|
PNEUMOCOCCAL VACCINE
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
9100004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.06 |
| Max. Negotiated Rate |
$148.28 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$148.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$48.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$148.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$117.46
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$68.85
|
| Rate for Payer: First Health Commercial |
$72.90
|
| Rate for Payer: First Health Workers Compensation |
$31.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.90
|
| Rate for Payer: GEHA Commercial |
$146.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.90
|
| Rate for Payer: Humana ChoiceCare |
$21.06
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$119.86
|
| Rate for Payer: Multiplan All |
$73.71
|
| Rate for Payer: New Mexico Health Connections Medicare |
$48.60
|
| Rate for Payer: OMNI Networks Commercial |
$56.70
|
| Rate for Payer: One Health Plan PPO/POS |
$72.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$138.39
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$119.86
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.95
|
| Rate for Payer: Three Rivers Provider Network All |
$60.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$71.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$119.86
|
| Rate for Payer: United Payors & United Providers UP&UP |
$75.33
|
| Rate for Payer: Zelis Auto |
$32.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$40.50
|
| Rate for Payer: Zelis Worker's Compensation |
$22.11
|
|
|
PNEUMOCOCCAL VACCINE
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
8590732
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.06 |
| Max. Negotiated Rate |
$148.28 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$148.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$48.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$148.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$117.46
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$68.85
|
| Rate for Payer: First Health Commercial |
$72.90
|
| Rate for Payer: First Health Workers Compensation |
$31.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.90
|
| Rate for Payer: GEHA Commercial |
$146.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.90
|
| Rate for Payer: Humana ChoiceCare |
$21.06
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$119.86
|
| Rate for Payer: Multiplan All |
$73.71
|
| Rate for Payer: New Mexico Health Connections Medicare |
$48.60
|
| Rate for Payer: OMNI Networks Commercial |
$56.70
|
| Rate for Payer: One Health Plan PPO/POS |
$72.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$138.39
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$119.86
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.95
|
| Rate for Payer: Three Rivers Provider Network All |
$60.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$71.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$119.86
|
| Rate for Payer: United Payors & United Providers UP&UP |
$75.33
|
| Rate for Payer: Zelis Auto |
$32.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$40.50
|
| Rate for Payer: Zelis Worker's Compensation |
$22.11
|
|
|
PNEUMOCOCCAL VACCINE
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
9100004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.11 |
| Max. Negotiated Rate |
$76.95 |
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$68.85
|
| Rate for Payer: First Health Commercial |
$72.90
|
| Rate for Payer: First Health Workers Compensation |
$31.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.90
|
| Rate for Payer: GEHA Commercial |
$56.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.90
|
| Rate for Payer: Multiplan All |
$73.71
|
| Rate for Payer: OMNI Networks Commercial |
$56.70
|
| Rate for Payer: One Health Plan PPO/POS |
$72.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.95
|
| Rate for Payer: Three Rivers Provider Network All |
$60.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$75.33
|
| Rate for Payer: Zelis Auto |
$32.40
|
| Rate for Payer: Zelis Worker's Compensation |
$22.11
|
|
|
PNEUMOCOCCAL VACCINE
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
9400051
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.11 |
| Max. Negotiated Rate |
$76.95 |
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$68.85
|
| Rate for Payer: First Health Commercial |
$72.90
|
| Rate for Payer: First Health Workers Compensation |
$31.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.90
|
| Rate for Payer: GEHA Commercial |
$56.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.90
|
| Rate for Payer: Multiplan All |
$73.71
|
| Rate for Payer: OMNI Networks Commercial |
$56.70
|
| Rate for Payer: One Health Plan PPO/POS |
$72.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.95
|
| Rate for Payer: Three Rivers Provider Network All |
$60.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$75.33
|
| Rate for Payer: Zelis Auto |
$32.40
|
| Rate for Payer: Zelis Worker's Compensation |
$22.11
|
|
|
PNEUMOCOCCAL VACCINE
|
Facility
|
OP
|
$556.31
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
7290732
