|
CL- HYDROXYZINE HCL IM SOLN 50MG/ML
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
CPT J3410
|
| Hospital Charge Code |
3350039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.50 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$129.20
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: First Health Workers Compensation |
$58.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$136.80
|
| Rate for Payer: GEHA Commercial |
$106.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$136.80
|
| Rate for Payer: Multiplan All |
$138.32
|
| Rate for Payer: OMNI Networks Commercial |
$106.40
|
| Rate for Payer: One Health Plan PPO/POS |
$136.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$144.40
|
| Rate for Payer: Three Rivers Provider Network All |
$114.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$141.36
|
| Rate for Payer: Zelis Auto |
$60.80
|
| Rate for Payer: Zelis Worker's Compensation |
$41.50
|
|
|
CL- HYDROXYZINE HCL IM SOLN 50MG/ML
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
CPT J3410
|
| Hospital Charge Code |
3350039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.83 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$129.20
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: First Health Workers Compensation |
$58.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$136.80
|
| Rate for Payer: GEHA Commercial |
$16.83
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$136.80
|
| Rate for Payer: Humana ChoiceCare |
$39.52
|
| Rate for Payer: Multiplan All |
$138.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$91.20
|
| Rate for Payer: OMNI Networks Commercial |
$106.40
|
| Rate for Payer: One Health Plan PPO/POS |
$136.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$144.40
|
| Rate for Payer: Three Rivers Provider Network All |
$114.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$133.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$38.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$141.36
|
| Rate for Payer: Zelis Auto |
$60.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$76.00
|
| Rate for Payer: Zelis Worker's Compensation |
$41.50
|
|
|
CL- HYLENEX 150UNITS/ML
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
NDC 18657011704
|
| Hospital Charge Code |
3350219
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.75 |
| Max. Negotiated Rate |
$93.10 |
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$83.30
|
| Rate for Payer: First Health Commercial |
$88.20
|
| Rate for Payer: First Health Workers Compensation |
$37.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$88.20
|
| Rate for Payer: GEHA Commercial |
$68.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$88.20
|
| Rate for Payer: Multiplan All |
$89.18
|
| Rate for Payer: OMNI Networks Commercial |
$68.60
|
| Rate for Payer: One Health Plan PPO/POS |
$88.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$93.10
|
| Rate for Payer: Three Rivers Provider Network All |
$73.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$91.14
|
| Rate for Payer: Zelis Auto |
$39.20
|
| Rate for Payer: Zelis Worker's Compensation |
$26.75
|
|
|
CL- HYLENEX 150UNITS/ML
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
NDC 18657011704
|
| Hospital Charge Code |
3350219
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$93.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$58.80
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$83.30
|
| Rate for Payer: First Health Commercial |
$88.20
|
| Rate for Payer: First Health Workers Compensation |
$37.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$88.20
|
| Rate for Payer: GEHA Commercial |
$78.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$88.20
|
| Rate for Payer: Humana ChoiceCare |
$25.48
|
| Rate for Payer: Multiplan All |
$89.18
|
| Rate for Payer: New Mexico Health Connections Medicare |
$58.80
|
| Rate for Payer: OMNI Networks Commercial |
$68.60
|
| Rate for Payer: One Health Plan PPO/POS |
$88.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$93.10
|
| Rate for Payer: Three Rivers Provider Network All |
$73.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$86.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$24.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$91.14
|
| Rate for Payer: Zelis Auto |
$39.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$49.00
|
| Rate for Payer: Zelis Worker's Compensation |
$26.75
|
|
|
CL- IBANDRONATE 3MG/3ML- PT OWN MED
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J1740
|
| Hospital Charge Code |
3350156
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$186.18 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$186.18
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$186.18
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$147.49
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$31.47
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$150.50
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$173.77
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$150.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.01
|
| Rate for Payer: United Healthcare Managed Medicaid |
$150.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.01
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- IBANDRONATE 3MG/3ML- PT OWN MED
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J1740
|
| Hospital Charge Code |
3350156
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- IBUPROFEN SUSP 100MG/5ML
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$8.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Humana ChoiceCare |
$2.86
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.60
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
CL- IBUPROFEN SUSP 100MG/5ML
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$7.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
CL- IBUPROFEN TAB 200 MG
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350043
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
CL- IBUPROFEN TAB 200 MG
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3350043
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
CL- IBUPROFEN TAB 800MG
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00904585561
|
| Hospital Charge Code |
3350044
|
|
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
|
