|
HYDROMORPHONE 2MG/ML INJECTION
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
CPT J1171
|
| Hospital Charge Code |
3302462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.11 |
| 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: 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 |
$0.11
|
| 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
|
|
|
HYDROMORPHONE 2MG/ML INJECTION
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
CPT J1171
|
| Hospital Charge Code |
3302462
|
|
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
|
|
|
HYDROmorphone HCL 2MG TAB
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 42858030125
|
| Hospital Charge Code |
3300426
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
HYDROmorphone HCL 2MG TAB
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 42858030125
|
| Hospital Charge Code |
3300426
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$6.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Humana ChoiceCare |
$2.08
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.80
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
HYDROMORPHONE PCA 6 MG/NS 30ML
|
Facility
|
OP
|
$103.00
|
|
|
Service Code
|
NDC 00409336511
|
| Hospital Charge Code |
3305019
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$25.75 |
| Max. Negotiated Rate |
$97.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$61.80
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$87.55
|
| Rate for Payer: First Health Commercial |
$92.70
|
| Rate for Payer: First Health Workers Compensation |
$39.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$92.70
|
| Rate for Payer: GEHA Commercial |
$82.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$92.70
|
| Rate for Payer: Humana ChoiceCare |
$26.78
|
| Rate for Payer: Multiplan All |
$93.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$61.80
|
| Rate for Payer: OMNI Networks Commercial |
$72.10
|
| Rate for Payer: One Health Plan PPO/POS |
$92.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$97.85
|
| Rate for Payer: Three Rivers Provider Network All |
$77.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$90.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$25.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$95.79
|
| Rate for Payer: Zelis Auto |
$41.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$51.50
|
| Rate for Payer: Zelis Worker's Compensation |
$28.12
|
|
|
HYDROMORPHONE PCA 6 MG/NS 30ML
|
Facility
|
IP
|
$103.00
|
|
|
Service Code
|
NDC 00409336511
|
| Hospital Charge Code |
3305019
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$28.12 |
| Max. Negotiated Rate |
$97.85 |
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$87.55
|
| Rate for Payer: First Health Commercial |
$92.70
|
| Rate for Payer: First Health Workers Compensation |
$39.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$92.70
|
| Rate for Payer: GEHA Commercial |
$72.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$92.70
|
| Rate for Payer: Multiplan All |
$93.73
|
| Rate for Payer: OMNI Networks Commercial |
$72.10
|
| Rate for Payer: One Health Plan PPO/POS |
$92.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$97.85
|
| Rate for Payer: Three Rivers Provider Network All |
$77.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$95.79
|
| Rate for Payer: Zelis Auto |
$41.20
|
| Rate for Payer: Zelis Worker's Compensation |
$28.12
|
|
|
HYDROXOCOBALAMIN 5 GM INJ
|
Facility
|
IP
|
$3,290.00
|
|
|
Service Code
|
NDC 47781001101
|
| Hospital Charge Code |
3303100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$898.17 |
| Max. Negotiated Rate |
$3,125.50 |
| Rate for Payer: Cash Price |
$1,974.00
|
| Rate for Payer: Cigna Commercial |
$2,796.50
|
| Rate for Payer: First Health Commercial |
$2,961.00
|
| Rate for Payer: First Health Workers Compensation |
$1,270.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,961.00
|
| Rate for Payer: GEHA Commercial |
$2,303.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,961.00
|
| Rate for Payer: Multiplan All |
$2,993.90
|
| Rate for Payer: OMNI Networks Commercial |
$2,303.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,961.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,125.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,467.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,059.70
|
| Rate for Payer: Zelis Auto |
$1,316.00
|
| Rate for Payer: Zelis Worker's Compensation |
$898.17
|
|
|
HYDROXOCOBALAMIN 5 GM INJ
|
Facility
|
OP
|
$3,290.00
|
|
|
Service Code
|
NDC 47781001101
|
| Hospital Charge Code |
3303100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$822.50 |
| Max. Negotiated Rate |
$3,125.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,974.00
|
| Rate for Payer: Cash Price |
$1,974.00
|
| Rate for Payer: Cigna Commercial |
$2,796.50
|
| Rate for Payer: First Health Commercial |
$2,961.00
|
| Rate for Payer: First Health Workers Compensation |
$1,270.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,961.00
|
| Rate for Payer: GEHA Commercial |
$2,632.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,961.00
|
| Rate for Payer: Humana ChoiceCare |
$855.40
|
| Rate for Payer: Multiplan All |
$2,993.90
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,974.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,303.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,961.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,125.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,467.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,895.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$822.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,059.70
|
| Rate for Payer: Zelis Auto |
$1,316.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,645.00
|
| Rate for Payer: Zelis Worker's Compensation |
$898.17
|
|
|
HYDROXYCHLOROQUINE 200 MG TAB
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 00781599401
|
| Hospital Charge Code |
3300427
|
|
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
|
|
|
HYDROXYCHLOROQUINE 200 MG TAB
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 00781599401
|
| Hospital Charge Code |
3300427
|
|
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
|
|
|
HYDROXYUREA 500 MG CAP
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
CPT J8999
|
| Hospital Charge Code |
3302938
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
HYDROXYUREA 500 MG CAP
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
CPT J8999
|
| Hospital Charge Code |
3302938
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
hydrOXYzine 10 MG TAB
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 51079079620
|
| Hospital Charge Code |
3300430
|
|
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
|
|
|
hydrOXYzine 10 MG TAB
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 51079079620
|
| Hospital Charge Code |
3300430
|
|
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
|
|
|
hydrOXYzine 25MG/ML INJ.
