|
HYDROCORTISONE CREAM 1%
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 45802043803
|
| Hospital Charge Code |
3300420
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$26.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$23.80
|
| Rate for Payer: First Health Commercial |
$25.20
|
| Rate for Payer: First Health Workers Compensation |
$10.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$25.20
|
| Rate for Payer: GEHA Commercial |
$22.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$25.20
|
| Rate for Payer: Humana ChoiceCare |
$7.28
|
| Rate for Payer: Multiplan All |
$25.48
|
| Rate for Payer: New Mexico Health Connections Medicare |
$16.80
|
| Rate for Payer: OMNI Networks Commercial |
$19.60
|
| Rate for Payer: One Health Plan PPO/POS |
$25.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$26.60
|
| Rate for Payer: Three Rivers Provider Network All |
$21.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$24.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$26.04
|
| Rate for Payer: Zelis Auto |
$11.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$14.00
|
| Rate for Payer: Zelis Worker's Compensation |
$7.64
|
|
|
HYDROCORTISONE CREAM 2.5%
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
NDC 00168008031
|
| Hospital Charge Code |
3300421
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.84 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$68.00
|
| Rate for Payer: First Health Commercial |
$72.00
|
| Rate for Payer: First Health Workers Compensation |
$30.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.00
|
| Rate for Payer: GEHA Commercial |
$56.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.00
|
| Rate for Payer: Multiplan All |
$72.80
|
| Rate for Payer: OMNI Networks Commercial |
$56.00
|
| Rate for Payer: One Health Plan PPO/POS |
$72.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.00
|
| Rate for Payer: Three Rivers Provider Network All |
$60.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$74.40
|
| Rate for Payer: Zelis Auto |
$32.00
|
| Rate for Payer: Zelis Worker's Compensation |
$21.84
|
|
|
HYDROCORTISONE CREAM 2.5%
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
NDC 00168008031
|
| Hospital Charge Code |
3300421
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$68.00
|
| Rate for Payer: First Health Commercial |
$72.00
|
| Rate for Payer: First Health Workers Compensation |
$30.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.00
|
| Rate for Payer: GEHA Commercial |
$64.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.00
|
| Rate for Payer: Humana ChoiceCare |
$20.80
|
| Rate for Payer: Multiplan All |
$72.80
|
| Rate for Payer: New Mexico Health Connections Medicare |
$48.00
|
| Rate for Payer: OMNI Networks Commercial |
$56.00
|
| Rate for Payer: One Health Plan PPO/POS |
$72.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.00
|
| Rate for Payer: Three Rivers Provider Network All |
$60.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$70.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$20.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$74.40
|
| Rate for Payer: Zelis Auto |
$32.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$40.00
|
| Rate for Payer: Zelis Worker's Compensation |
$21.84
|
|
|
HYDROCORTISONE ENEMA 100MG/60ML
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
NDC 62559013807
|
| Hospital Charge Code |
3300422
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.75 |
| Max. Negotiated Rate |
$82.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$52.20
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$73.95
|
| Rate for Payer: First Health Commercial |
$78.30
|
| Rate for Payer: First Health Workers Compensation |
$33.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$78.30
|
| Rate for Payer: GEHA Commercial |
$69.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$78.30
|
| Rate for Payer: Humana ChoiceCare |
$22.62
|
| Rate for Payer: Multiplan All |
$79.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$52.20
|
| Rate for Payer: OMNI Networks Commercial |
$60.90
|
| Rate for Payer: One Health Plan PPO/POS |
$78.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$82.65
|
| Rate for Payer: Three Rivers Provider Network All |
$65.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$76.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$80.91
|
| Rate for Payer: Zelis Auto |
$34.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$43.50
|
| Rate for Payer: Zelis Worker's Compensation |
$23.75
|
|
|
HYDROCORTISONE ENEMA 100MG/60ML
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
NDC 62559013807
|
| Hospital Charge Code |
3300422
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.75 |
| Max. Negotiated Rate |
$82.65 |
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$73.95
|
| Rate for Payer: First Health Commercial |
$78.30
|
| Rate for Payer: First Health Workers Compensation |
$33.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$78.30
|
| Rate for Payer: GEHA Commercial |