|
|
CL- IBUPROFEN TAB 800MG
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 00904585561
|
| Hospital Charge Code |
3350044
|
|
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
|
|
|
CL- IFOSFAMIDE 1 GM
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
CPT J9208
|
| Hospital Charge Code |
3350313
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.58 |
| Max. Negotiated Rate |
$78.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$48.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$49.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$48.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$38.55
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cigna Commercial |
$70.55
|
| Rate for Payer: First Health Commercial |
$74.70
|
| Rate for Payer: First Health Workers Compensation |
$32.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$74.70
|
| Rate for Payer: GEHA Commercial |
$27.72
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$74.70
|
| Rate for Payer: Humana ChoiceCare |
$21.58
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$39.33
|
| Rate for Payer: Multiplan All |
$75.53
|
| Rate for Payer: New Mexico Health Connections Medicare |
$49.80
|
| Rate for Payer: OMNI Networks Commercial |
$58.10
|
| Rate for Payer: One Health Plan PPO/POS |
$74.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$45.42
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$39.33
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$78.85
|
| Rate for Payer: Three Rivers Provider Network All |
$62.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$73.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$39.33
|
| Rate for Payer: United Payors & United Providers UP&UP |
$77.19
|
| Rate for Payer: Zelis Auto |
$33.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$41.50
|
| Rate for Payer: Zelis Worker's Compensation |
$22.66
|
|
|
CL- IFOSFAMIDE 1 GM
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
CPT J9208
|
| Hospital Charge Code |
3350313
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.66 |
| Max. Negotiated Rate |
$78.85 |
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cigna Commercial |
$70.55
|
| Rate for Payer: First Health Commercial |
$74.70
|
| Rate for Payer: First Health Workers Compensation |
$32.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$74.70
|
| Rate for Payer: GEHA Commercial |
$58.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$74.70
|
| Rate for Payer: Multiplan All |
$75.53
|
| Rate for Payer: OMNI Networks Commercial |
$58.10
|
| Rate for Payer: One Health Plan PPO/POS |
$74.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$78.85
|
| Rate for Payer: Three Rivers Provider Network All |
$62.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$77.19
|
| Rate for Payer: Zelis Auto |
$33.20
|
| Rate for Payer: Zelis Worker's Compensation |
$22.66
|
|
|
CL- IMOGAM RABIES-HT IM 150 UNIT/ML
|
Facility
|
OP
|
$2,842.00
|
|
|
Service Code
|
NDC 49281019020
|
| Hospital Charge Code |
3302346
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$710.50 |
| Max. Negotiated Rate |
$2,699.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,705.20
|
| Rate for Payer: Cash Price |
$1,705.20
|
| Rate for Payer: Cigna Commercial |
$2,415.70
|
| Rate for Payer: First Health Commercial |
$2,557.80
|
| Rate for Payer: First Health Workers Compensation |
$1,097.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,557.80
|
| Rate for Payer: GEHA Commercial |
$2,273.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,557.80
|
| Rate for Payer: Humana ChoiceCare |
$738.92
|
| Rate for Payer: Multiplan All |
$2,586.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,705.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,989.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,557.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,699.90
|
| Rate for Payer: Three Rivers Provider Network All |
$2,131.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,500.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$710.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,643.06
|
| Rate for Payer: Zelis Auto |
$1,136.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,421.00
|
| Rate for Payer: Zelis Worker's Compensation |
$775.87
|
|
|
CL- IMOGAM RABIES-HT IM 150 UNIT/ML
|
Facility
|
IP
|
$2,842.00
|
|
|
Service Code
|
NDC 49281019020
|
| Hospital Charge Code |
3302346
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$775.87 |
| Max. Negotiated Rate |
$2,699.90 |
| Rate for Payer: Cash Price |
$1,705.20
|
| Rate for Payer: Cigna Commercial |
$2,415.70
|
| Rate for Payer: First Health Commercial |
$2,557.80
|
| Rate for Payer: First Health Workers Compensation |
$1,097.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,557.80
|
| Rate for Payer: GEHA Commercial |
$1,989.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,557.80
|
| Rate for Payer: Multiplan All |
$2,586.22
|
| Rate for Payer: OMNI Networks Commercial |
$1,989.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,557.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,699.90
|
| Rate for Payer: Three Rivers Provider Network All |
$2,131.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,643.06
|
| Rate for Payer: Zelis Auto |
$1,136.80
|
| Rate for Payer: Zelis Worker's Compensation |
$775.87
|
|
|
CL- IMOVAX RABIES VAC IM
|
Facility
|
IP
|
$2,105.00
|
|
|
Service Code
|
CPT 90675
|
| Hospital Charge Code |
3302348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$574.66 |
| Max. Negotiated Rate |
$1,999.75 |
| Rate for Payer: Cash Price |
$1,263.00
|
| Rate for Payer: Cigna Commercial |
$1,789.25
|
| Rate for Payer: First Health Commercial |
$1,894.50
|
| Rate for Payer: First Health Workers Compensation |
$812.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,894.50
|
| Rate for Payer: GEHA Commercial |
$1,473.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,894.50
|
| Rate for Payer: Multiplan All |
$1,915.55
|
| Rate for Payer: OMNI Networks Commercial |
$1,473.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,894.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,999.75
|
| Rate for Payer: Three Rivers Provider Network All |
$1,578.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,957.65
|
| Rate for Payer: Zelis Auto |
$842.00
|
| Rate for Payer: Zelis Worker's Compensation |