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
CPT J3410
|
| Hospital Charge Code |
3301652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.75 |
| Max. Negotiated Rate |
$29.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$18.60
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$26.35
|
| Rate for Payer: First Health Commercial |
$27.90
|
| Rate for Payer: First Health Workers Compensation |
$11.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.90
|
| Rate for Payer: GEHA Commercial |
$16.83
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.90
|
| Rate for Payer: Humana ChoiceCare |
$8.06
|
| Rate for Payer: Multiplan All |
$28.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$18.60
|
| Rate for Payer: OMNI Networks Commercial |
$21.70
|
| Rate for Payer: One Health Plan PPO/POS |
$27.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$29.45
|
| Rate for Payer: Three Rivers Provider Network All |
$23.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$27.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$28.83
|
| Rate for Payer: Zelis Auto |
$12.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.50
|
| Rate for Payer: Zelis Worker's Compensation |
$8.46
|
|
|
hydrOXYzine 25MG/ML INJ.
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
CPT J3410
|
| Hospital Charge Code |
3301652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$29.45 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$26.35
|
| Rate for Payer: First Health Commercial |
$27.90
|
| Rate for Payer: First Health Workers Compensation |
$11.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.90
|
| Rate for Payer: GEHA Commercial |
$21.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.90
|
| Rate for Payer: Multiplan All |
$28.21
|
| Rate for Payer: OMNI Networks Commercial |
$21.70
|
| Rate for Payer: One Health Plan PPO/POS |
$27.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$29.45
|
| Rate for Payer: Three Rivers Provider Network All |
$23.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$28.83
|
| Rate for Payer: Zelis Auto |
$12.40
|
| Rate for Payer: Zelis Worker's Compensation |
$8.46
|
|
|
HYDROXYZINE HCL 25 MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3303166
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
HYDROXYZINE HCL 25 MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3303166
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
hydrOXYzine HCL 50 MG/ML INJ-IM
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
CPT J3410
|
| Hospital Charge Code |
3300428
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.83 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$75.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$107.10
|
| Rate for Payer: First Health Commercial |
$113.40
|
| Rate for Payer: First Health Workers Compensation |
$48.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$113.40
|
| Rate for Payer: GEHA Commercial |
$16.83
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$113.40
|
| Rate for Payer: Humana ChoiceCare |
$32.76
|
| Rate for Payer: Multiplan All |
$114.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$75.60
|
| Rate for Payer: OMNI Networks Commercial |
$88.20
|
| Rate for Payer: One Health Plan PPO/POS |
$113.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$119.70
|
| Rate for Payer: Three Rivers Provider Network All |
$94.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$110.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$117.18
|
| Rate for Payer: Zelis Auto |
$50.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$63.00
|
| Rate for Payer: Zelis Worker's Compensation |
$34.40
|
|
|
hydrOXYzine HCL 50 MG/ML INJ-IM
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
CPT J3410
|
| Hospital Charge Code |
3300428
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.40 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$107.10
|
| Rate for Payer: First Health Commercial |
$113.40
|
| Rate for Payer: First Health Workers Compensation |
$48.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$113.40
|
| Rate for Payer: GEHA Commercial |
$88.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$113.40
|
| Rate for Payer: Multiplan All |
$114.66
|
| Rate for Payer: OMNI Networks Commercial |
$88.20
|
| Rate for Payer: One Health Plan PPO/POS |
$113.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$119.70
|
| Rate for Payer: Three Rivers Provider Network All |
$94.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$117.18
|
| Rate for Payer: Zelis Auto |
$50.40
|
| Rate for Payer: Zelis Worker's Compensation |
$34.40
|
|
|
hydrOXYzine HCL SYRUP 10MG/5ML
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 60432015004
|
| Hospital Charge Code |
3300429
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
hydrOXYzine HCL SYRUP 10MG/5ML
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 60432015004
|
| Hospital Charge Code |
3300429
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
hydrOXYzine PAMOATE 25MG CAP
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
CPT Q0177
|
| Hospital Charge Code |
3300431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$8.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
hydrOXYzine PAMOATE 25MG CAP
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
CPT Q0177
|
| Hospital Charge Code |
3300431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$9.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Humana ChoiceCare |
$3.12
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.20
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
HYLENEX 150 USP/ 1 ML INJ
|
Facility
|
IP
|
$364.00
|
|
|
Service Code
|
CPT J3473
|
| Hospital Charge Code |
3302627
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.37 |
| Max. Negotiated Rate |
$345.80 |
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$309.40
|
| Rate for Payer: First Health Commercial |
$327.60
|
| Rate for Payer: First Health Workers Compensation |
$140.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$327.60
|
| Rate for Payer: GEHA Commercial |
$254.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$327.60
|
| Rate for Payer: Multiplan All |
$331.24
|
| Rate for Payer: OMNI Networks Commercial |
$254.80
|
| Rate for Payer: One Health Plan PPO/POS |
$327.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$345.80
|
| Rate for Payer: Three Rivers Provider Network All |
$273.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$338.52
|
| Rate for Payer: Zelis Auto |
$145.60
|
| Rate for Payer: Zelis Worker's Compensation |
$99.37
|
|
