|
PHENOBARBITAL 30 MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00143150001
|
| Hospital Charge Code |
3302959
|
|
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
|
|
|
PHENOBARBITAL 32.4 MG TAB
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 75826013910
|
| Hospital Charge Code |
3303260
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$4.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Humana ChoiceCare |
$1.30
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.00
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
PHENOBARBITAL 32.4 MG TAB
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 75826013910
|
| Hospital Charge Code |
3303260
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
PHENOBARBITAL 64.8MG TAB
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
NDC 00603516721
|
| Hospital Charge Code |
3305018
|
|
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
|
|
|
PHENOBARBITAL 64.8MG TAB
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
NDC 00603516721
|
| Hospital Charge Code |
3305018
|
|
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
|
|
|
PHENOBARBITAL 65 MG/1 ML VIAL, INJ
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
CPT J2560
|
| Hospital Charge Code |
3300706
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.02 |
| Max. Negotiated Rate |
$83.60 |
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Cigna Commercial |
$74.80
|
| Rate for Payer: First Health Commercial |
$79.20
|
| Rate for Payer: First Health Workers Compensation |
$33.98
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$79.20
|
| Rate for Payer: GEHA Commercial |
$61.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$79.20
|
| Rate for Payer: Multiplan All |
$80.08
|
| Rate for Payer: OMNI Networks Commercial |
$61.60
|
| Rate for Payer: One Health Plan PPO/POS |
$79.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$83.60
|
| Rate for Payer: Three Rivers Provider Network All |
$66.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$81.84
|
| Rate for Payer: Zelis Auto |
$35.20
|
| Rate for Payer: Zelis Worker's Compensation |
$24.02
|
|
|
PHENOBARBITAL 65 MG/1 ML VIAL, INJ
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
CPT J2560
|
| Hospital Charge Code |
3300706
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.00 |
| Max. Negotiated Rate |
$83.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$52.80
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Cigna Commercial |
$74.80
|
| Rate for Payer: First Health Commercial |
$79.20
|
| Rate for Payer: First Health Workers Compensation |
$33.98
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$79.20
|
| Rate for Payer: GEHA Commercial |
$33.19
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$79.20
|
| Rate for Payer: Humana ChoiceCare |
$22.88
|
| Rate for Payer: Multiplan All |
$80.08
|
| Rate for Payer: New Mexico Health Connections Medicare |
$52.80
|
| Rate for Payer: OMNI Networks Commercial |
$61.60
|
| Rate for Payer: One Health Plan PPO/POS |
$79.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$83.60
|
| Rate for Payer: Three Rivers Provider Network All |
$66.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$77.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$22.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$81.84
|
| Rate for Payer: Zelis Auto |
$35.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$44.00
|
| Rate for Payer: Zelis Worker's Compensation |
$24.02
|
|
|
PHENOBARBITAL (Vitros)
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
2232271
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.40 |
| Max. Negotiated Rate |
$114.95 |
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cigna Commercial |
$102.85
|
| Rate for Payer: First Health Commercial |
$108.90
|
| Rate for Payer: First Health Workers Compensation |
$26.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.90
|
| Rate for Payer: GEHA Commercial |
$84.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.90
|
| Rate for Payer: Multiplan All |
$110.11
|
| Rate for Payer: OMNI Networks Commercial |
$84.70
|
| Rate for Payer: One Health Plan PPO/POS |
$108.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.95
|
| Rate for Payer: Three Rivers Provider Network All |
$90.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$112.53
|
| Rate for Payer: Zelis Auto |
$48.40
|
| Rate for Payer: Zelis Worker's Compensation |
$18.40
|
|
|
PHENOBARBITAL (Vitros)
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
2232271
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.01 |
| Max. Negotiated Rate |
$114.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$27.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$27.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$21.82
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$15.30
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cigna Commercial |
$102.85
|
| Rate for Payer: First Health Commercial |
$108.90
|
| Rate for Payer: First Health Workers Compensation |
$26.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.90
|
| Rate for Payer: GEHA Commercial |
$96.80
|
| Rate for Payer: GEHA Medicare |
$15.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.90
|
| Rate for Payer: Humana ChoiceCare |
$16.83
|
| Rate for Payer: Humana Medicare Advantage |
$15.30
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$25.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$22.26
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$15.30
|
| Rate for Payer: Multiplan All |