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$117.46 |
| Max. Negotiated Rate |
$528.49 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$148.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$333.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$148.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$117.46
|
| Rate for Payer: Cash Price |
$333.79
|
| Rate for Payer: Cash Price |
$333.79
|
| Rate for Payer: Cigna Commercial |
$472.86
|
| Rate for Payer: First Health Commercial |
$500.68
|
| Rate for Payer: First Health Workers Compensation |
$214.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$500.68
|
| Rate for Payer: GEHA Commercial |
$146.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$500.68
|
| Rate for Payer: Humana ChoiceCare |
$144.64
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$119.86
|
| Rate for Payer: Multiplan All |
$506.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$333.79
|
| Rate for Payer: OMNI Networks Commercial |
$389.42
|
| Rate for Payer: One Health Plan PPO/POS |
$500.68
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$138.39
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$119.86
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$528.49
|
| Rate for Payer: Three Rivers Provider Network All |
$417.23
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$489.55
|
| Rate for Payer: United Healthcare Managed Medicaid |
$119.86
|
| Rate for Payer: United Payors & United Providers UP&UP |
$517.37
|
| Rate for Payer: Zelis Auto |
$222.52
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$278.15
|
| Rate for Payer: Zelis Worker's Compensation |
$151.87
|
|
|
PNEUMOCOCCAL VACCINE
|
Facility
|
IP
|
$556.31
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
7290732
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$151.87 |
| Max. Negotiated Rate |
$528.49 |
| Rate for Payer: Cash Price |
$333.79
|
| Rate for Payer: Cigna Commercial |
$472.86
|
| Rate for Payer: First Health Commercial |
$500.68
|
| Rate for Payer: First Health Workers Compensation |
$214.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$500.68
|
| Rate for Payer: GEHA Commercial |
$389.42
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$500.68
|
| Rate for Payer: Multiplan All |
$506.24
|
| Rate for Payer: OMNI Networks Commercial |
$389.42
|
| Rate for Payer: One Health Plan PPO/POS |
$500.68
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$528.49
|
| Rate for Payer: Three Rivers Provider Network All |
$417.23
|
| Rate for Payer: United Payors & United Providers UP&UP |
$517.37
|
| Rate for Payer: Zelis Auto |
$222.52
|
| Rate for Payer: Zelis Worker's Compensation |
$151.87
|
|
|
PNEUMOCOCCAL VACCINE
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
9400051
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.06 |
| Max. Negotiated Rate |
$148.28 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$148.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$48.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$148.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$117.46
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$68.85
|
| Rate for Payer: First Health Commercial |
$72.90
|
| Rate for Payer: First Health Workers Compensation |
$31.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$72.90
|
| Rate for Payer: GEHA Commercial |
$146.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$72.90
|
| Rate for Payer: Humana ChoiceCare |
$21.06
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$119.86
|
| Rate for Payer: Multiplan All |
$73.71
|
| Rate for Payer: New Mexico Health Connections Medicare |
$48.60
|
| Rate for Payer: OMNI Networks Commercial |
$56.70
|
| Rate for Payer: One Health Plan PPO/POS |
$72.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$138.39
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$119.86
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$76.95
|
| Rate for Payer: Three Rivers Provider Network All |
$60.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$71.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$119.86
|
| Rate for Payer: United Payors & United Providers UP&UP |
$75.33
|
| Rate for Payer: Zelis Auto |
$32.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$40.50
|
| Rate for Payer: Zelis Worker's Compensation |
$22.11
|
|
|
PNEUMOVAX 23 0.5 ML
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3300728
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.76 |
| Max. Negotiated Rate |
$103.55 |
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cigna Commercial |
$92.65
|
| Rate for Payer: First Health Commercial |
$98.10
|
| Rate for Payer: First Health Workers Compensation |
$42.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$98.10
|
| Rate for Payer: GEHA Commercial |
$76.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$98.10
|
| Rate for Payer: Multiplan All |
$99.19
|
| Rate for Payer: OMNI Networks Commercial |
$76.30
|
| Rate for Payer: One Health Plan PPO/POS |
$98.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$103.55
|
| Rate for Payer: Three Rivers Provider Network All |
$81.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$101.37
|
| Rate for Payer: Zelis Auto |
$43.60
|