$60.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$78.30
|
| Rate for Payer: Multiplan All |
$79.17
|
| Rate for Payer: OMNI Networks Commercial |
$60.90
|
| Rate for Payer: One Health Plan PPO/POS |
$78.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$82.65
|
| Rate for Payer: Three Rivers Provider Network All |
$65.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$80.91
|
| Rate for Payer: Zelis Auto |
$34.80
|
| Rate for Payer: Zelis Worker's Compensation |
$23.75
|
|
|
HYDROCORTISONE SOD SUCC 100 MG INJ
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
CPT J1720
|
| Hospital Charge Code |
3300423
|
|
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
|
|
|
HYDROCORTISONE SOD SUCC 100 MG INJ
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
CPT J1720
|
| Hospital Charge Code |
3300423
|
|
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: 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 |
$23.44
|
| 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
|
|
|
HYDROGEL DSG>16<=48 SQ IN
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
CPT A6232
|
| Hospital Charge Code |
8806232
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$22.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$14.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$14.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$14.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$11.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$20.40
|
| Rate for Payer: First Health Commercial |
$21.60
|
| Rate for Payer: First Health Workers Compensation |
$9.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$21.60
|
| Rate for Payer: GEHA Commercial |
$19.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$21.60
|
| Rate for Payer: Humana ChoiceCare |
$6.24
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$11.63
|
| Rate for Payer: Multiplan All |
$21.84
|
| Rate for Payer: New Mexico Health Connections Medicare |
$14.40
|
| Rate for Payer: OMNI Networks Commercial |
$16.80
|
| Rate for Payer: One Health Plan PPO/POS |
$21.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$13.43
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$11.63
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$22.80
|
| Rate for Payer: Three Rivers Provider Network All |
$18.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$21.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.63
|
| Rate for Payer: United Payors & United Providers UP&UP |
$22.32
|
| Rate for Payer: Zelis Auto |
$9.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6.55
|
|
|
HYDROGEL DSG>16<=48 SQ IN
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
CPT A6232
|
| Hospital Charge Code |
8206232
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$22.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$14.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$14.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$14.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$11.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$20.40
|
| Rate for Payer: First Health Commercial |
$21.60
|
| Rate for Payer: First Health Workers Compensation |
$9.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$21.60
|
| Rate for Payer: GEHA Commercial |
$19.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$21.60
|
| Rate for Payer: Humana ChoiceCare |
$6.24
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$11.63
|
| Rate for Payer: Multiplan All |
$21.84
|
| Rate for Payer: New Mexico Health Connections Medicare |
$14.40
|
| Rate for Payer: OMNI Networks Commercial |
$16.80
|
| Rate for Payer: One Health Plan PPO/POS |
$21.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$13.43
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$11.63
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$22.80
|
| Rate for Payer: Three Rivers Provider Network All |
$18.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$21.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.63
|
| Rate for Payer: United Payors & United Providers UP&UP |
$22.32
|
| Rate for Payer: Zelis Auto |
$9.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6.55
|
|
|
HYDROGEL DSG>16<=48 SQ IN
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
CPT A6232
|
| Hospital Charge Code |
8806232
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.55 |
| Max. Negotiated Rate |
$22.80 |
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$20.40
|
| Rate for Payer: First Health Commercial |
$21.60
|
| Rate for Payer: First Health Workers Compensation |
$9.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$21.60
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$21.60
|
| Rate for Payer: Multiplan All |
$21.84
|
| Rate for Payer: OMNI Networks Commercial |
$16.80
|
| Rate for Payer: One Health Plan PPO/POS |
$21.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$22.80
|
| Rate for Payer: Three Rivers Provider Network All |
$18.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$22.32
|
| Rate for Payer: Zelis Auto |
$9.60
|
| Rate for Payer: Zelis Worker's Compensation |