$110.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$26.01
|
| Rate for Payer: OMNI Networks Commercial |
$84.70
|
| Rate for Payer: One Health Plan PPO/POS |
$108.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$25.70
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$22.26
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.95
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$30.60
|
| Rate for Payer: Three Rivers Provider Network All |
$90.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.99
|
| Rate for Payer: United Healthcare Commercial |
$102.85
|
| Rate for Payer: United Healthcare Managed Medicaid |
$22.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.30
|
| Rate for Payer: United Payors & United Providers UP&UP |
$112.53
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$15.30
|
| Rate for Payer: Zelis Auto |
$48.40
|
| Rate for Payer: Zelis Medicare |
$13.01
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$18.36
|
| Rate for Payer: Zelis Worker's Compensation |
$18.40
|
|
|
PHENOL 1.4% ORAL THROAT SPRAY 20 ML
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
NDC 78112001103
|
| Hospital Charge Code |
3300707
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$20.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$13.20
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$18.70
|
| Rate for Payer: First Health Commercial |
$19.80
|
| Rate for Payer: First Health Workers Compensation |
$8.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$19.80
|
| Rate for Payer: GEHA Commercial |
$17.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$19.80
|
| Rate for Payer: Humana ChoiceCare |
$5.72
|
| Rate for Payer: Multiplan All |
$20.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$13.20
|
| Rate for Payer: OMNI Networks Commercial |
$15.40
|
| Rate for Payer: One Health Plan PPO/POS |
$19.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$20.90
|
| Rate for Payer: Three Rivers Provider Network All |
$16.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$19.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$20.46
|
| Rate for Payer: Zelis Auto |
$8.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$11.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6.01
|
|
|
PHENOL 1.4% ORAL THROAT SPRAY 20 ML
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
NDC 78112001103
|
| Hospital Charge Code |
3300707
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.01 |
| Max. Negotiated Rate |
$20.90 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$18.70
|
| Rate for Payer: First Health Commercial |
$19.80
|
| Rate for Payer: First Health Workers Compensation |
$8.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$19.80
|
| Rate for Payer: GEHA Commercial |
$15.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$19.80
|
| Rate for Payer: Multiplan All |
$20.02
|
| Rate for Payer: OMNI Networks Commercial |
$15.40
|
| Rate for Payer: One Health Plan PPO/POS |
$19.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$20.90
|
| Rate for Payer: Three Rivers Provider Network All |
$16.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$20.46
|
| Rate for Payer: Zelis Auto |
$8.80
|
| Rate for Payer: Zelis Worker's Compensation |
$6.01
|
|
|
PHENOL SWAB 89% TOPICAL
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
NDC 00884629730
|
| Hospital Charge Code |
3300708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.25 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22.20
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$29.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Humana ChoiceCare |
$9.62
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.20
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$32.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$18.50
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
PHENOL SWAB 89% TOPICAL
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
NDC 00884629730
|
| Hospital Charge Code |
3300708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$31.45
|
| Rate for Payer: First Health Commercial |
$33.30
|
| Rate for Payer: First Health Workers Compensation |
$14.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$33.30
|
| Rate for Payer: GEHA Commercial |
$25.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$33.30
|
| Rate for Payer: Multiplan All |
$33.67
|
| Rate for Payer: OMNI Networks Commercial |
$25.90
|
| Rate for Payer: One Health Plan PPO/POS |
$33.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$35.15
|
| Rate for Payer: Three Rivers Provider Network All |
$27.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$34.41
|
| Rate for Payer: Zelis Auto |
$14.80
|
| Rate for Payer: Zelis Worker's Compensation |
$10.10
|
|
|
PHENTOLAMINE MESYLATE FOR INJ 5MG
|
Facility
|
OP
|
$624.00
|
|
|
Service Code
|
CPT J2760
|
| Hospital Charge Code |
3300709
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$156.00 |
| Max. Negotiated Rate |
$864.04 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$374.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$432.02
|
| Rate for Payer: Cash Price |
$374.40
|
| Rate for Payer: Cash Price |
$374.40
|
| Rate for Payer: Cigna Commercial |
$530.40
|
| Rate for Payer: First Health Commercial |
$561.60
|
| Rate for Payer: First Health Workers Compensation |
$240.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$561.60
|
| Rate for Payer: GEHA Commercial |
$475.22
|
| Rate for Payer: GEHA Medicare |
$432.02
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$561.60
|
| Rate for Payer: Humana ChoiceCare |
$475.22
|
