|
| Hospital Charge Code |
6115730
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$562.65 |
| Max. Negotiated Rate |
$6,952.48 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$4,065.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,236.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$4,065.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3,220.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,476.24
|
| Rate for Payer: Cash Price |
$1,236.60
|
| Rate for Payer: Cash Price |
$1,236.60
|
| Rate for Payer: Cigna Commercial |
$1,751.85
|
| Rate for Payer: First Health Commercial |
$1,854.90
|
| Rate for Payer: First Health Workers Compensation |
$795.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,854.90
|
| Rate for Payer: GEHA Commercial |
$1,648.80
|
| Rate for Payer: GEHA Medicare |
$3,476.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,854.90
|
| Rate for Payer: Humana ChoiceCare |
$3,823.86
|
| Rate for Payer: Humana Medicare Advantage |
$3,476.24
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,840.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,286.24
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,476.24
|
| Rate for Payer: Multiplan All |
$1,875.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,909.61
|
| Rate for Payer: OMNI Networks Commercial |
$1,442.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,854.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$3,794.42
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3,286.24
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,476.24
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,957.95
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,952.48
|
| Rate for Payer: Three Rivers Provider Network All |
$1,545.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,406.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,286.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,476.24
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,916.73
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,476.24
|
| Rate for Payer: Zelis Auto |
$824.40
|
| Rate for Payer: Zelis Medicare |
$2,954.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,171.49
|
| Rate for Payer: Zelis Worker's Compensation |
$562.65
|
|
|
MIDFACE FLAP W/PRSRV OF VASC PEDCL
|
Facility
|
IP
|
$2,061.00
|
|
|
Service Code
|
CPT 15730
|
| Hospital Charge Code |
6115730
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$562.65 |
| Max. Negotiated Rate |
$1,957.95 |
| Rate for Payer: Cash Price |
$1,236.60
|
| Rate for Payer: Cigna Commercial |
$1,751.85
|
| Rate for Payer: First Health Commercial |
$1,854.90
|
| Rate for Payer: First Health Workers Compensation |
$795.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,854.90
|
| Rate for Payer: GEHA Commercial |
$1,442.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,854.90
|
| Rate for Payer: Multiplan All |
$1,875.51
|
| Rate for Payer: OMNI Networks Commercial |
$1,442.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,854.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,957.95
|
| Rate for Payer: Three Rivers Provider Network All |
$1,545.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,916.73
|
| Rate for Payer: Zelis Auto |
$824.40
|
| Rate for Payer: Zelis Worker's Compensation |
$562.65
|
|
|
MIDODRINE HCL 5 MG TAB
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 00245021201
|
| Hospital Charge Code |
3302857
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$25.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$22.95
|
| Rate for Payer: First Health Commercial |
$24.30
|
| Rate for Payer: First Health Workers Compensation |
$10.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$24.30
|
| Rate for Payer: GEHA Commercial |
$21.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$24.30
|
| Rate for Payer: Humana ChoiceCare |
$7.02
|
| Rate for Payer: Multiplan All |
$24.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$16.20
|
| Rate for Payer: OMNI Networks Commercial |
$18.90
|
| Rate for Payer: One Health Plan PPO/POS |
$24.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$25.65
|
| Rate for Payer: Three Rivers Provider Network All |
$20.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$23.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$25.11
|
| Rate for Payer: Zelis Auto |
$10.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$13.50
|
| Rate for Payer: Zelis Worker's Compensation |
$7.37
|
|
|
MIDODRINE HCL 5 MG TAB
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 00245021201
|
| Hospital Charge Code |
3302857
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.37 |
| Max. Negotiated Rate |
$25.65 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$22.95
|
| Rate for Payer: First Health Commercial |
$24.30
|
| Rate for Payer: First Health Workers Compensation |
$10.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$24.30
|
| Rate for Payer: GEHA Commercial |
$18.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$24.30
|
| Rate for Payer: Multiplan All |
$24.57
|
| Rate for Payer: OMNI Networks Commercial |
$18.90
|
| Rate for Payer: One Health Plan PPO/POS |
$24.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$25.65
|
| Rate for Payer: Three Rivers Provider Network All |
$20.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$25.11
|
| Rate for Payer: Zelis Auto |
$10.80
|
| Rate for Payer: Zelis Worker's Compensation |
$7.37
|
|
|
milk (cow) IgE REF602453
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299193
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
milk (cow) IgE REF602453
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299193
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.22
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: GEHA Medicare |
$5.22
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.22
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.76
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.59
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.22
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10.44
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.12
|
| Rate for Payer: United Healthcare Commercial |
$47.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.22
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Medicare |
$4.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.26
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
MILK OF MAGNESIA 30ML UNIT DOSE
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 66689005301
|
| Hospital Charge Code |
3300550
|
|
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
|
|
|
MILK OF MAGNESIA 30ML UNIT DOSE
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 66689005301