$574.66
|
|
|
CL- IMOVAX RABIES VAC IM
|
Facility
|
OP
|
$2,105.00
|
|
|
Service Code
|
CPT 90675
|
| Hospital Charge Code |
3302348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$266.63 |
| Max. Negotiated Rate |
$1,999.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$356.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,263.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$356.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$282.08
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$313.68
|
| Rate for Payer: Cash Price |
$1,263.00
|
| Rate for Payer: Cash Price |
$1,263.00
|
| Rate for Payer: Cigna Commercial |
$1,789.25
|
| Rate for Payer: First Health Commercial |
$1,894.50
|
| Rate for Payer: First Health Workers Compensation |
$812.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,894.50
|
| Rate for Payer: GEHA Commercial |
$345.05
|
| Rate for Payer: GEHA Medicare |
$313.68
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,894.50
|
| Rate for Payer: Humana ChoiceCare |
$345.05
|
| Rate for Payer: Humana Medicare Advantage |
$313.68
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$526.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$287.82
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$313.68
|
| Rate for Payer: Multiplan All |
$1,915.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$533.26
|
| Rate for Payer: OMNI Networks Commercial |
$1,473.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,894.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$332.33
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$287.82
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$313.68
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,999.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$627.36
|
| Rate for Payer: Three Rivers Provider Network All |
$1,578.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$307.41
|
| Rate for Payer: United Healthcare Managed Medicaid |
$287.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$313.68
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,957.65
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$313.68
|
| Rate for Payer: Zelis Auto |
$842.00
|
| Rate for Payer: Zelis Medicare |
$266.63
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$376.42
|
| Rate for Payer: Zelis Worker's Compensation |
$574.66
|
|
|
CLINDAMYCIN 900 MG/6 ML INJ SDV
|
Facility
|
OP
|
$23.90
|
|
|
Service Code
|
NDC 25021011506
|
| Hospital Charge Code |
3301145
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.97 |
| Max. Negotiated Rate |
$22.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$14.34
|
| Rate for Payer: Cash Price |
$14.34
|
| Rate for Payer: Cigna Commercial |
$20.32
|
| Rate for Payer: First Health Commercial |
$21.51
|
| Rate for Payer: First Health Workers Compensation |
$9.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$21.51
|
| Rate for Payer: GEHA Commercial |
$19.12
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$21.51
|
| Rate for Payer: Humana ChoiceCare |
$6.21
|
| Rate for Payer: Multiplan All |
$21.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$14.34
|
| Rate for Payer: OMNI Networks Commercial |
$16.73
|
| Rate for Payer: One Health Plan PPO/POS |
$21.51
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$22.70
|
| Rate for Payer: Three Rivers Provider Network All |
$17.93
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$21.03
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$22.23
|
| Rate for Payer: Zelis Auto |
$9.56
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$11.95
|
| Rate for Payer: Zelis Worker's Compensation |
$6.52
|
|
|
CLINDAMYCIN 900 MG/6 ML INJ SDV
|
Facility
|
IP
|
$23.90
|
|
|
Service Code
|
NDC 25021011506
|
| Hospital Charge Code |
3301145
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.52 |
| Max. Negotiated Rate |
$22.70 |
| Rate for Payer: Cash Price |
$14.34
|
| Rate for Payer: Cigna Commercial |
$20.32
|
| Rate for Payer: First Health Commercial |
$21.51
|
| Rate for Payer: First Health Workers Compensation |
$9.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$21.51
|
| Rate for Payer: GEHA Commercial |
$16.73
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$21.51
|
| Rate for Payer: Multiplan All |
$21.75
|
| Rate for Payer: OMNI Networks Commercial |
$16.73
|
| Rate for Payer: One Health Plan PPO/POS |
$21.51
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$22.70
|
| Rate for Payer: Three Rivers Provider Network All |
$17.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$22.23
|
| Rate for Payer: Zelis Auto |
$9.56
|
| Rate for Payer: Zelis Worker's Compensation |
$6.52
|
|
|
CLINDAMYCIN HCL 150MG CAP
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300187
|
|
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
|
|
|
CLINDAMYCIN HCL 150MG CAP
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300187
|
|
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
|
|
|
CLINDAMYCIN IVPB 300MG/50ML - Premix
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
NDC 00781328809
|
| Hospital Charge Code |
3300188
|
|
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
|
|
|
CLINDAMYCIN IVPB 300MG/50ML - Premix
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
NDC 00781328809
|
| Hospital Charge Code |
3300188
|
|
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
|
|
|
CLINDAMYCIN IVPB 600MG/50ML - Premix
|
Facility
|
IP
|
$64.00
|
|
|
Service Code
|
NDC 00338954950
|
| Hospital Charge Code |
3300189
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.47 |
| Max. Negotiated Rate |
$60.80 |
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$54.40
|
| Rate for Payer: First Health Commercial |
$57.60
|
| Rate for Payer: First Health Workers Compensation |
$24.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$57.60
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$57.60
|
| Rate for Payer: Multiplan All |
$58.24
|
| Rate for Payer: OMNI Networks Commercial |
$44.80
|
| Rate for Payer: One Health Plan PPO/POS |
$57.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$60.80
|
| Rate for Payer: Three Rivers Provider Network All |
$48.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$59.52
|
| Rate for Payer: Zelis Auto |
$25.60
|
| Rate for Payer: Zelis Worker's Compensation |
$17.47
|
|