| Rate for Payer: Humana Medicare Advantage |
$432.02
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$725.79
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$432.02
|
| Rate for Payer: Multiplan All |
$567.84
|
| Rate for Payer: New Mexico Health Connections Medicare |
$734.43
|
| Rate for Payer: OMNI Networks Commercial |
$436.80
|
| Rate for Payer: One Health Plan PPO/POS |
$561.60
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$432.02
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$592.80
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$864.04
|
| Rate for Payer: Three Rivers Provider Network All |
$468.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$423.38
|
| Rate for Payer: United Healthcare Managed Medicaid |
$156.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$432.02
|
| Rate for Payer: United Payors & United Providers UP&UP |
$580.32
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$432.02
|
| Rate for Payer: Zelis Auto |
$249.60
|
| Rate for Payer: Zelis Medicare |
$367.22
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$518.42
|
| Rate for Payer: Zelis Worker's Compensation |
$170.35
|
|
|
PHENTOLAMINE MESYLATE FOR INJ 5MG
|
Facility
|
IP
|
$624.00
|
|
|
Service Code
|
CPT J2760
|
| Hospital Charge Code |
3300709
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$170.35 |
| Max. Negotiated Rate |
$592.80 |
| Rate for Payer: Cash Price |
$374.40
|
| Rate for Payer: Cigna Commercial |
$530.40
|
| Rate for Payer: First Health Commercial |
$561.60
|
| Rate for Payer: First Health Workers Compensation |
$240.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$561.60
|
| Rate for Payer: GEHA Commercial |
$436.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$561.60
|
| Rate for Payer: Multiplan All |
$567.84
|
| Rate for Payer: OMNI Networks Commercial |
$436.80
|
| Rate for Payer: One Health Plan PPO/POS |
$561.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$592.80
|
| Rate for Payer: Three Rivers Provider Network All |
$468.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$580.32
|
| Rate for Payer: Zelis Auto |
$249.60
|
| Rate for Payer: Zelis Worker's Compensation |
$170.35
|
|
|
PHENYLephrine 100MCG/ML - ANESTHESIA
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
CPT J2371
|
| Hospital Charge Code |
3305005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.74 |
| Max. Negotiated Rate |
$40.85 |
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$36.55
|
| Rate for Payer: First Health Commercial |
$38.70
|
| Rate for Payer: First Health Workers Compensation |
$16.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$38.70
|
| Rate for Payer: GEHA Commercial |
$30.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$38.70
|
| Rate for Payer: Multiplan All |
$39.13
|
| Rate for Payer: OMNI Networks Commercial |
$30.10
|
| Rate for Payer: One Health Plan PPO/POS |
$38.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$40.85
|
| Rate for Payer: Three Rivers Provider Network All |
$32.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$39.99
|
| Rate for Payer: Zelis Auto |
$17.20
|
| Rate for Payer: Zelis Worker's Compensation |
$11.74
|
|
|
PHENYLephrine 100MCG/ML - ANESTHESIA
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
CPT J2371
|
| Hospital Charge Code |
3305005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.75 |
| Max. Negotiated Rate |
$40.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$25.80
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$36.55
|
| Rate for Payer: First Health Commercial |
$38.70
|
| Rate for Payer: First Health Workers Compensation |
$16.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$38.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$38.70
|
| Rate for Payer: Humana ChoiceCare |
$11.18
|
| Rate for Payer: Multiplan All |
$39.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.80
|
| Rate for Payer: OMNI Networks Commercial |
$30.10
|
| Rate for Payer: One Health Plan PPO/POS |
$38.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$40.85
|
| Rate for Payer: Three Rivers Provider Network All |
$32.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$37.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$39.99
|
| Rate for Payer: Zelis Auto |
$17.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.50
|
| Rate for Payer: Zelis Worker's Compensation |
$11.74
|
|
|
PHENYLEPHRINE HCL INJ 1000MCG/ML
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT J2371
|
| Hospital Charge Code |
3300710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.50 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$42.50
|
| Rate for Payer: First Health Commercial |
$45.00
|
| Rate for Payer: First Health Workers Compensation |
$19.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Humana ChoiceCare |
$13.00
|
| Rate for Payer: Multiplan All |
$45.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.00
|
| Rate for Payer: OMNI Networks Commercial |
$35.00
|
| Rate for Payer: One Health Plan PPO/POS |
$45.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47.50
|
| Rate for Payer: Three Rivers Provider Network All |
$37.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$44.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46.50
|
| Rate for Payer: Zelis Auto |
$20.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$25.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.65
|
|
|
PHENYLEPHRINE HCL INJ 1000MCG/ML
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT J2371
|
| Hospital Charge Code |