| Rate for Payer: Zelis Worker's Compensation |
$29.76
|
|
|
PNEUMOVAX 23 0.5 ML
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3300728
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.34 |
| Max. Negotiated Rate |
$148.28 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$148.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$65.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$148.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$117.46
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cigna Commercial |
$92.65
|
| Rate for Payer: First Health Commercial |
$98.10
|
| Rate for Payer: First Health Workers Compensation |
$42.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$98.10
|
| Rate for Payer: GEHA Commercial |
$146.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$98.10
|
| Rate for Payer: Humana ChoiceCare |
$28.34
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$119.86
|
| Rate for Payer: Multiplan All |
$99.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$65.40
|
| Rate for Payer: OMNI Networks Commercial |
$76.30
|
| Rate for Payer: One Health Plan PPO/POS |
$98.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$138.39
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$119.86
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$103.55
|
| Rate for Payer: Three Rivers Provider Network All |
$81.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$95.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$119.86
|
| Rate for Payer: United Payors & United Providers UP&UP |
$101.37
|
| Rate for Payer: Zelis Auto |
$43.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$54.50
|
| Rate for Payer: Zelis Worker's Compensation |
$29.76
|
|
|
POLIBAR LIQUID 105% SUSP
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
NDC 32909072802
|
| Hospital Charge Code |
3300088
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.06 |
| Max. Negotiated Rate |
$209.00 |
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$187.00
|
| Rate for Payer: First Health Commercial |
$198.00
|
| Rate for Payer: First Health Workers Compensation |
$84.94
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$198.00
|
| Rate for Payer: GEHA Commercial |
$154.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$198.00
|
| Rate for Payer: Multiplan All |
$200.20
|
| Rate for Payer: OMNI Networks Commercial |
$154.00
|
| Rate for Payer: One Health Plan PPO/POS |
$198.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$209.00
|
| Rate for Payer: Three Rivers Provider Network All |
$165.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$204.60
|
| Rate for Payer: Zelis Auto |
$88.00
|
| Rate for Payer: Zelis Worker's Compensation |
$60.06
|
|
|
POLIBAR LIQUID 105% SUSP
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
NDC 32909072802
|
| Hospital Charge Code |
3300088
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.00 |
| Max. Negotiated Rate |
$209.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$132.00
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$187.00
|
| Rate for Payer: First Health Commercial |
$198.00
|
| Rate for Payer: First Health Workers Compensation |
$84.94
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$198.00
|
| Rate for Payer: GEHA Commercial |
$176.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$198.00
|
| Rate for Payer: Humana ChoiceCare |
$57.20
|
| Rate for Payer: Multiplan All |
$200.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$132.00
|
| Rate for Payer: OMNI Networks Commercial |
$154.00
|
| Rate for Payer: One Health Plan PPO/POS |
$198.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$209.00
|
| Rate for Payer: Three Rivers Provider Network All |
$165.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$193.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$55.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$204.60
|
| Rate for Payer: Zelis Auto |
$88.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$110.00
|
| Rate for Payer: Zelis Worker's Compensation |
$60.06
|
|
|
poliovirus 1-3 ab REF830764
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
CPT 86658
|
| Hospital Charge Code |
2200781
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$121.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$23.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$76.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$23.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$18.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$13.03
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Cigna Commercial |
$108.80
|
| Rate for Payer: First Health Commercial |
$115.20
|
| Rate for Payer: First Health Workers Compensation |
$20.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$115.20
|
| Rate for Payer: GEHA Commercial |
$102.40
|
| Rate for Payer: GEHA Medicare |
$13.03
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$115.20
|
| Rate for Payer: Humana ChoiceCare |
$14.33
|
| Rate for Payer: Humana Medicare Advantage |
$13.03
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$21.89
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$18.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$13.03
|
| Rate for Payer: Multiplan All |
$116.48