|
| Hospital Charge Code |
3300550
|
|
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
|
|
|
MILRINONE LACTATE /D5W 20MG/100ML
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
CPT J2260
|
| Hospital Charge Code |
3303252
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$57.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$36.60
|
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Cigna Commercial |
$51.85
|
| Rate for Payer: First Health Commercial |
$54.90
|
| Rate for Payer: First Health Workers Compensation |
$23.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$54.90
|
| Rate for Payer: GEHA Commercial |
$1.59
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$54.90
|
| Rate for Payer: Humana ChoiceCare |
$15.86
|
| Rate for Payer: Multiplan All |
$55.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$36.60
|
| Rate for Payer: OMNI Networks Commercial |
$42.70
|
| Rate for Payer: One Health Plan PPO/POS |
$54.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$57.95
|
| Rate for Payer: Three Rivers Provider Network All |
$45.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$53.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$15.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$56.73
|
| Rate for Payer: Zelis Auto |
$24.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$30.50
|
| Rate for Payer: Zelis Worker's Compensation |
$16.65
|
|
|
MILRINONE LACTATE /D5W 20MG/100ML
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
CPT J2260
|
| Hospital Charge Code |
3303252
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.65 |
| Max. Negotiated Rate |
$57.95 |
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Cigna Commercial |
$51.85
|
| Rate for Payer: First Health Commercial |
$54.90
|
| Rate for Payer: First Health Workers Compensation |
$23.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$54.90
|
| Rate for Payer: GEHA Commercial |
$42.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$54.90
|
| Rate for Payer: Multiplan All |
$55.51
|
| Rate for Payer: OMNI Networks Commercial |
$42.70
|
| Rate for Payer: One Health Plan PPO/POS |
$54.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$57.95
|
| Rate for Payer: Three Rivers Provider Network All |
$45.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$56.73
|
| Rate for Payer: Zelis Auto |
$24.40
|
| Rate for Payer: Zelis Worker's Compensation |
$16.65
|
|
|
MINERAL OIL
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 70000044801
|
| Hospital Charge Code |
3300607
|
|
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
|
|
|
MINERAL OIL
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 70000044801
|
| Hospital Charge Code |
3300607
|
|
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
|
|
|
MINERAL OIL LIGHT - STERILE
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
NDC 63323025410
|
| Hospital Charge Code |
3300608
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.11 |
| Max. Negotiated Rate |
$76.95 |
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$68.85
|
| Rate for Payer: First Health Commercial |
$72.90
|
| Rate for Payer: First Health Workers Compensation |
$31.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.90
|
| Rate for Payer: GEHA Commercial |
$56.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.90
|
| Rate for Payer: Multiplan All |
$73.71
|
| Rate for Payer: OMNI Networks Commercial |
$56.70
|
| Rate for Payer: One Health Plan PPO/POS |
$72.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.95
|
| Rate for Payer: Three Rivers Provider Network All |
$60.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$75.33
|
| Rate for Payer: Zelis Auto |
$32.40
|
| Rate for Payer: Zelis Worker's Compensation |
$22.11
|
|
|
MINERAL OIL LIGHT - STERILE
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
NDC 63323025410
|
| Hospital Charge Code |
3300608
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.25 |
| Max. Negotiated Rate |
$76.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$68.85
|
| Rate for Payer: First Health Commercial |
$72.90
|
| Rate for Payer: First Health Workers Compensation |
$31.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.90
|
| Rate for Payer: GEHA Commercial |
$64.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.90
|
| Rate for Payer: Humana ChoiceCare |
$21.06
|
| Rate for Payer: Multiplan All |
$73.71
|
| Rate for Payer: New Mexico Health Connections Medicare |
$48.60
|
| Rate for Payer: OMNI Networks Commercial |
$56.70
|
| Rate for Payer: One Health Plan PPO/POS |
$72.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.95
|
| Rate for Payer: Three Rivers Provider Network All |
$60.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$71.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$20.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$75.33
|
| Rate for Payer: Zelis Auto |
$32.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$40.50
|
| Rate for Payer: Zelis Worker's Compensation |
$22.11
|
|
|
MINERAL OIL/PETROLATUM EYE OINT TUBE
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
NDC 70000051301
|
| Hospital Charge Code |
3300067
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
MINERAL OIL/PETROLATUM EYE OINT TUBE
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
NDC 70000051301
|
| Hospital Charge Code |
3300067
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$28.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$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: 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: 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 |
$7.50
|
| 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
|
|
|
min inhibitory conc(MIC),1drug REF096388
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
2200714
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$176.70 |
| Rate for Payer: Cash Price |
$111.60
|
| Rate for Payer: Cash Price |
$111.60
|
| Rate for Payer: Cigna Commercial |
$158.10
|
| Rate for Payer: First Health Commercial |
$167.40
|
| Rate for Payer: First Health Workers Compensation |
$13.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$167.40
|
| Rate for Payer: GEHA Commercial |
$130.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$167.40
|
| Rate for Payer: Multiplan All |
$169.26
|
| Rate for Payer: OMNI Networks Commercial |
$130.20
|
| Rate for Payer: One Health Plan PPO/POS |
$167.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$176.70
|
| Rate for Payer: Three Rivers Provider Network All |
$139.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$172.98
|
| Rate for Payer: Zelis Auto |
$74.40
|
| Rate for Payer: Zelis Worker's Compensation |
$9.50
|
|