$6.55
|
|
|
HYDROGEL DSG>16<=48 SQ IN
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
CPT A6232
|
| Hospital Charge Code |
8206232
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.55 |
| Max. Negotiated Rate |
$22.80 |
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$20.40
|
| Rate for Payer: First Health Commercial |
$21.60
|
| Rate for Payer: First Health Workers Compensation |
$9.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$21.60
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$21.60
|
| Rate for Payer: Multiplan All |
$21.84
|
| Rate for Payer: OMNI Networks Commercial |
$16.80
|
| Rate for Payer: One Health Plan PPO/POS |
$21.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$22.80
|
| Rate for Payer: Three Rivers Provider Network All |
$18.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$22.32
|
| Rate for Payer: Zelis Auto |
$9.60
|
| Rate for Payer: Zelis Worker's Compensation |
$6.55
|
|
|
HYDROGEL DSG<=16 SQ IN
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
CPT A6231
|
| Hospital Charge Code |
8806231
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.16 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.82
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.82
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.78
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$12.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Humana ChoiceCare |
$4.16
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.94
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.60
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$9.17
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
HYDROGEL DSG<=16 SQ IN
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
CPT A6231
|
| Hospital Charge Code |
8806231
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$11.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
HYDROGEL DSG<=16 SQ IN
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
CPT A6231
|
| Hospital Charge Code |
8206231
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.16 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.82
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.82
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.78
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$12.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Humana ChoiceCare |
$4.16
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.94
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.60
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$9.17
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
HYDROGEL DSG<=16 SQ IN
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
CPT A6231
|
| Hospital Charge Code |
8206231
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$11.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
HYDROGEL TUBES WOUN DRES COLLAGEN 3OZ
|
Facility
|
OP
|
$296.00
|
|
| Hospital Charge Code |
90030840
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$74.00 |
| Max. Negotiated Rate |
$281.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$177.60
|
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Cigna Commercial |
$251.60
|
| Rate for Payer: First Health Commercial |
$266.40
|
| Rate for Payer: First Health Workers Compensation |
$114.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$266.40
|
| Rate for Payer: GEHA Commercial |
$236.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$266.40
|
| Rate for Payer: Humana ChoiceCare |
$76.96
|
| Rate for Payer: Multiplan All |
$269.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$177.60
|
| Rate for Payer: OMNI Networks Commercial |
$207.20
|
| Rate for Payer: One Health Plan PPO/POS |
$266.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$281.20
|
| Rate for Payer: Three Rivers Provider Network All |
$222.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$260.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$74.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$275.28
|
| Rate for Payer: Zelis Auto |
$118.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$148.00
|
| Rate for Payer: Zelis Worker's Compensation |
$80.81
|
|
|
HYDROGEL TUBES WOUN DRES COLLAGEN 3OZ
|
Facility
|
IP
|
$296.00
|
|
| Hospital Charge Code |
90030840
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$80.81 |
| Max. Negotiated Rate |
$281.20 |
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Cigna Commercial |
$251.60
|
| Rate for Payer: First Health Commercial |
$266.40
|
| Rate for Payer: First Health Workers Compensation |
$114.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$266.40
|
| Rate for Payer: GEHA Commercial |
$207.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$266.40
|
| Rate for Payer: Multiplan All |
$269.36
|
| Rate for Payer: OMNI Networks Commercial |
$207.20
|
| Rate for Payer: One Health Plan PPO/POS |
$266.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$281.20
|
| Rate for Payer: Three Rivers Provider Network All |
$222.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$275.28
|
| Rate for Payer: Zelis Auto |