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.15
|
| Rate for Payer: OMNI Networks Commercial |
$89.60
|
| Rate for Payer: One Health Plan PPO/POS |
$115.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$21.90
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$18.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$13.03
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$121.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$26.06
|
| Rate for Payer: Three Rivers Provider Network All |
$96.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.77
|
| Rate for Payer: United Healthcare Commercial |
$108.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$18.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.03
|
| Rate for Payer: United Payors & United Providers UP&UP |
$119.04
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$13.03
|
| Rate for Payer: Zelis Auto |
$51.20
|
| Rate for Payer: Zelis Medicare |
$11.08
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.64
|
| Rate for Payer: Zelis Worker's Compensation |
$14.15
|
|
|
poliovirus 1-3 ab REF830764
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
CPT 86658
|
| Hospital Charge Code |
2200781
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.15 |
| Max. Negotiated Rate |
$121.60 |
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Cigna Commercial |
$108.80
|
| Rate for Payer: First Health Commercial |
$115.20
|
| Rate for Payer: First Health Workers Compensation |
$20.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$115.20
|
| Rate for Payer: GEHA Commercial |
$89.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$115.20
|
| Rate for Payer: Multiplan All |
$116.48
|
| Rate for Payer: OMNI Networks Commercial |
$89.60
|
| Rate for Payer: One Health Plan PPO/POS |
$115.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$121.60
|
| Rate for Payer: Three Rivers Provider Network All |
$96.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$119.04
|
| Rate for Payer: Zelis Auto |
$51.20
|
| Rate for Payer: Zelis Worker's Compensation |
$14.15
|
|
|
POLIOVIRUS, IPV, SC/IM
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 90713
|
| Hospital Charge Code |
8590713
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.50 |
| Max. Negotiated Rate |
$55.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$34.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$49.30
|
| Rate for Payer: First Health Commercial |
$52.20
|
| Rate for Payer: First Health Workers Compensation |
$22.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$52.20
|
| Rate for Payer: GEHA Commercial |
$46.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$52.20
|
| Rate for Payer: Humana ChoiceCare |
$15.08
|
| Rate for Payer: Multiplan All |
$52.78
|
| Rate for Payer: New Mexico Health Connections Medicare |
$34.80
|
| Rate for Payer: OMNI Networks Commercial |
$40.60
|
| Rate for Payer: One Health Plan PPO/POS |
$52.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$55.10
|
| Rate for Payer: Three Rivers Provider Network All |
$43.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$51.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.94
|
| Rate for Payer: Zelis Auto |
$23.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$29.00
|
| Rate for Payer: Zelis Worker's Compensation |
$15.83
|
|
|
POLIOVIRUS, IPV, SC/IM
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 90713
|
| Hospital Charge Code |
8590713
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.83 |
| Max. Negotiated Rate |
$55.10 |
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$49.30
|
| Rate for Payer: First Health Commercial |
$52.20
|
| Rate for Payer: First Health Workers Compensation |
$22.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$52.20
|
| Rate for Payer: GEHA Commercial |
$40.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$52.20
|
| Rate for Payer: Multiplan All |
$52.78
|
| Rate for Payer: OMNI Networks Commercial |
$40.60
|
| Rate for Payer: One Health Plan PPO/POS |
$52.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$55.10
|
| Rate for Payer: Three Rivers Provider Network All |
$43.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53.94
|
| Rate for Payer: Zelis Auto |
$23.20
|
| Rate for Payer: Zelis Worker's Compensation |
$15.83
|
|
|
POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTN
|
Facility
|
OP
|
$1,782.00
|
|
|
Service Code
|
CPT 95810
|
| Hospital Charge Code |
21800001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$486.49 |
| Max. Negotiated Rate |
$1,932.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,155.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,069.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,155.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$915.64
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$966.05
|
| Rate for Payer: Cash Price |
$1,069.20
|
| Rate for Payer: Cash Price |
$1,069.20
|
| Rate for Payer: Cigna Commercial |
$1,514.70
|
| Rate for Payer: First Health Commercial |
$1,603.80
|
| Rate for Payer: First Health Workers Compensation |
$688.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,603.80
|
| Rate for Payer: GEHA Commercial |
$1,425.60
|
| Rate for Payer: GEHA Medicare |
$966.05