3300710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.65 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$42.50
|
| Rate for Payer: First Health Commercial |
$45.00
|
| Rate for Payer: First Health Workers Compensation |
$19.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.00
|
| Rate for Payer: GEHA Commercial |
$35.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Multiplan All |
$45.50
|
| Rate for Payer: OMNI Networks Commercial |
$35.00
|
| Rate for Payer: One Health Plan PPO/POS |
$45.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47.50
|
| Rate for Payer: Three Rivers Provider Network All |
$37.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46.50
|
| Rate for Payer: Zelis Auto |
$20.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.65
|
|
|
PHENYLEPHRINE HCL NASAL SOLN 0.5%
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
NDC 00225080547
|
| Hospital Charge Code |
3300711
|
|
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
|
|
|
PHENYLEPHRINE HCL NASAL SOLN 0.5%
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
NDC 00225080547
|
| Hospital Charge Code |
3300711
|
|
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
|
|
|
PHENYLEPHRINE HCL NASAL SOLN 1%
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
NDC 00225080547
|
| Hospital Charge Code |
3300712
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.28 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cigna Commercial |
$28.90
|
| Rate for Payer: First Health Commercial |
$30.60
|
| Rate for Payer: First Health Workers Compensation |
$13.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$30.60
|
| Rate for Payer: GEHA Commercial |
$23.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$30.60
|
| Rate for Payer: Multiplan All |
$30.94
|
| Rate for Payer: OMNI Networks Commercial |
$23.80
|
| Rate for Payer: One Health Plan PPO/POS |
$30.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$32.30
|
| Rate for Payer: Three Rivers Provider Network All |
$25.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$31.62
|
| Rate for Payer: Zelis Auto |
$13.60
|
| Rate for Payer: Zelis Worker's Compensation |
$9.28
|
|
|
PHENYLEPHRINE HCL NASAL SOLN 1%
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
NDC 00225080547
|
| Hospital Charge Code |
3300712
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$20.40
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cigna Commercial |
$28.90
|
| Rate for Payer: First Health Commercial |
$30.60
|
| Rate for Payer: First Health Workers Compensation |
$13.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$30.60
|
| Rate for Payer: GEHA Commercial |
$27.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$30.60
|
| Rate for Payer: Humana ChoiceCare |
$8.84
|
| Rate for Payer: Multiplan All |
$30.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$20.40
|
| Rate for Payer: OMNI Networks Commercial |
$23.80
|
| Rate for Payer: One Health Plan PPO/POS |
$30.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$32.30
|
| Rate for Payer: Three Rivers Provider Network All |
$25.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$29.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$31.62
|
| Rate for Payer: Zelis Auto |
$13.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.28
|
|
|
PHENYLEPHRINE HCL OPTH SOLN 2.5%
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
NDC 70756062925
|
| Hospital Charge Code |
3300713
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.49 |
| Max. Negotiated Rate |
$123.50 |
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$110.50
|
| Rate for Payer: First Health Commercial |
$117.00
|
| Rate for Payer: First Health Workers Compensation |
$50.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$117.00
|
| Rate for Payer: GEHA Commercial |
$91.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$117.00
|
| Rate for Payer: Multiplan All |
$118.30
|
| Rate for Payer: OMNI Networks Commercial |
$91.00
|
| Rate for Payer: One Health Plan PPO/POS |
$117.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$123.50
|
| Rate for Payer: Three Rivers Provider Network All |
$97.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$120.90
|
| Rate for Payer: Zelis Auto |
$52.00
|
| Rate for Payer: Zelis Worker's Compensation |
$35.49
|
|
|
PHENYLEPHRINE HCL OPTH SOLN 2.5%
|
Facility
|
OP
|
$130.00
|
|
|
Service Code
|
NDC 70756062925
|
| Hospital Charge Code |
3300713
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.50 |
| Max. Negotiated Rate |
$123.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$78.00
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$110.50
|
| Rate for Payer: First Health Commercial |
$117.00
|
| Rate for Payer: First Health Workers Compensation |
$50.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$117.00
|
| Rate for Payer: GEHA Commercial |
$104.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$117.00
|
| Rate for Payer: Humana ChoiceCare |
$33.80
|
| Rate for Payer: Multiplan All |
$118.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$78.00
|
| Rate for Payer: OMNI Networks Commercial |
$91.00
|
| Rate for Payer: One Health Plan PPO/POS |
$117.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$123.50
|
| Rate for Payer: Three Rivers Provider Network All |
$97.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$114.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$32.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$120.90
|
| Rate for Payer: Zelis Auto |
$52.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$65.00
|
| Rate for Payer: Zelis Worker's Compensation |
$35.49
|
|