$118.40
|
| Rate for Payer: Zelis Worker's Compensation |
$80.81
|
|
|
HYDROGEN PEROXIDE
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00869087143
|
| Hospital Charge Code |
3301421
|
|
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
|
|
|
HYDROGEN PEROXIDE
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00869087143
|
| Hospital Charge Code |
3301421
|
|
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
|
|
|
HYDROmorphone 0.5MG/0.5ML
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
CPT J1170
|
| Hospital Charge Code |
3302519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Humana ChoiceCare |
$5.46
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.60
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
HYDROmorphone 0.5MG/0.5ML
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
CPT J1170
|
| Hospital Charge Code |
3302519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
HYDROmorphone 1MG/ML INJECTION
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
CPT J1171
|
| Hospital Charge Code |
3300425
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.19 |
| Max. Negotiated Rate |
$18.05 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: First Health Commercial |
$17.10
|
| Rate for Payer: First Health Workers Compensation |
$7.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$17.10
|
| Rate for Payer: GEHA Commercial |
$13.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17.10
|
| Rate for Payer: Multiplan All |
$17.29
|
| Rate for Payer: OMNI Networks Commercial |
$13.30
|
| Rate for Payer: One Health Plan PPO/POS |
$17.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18.05
|
| Rate for Payer: Three Rivers Provider Network All |
$14.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17.67
|
| Rate for Payer: Zelis Auto |
$7.60
|
| Rate for Payer: Zelis Worker's Compensation |
$5.19
|
|
|
HYDROmorphone 1MG/ML INJECTION
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
CPT J1171
|
| Hospital Charge Code |
3300425
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$18.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$11.40
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: First Health Commercial |
$17.10
|
| Rate for Payer: First Health Workers Compensation |
$7.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$17.10
|
| Rate for Payer: GEHA Commercial |
$0.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17.10
|
| Rate for Payer: Humana ChoiceCare |
$4.94
|
| Rate for Payer: Multiplan All |
$17.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11.40
|
| Rate for Payer: OMNI Networks Commercial |
$13.30
|
| Rate for Payer: One Health Plan PPO/POS |
$17.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18.05
|
| Rate for Payer: Three Rivers Provider Network All |
$14.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17.67
|
| Rate for Payer: Zelis Auto |
$7.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$9.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.19
|
|
|
HYDROmorphone 2MG/2ML INJ - SYRINGE
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT J1170
|
| Hospital Charge Code |
3302810
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.92 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$43.35
|
| Rate for Payer: First Health Commercial |
$45.90
|
| Rate for Payer: First Health Workers Compensation |
$19.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.90
|
| Rate for Payer: GEHA Commercial |
$35.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.90
|
| Rate for Payer: Multiplan All |
$46.41
|
| Rate for Payer: OMNI Networks Commercial |
$35.70
|
| Rate for Payer: One Health Plan PPO/POS |
$45.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$48.45
|
| Rate for Payer: Three Rivers Provider Network All |
$38.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$47.43
|
| Rate for Payer: Zelis Auto |
$20.40
|
| Rate for Payer: Zelis Worker's Compensation |
$13.92
|
|
|
HYDROmorphone 2MG/2ML INJ - SYRINGE
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
CPT J1170
|
| Hospital Charge Code |
3302810
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$43.35
|
| Rate for Payer: First Health Commercial |
$45.90
|
| Rate for Payer: First Health Workers Compensation |
$19.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.90
|
| Rate for Payer: GEHA Commercial |
$40.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.90
|
| Rate for Payer: Humana ChoiceCare |
$13.26
|
| Rate for Payer: Multiplan All |
$46.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.60
|
| Rate for Payer: OMNI Networks Commercial |
$35.70
|
| Rate for Payer: One Health Plan PPO/POS |
$45.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$48.45
|
| Rate for Payer: Three Rivers Provider Network All |
$38.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$44.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$47.43
|
| Rate for Payer: Zelis Auto |
$20.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$25.50
|
| Rate for Payer: Zelis Worker's Compensation |
$13.92
|
|