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,603.80
|
| Rate for Payer: Humana ChoiceCare |
$1,062.65
|
| Rate for Payer: Humana Medicare Advantage |
$966.05
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,622.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$934.29
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$966.05
|
| Rate for Payer: Multiplan All |
$1,621.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,642.29
|
| Rate for Payer: OMNI Networks Commercial |
$1,247.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,603.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,078.77
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$934.29
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$966.05
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,692.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,932.10
|
| Rate for Payer: Three Rivers Provider Network All |
$1,336.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$946.73
|
| Rate for Payer: United Healthcare Managed Medicaid |
$934.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$966.05
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,657.26
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$966.05
|
| Rate for Payer: Zelis Auto |
$712.80
|
| Rate for Payer: Zelis Medicare |
$821.14
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,159.26
|
| Rate for Payer: Zelis Worker's Compensation |
$486.49
|
|
|
POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTN
|
Facility
|
IP
|
$1,782.00
|
|
|
Service Code
|
CPT 95810
|
| Hospital Charge Code |
21800001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$486.49 |
| Max. Negotiated Rate |
$1,692.90 |
| Rate for Payer: Cash Price |
$1,069.20
|
| Rate for Payer: Cigna Commercial |
$1,514.70
|
| Rate for Payer: First Health Commercial |
$1,603.80
|
| Rate for Payer: First Health Workers Compensation |
$688.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,603.80
|
| Rate for Payer: GEHA Commercial |
$1,247.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,603.80
|
| Rate for Payer: Multiplan All |
$1,621.62
|
| Rate for Payer: OMNI Networks Commercial |
$1,247.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,603.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,692.90
|
| Rate for Payer: Three Rivers Provider Network All |
$1,336.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,657.26
|
| Rate for Payer: Zelis Auto |
$712.80
|
| Rate for Payer: Zelis Worker's Compensation |
$486.49
|
|
|
POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTN
|
Facility
|
OP
|
$6,253.00
|
|
|
Service Code
|
CPT 95810
|
| Hospital Charge Code |
3000002
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$821.14 |
| Max. Negotiated Rate |
$5,940.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,155.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,751.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,155.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$915.64
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$966.05
|
| Rate for Payer: Cash Price |
$3,751.80
|
| Rate for Payer: Cash Price |
$3,751.80
|
| Rate for Payer: Cigna Commercial |
$5,315.05
|
| Rate for Payer: First Health Commercial |
$5,627.70
|
| Rate for Payer: First Health Workers Compensation |
$2,414.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,627.70
|
| Rate for Payer: GEHA Commercial |
$5,002.40
|
| Rate for Payer: GEHA Medicare |
$966.05
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,627.70
|
| Rate for Payer: Humana ChoiceCare |
$1,062.65
|
| Rate for Payer: Humana Medicare Advantage |
$966.05
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,622.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$934.29
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$966.05
|
| Rate for Payer: Multiplan All |
$5,690.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,642.29
|
| Rate for Payer: OMNI Networks Commercial |
$4,377.10
|
| Rate for Payer: One Health Plan PPO/POS |
$5,627.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,078.77
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$934.29
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$966.05
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,940.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,932.10
|
| Rate for Payer: Three Rivers Provider Network All |
$4,689.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$946.73
|
| Rate for Payer: United Healthcare Managed Medicaid |
$934.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$966.05
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,815.29
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$966.05
|
| Rate for Payer: Zelis Auto |
$2,501.20
|
| Rate for Payer: Zelis Medicare |
$821.14
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,159.26
|
| Rate for Payer: Zelis Worker's Compensation |
$1,707.07
|
|
|
POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTN
|
Facility
|
IP
|
$6,253.00
|
|
|
Service Code
|
CPT 95810
|
| Hospital Charge Code |
3000002
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$1,707.07 |
| Max. Negotiated Rate |
$5,940.35 |
| Rate for Payer: Cash Price |
$3,751.80
|
| Rate for Payer: Cigna Commercial |
$5,315.05
|
| Rate for Payer: First Health Commercial |
$5,627.70
|
| Rate for Payer: First Health Workers Compensation |
$2,414.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,627.70
|
| Rate for Payer: GEHA Commercial |
$4,377.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,627.70
|
| Rate for Payer: Multiplan All |
$5,690.23
|
| Rate for Payer: OMNI Networks Commercial |
$4,377.10
|
| Rate for Payer: One Health Plan PPO/POS |
$5,627.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,940.35
|
| Rate for Payer: Three Rivers Provider Network All |
$4,689.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,815.29
|
| Rate for Payer: Zelis Auto |
$2,501.20
|
| Rate for Payer: Zelis Worker's Compensation |
$1,707.07
|
|
|
POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PAR
|
Facility
|
IP
|
$6,800.00
|
|
|
Service Code
|
CPT 95811
|
| Hospital Charge Code |
3000003
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$1,856.40 |
| Max. Negotiated Rate |
$6,460.00 |
| Rate for Payer: Cash Price |
$4,080.00
|
| Rate for Payer: Cigna Commercial |
$5,780.00
|
| Rate for Payer: First Health Commercial |
$6,120.00
|
| Rate for Payer: First Health Workers Compensation |
$2,625.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,120.00
|
| Rate for Payer: GEHA Commercial |
$4,760.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,120.00
|
| Rate for Payer: Multiplan All |
$6,188.00
|
| Rate for Payer: OMNI Networks Commercial |
$4,760.00
|
| Rate for Payer: One Health Plan PPO/POS |
$6,120.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,460.00
|
| Rate for Payer: Three Rivers Provider Network All |
$5,100.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,324.00
|
| Rate for Payer: Zelis Auto |
$2,720.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,856.40
|
|
|
POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PAR
|
Facility
|
IP
|
$1,869.00
|
|
|
Service Code
|
CPT 95811
|
| Hospital Charge Code |
21800002
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$510.24 |
| Max. Negotiated Rate |
$1,775.55 |
| Rate for Payer: Cash Price |
$1,121.40
|
| Rate for Payer: Cigna Commercial |
$1,588.65
|
| Rate for Payer: First Health Commercial |
$1,682.10
|
| Rate for Payer: First Health Workers Compensation |
$721.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,682.10
|
| Rate for Payer: GEHA Commercial |
$1,308.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,682.10
|
| Rate for Payer: Multiplan All |
$1,700.79
|
| Rate for Payer: OMNI Networks Commercial |
$1,308.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,682.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,775.55
|
| Rate for Payer: Three Rivers Provider Network All |
$1,401.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,738.17
|
| Rate for Payer: Zelis Auto |
$747.60
|
| Rate for Payer: Zelis Worker's Compensation |
$510.24
|
|
|
POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PAR
|
Facility
|
OP
|
$6,800.00
|
|
|
Service Code
|
CPT 95811
|
| Hospital Charge Code |
3000003
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$821.14 |
| Max. Negotiated Rate |
$6,460.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,155.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,080.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,155.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$915.64
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$966.05
|
| Rate for Payer: Cash Price |
$4,080.00
|
| Rate for Payer: Cash Price |
$4,080.00
|
| Rate for Payer: Cigna Commercial |
$5,780.00
|
| Rate for Payer: First Health Commercial |
$6,120.00
|
| Rate for Payer: First Health Workers Compensation |
$2,625.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,120.00
|
| Rate for Payer: GEHA Commercial |
$5,440.00
|
| Rate for Payer: GEHA Medicare |
$966.05
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,120.00
|
| Rate for Payer: Humana ChoiceCare |
$1,062.65
|
| Rate for Payer: Humana Medicare Advantage |
$966.05
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,622.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$934.29
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$966.05
|
| Rate for Payer: Multiplan All |
$6,188.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,642.29
|
| Rate for Payer: OMNI Networks Commercial |
$4,760.00
|
| Rate for Payer: One Health Plan PPO/POS |
$6,120.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,078.77
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$934.29
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$966.05
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,460.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,932.10
|
| Rate for Payer: Three Rivers Provider Network All |
$5,100.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$946.73
|
| Rate for Payer: United Healthcare Managed Medicaid |
$934.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$966.05
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,324.00
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$966.05
|
| Rate for Payer: Zelis Auto |
$2,720.00
|
| Rate for Payer: Zelis Medicare |
$821.14
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,159.26
|
| Rate for Payer: Zelis Worker's Compensation |
$1,856.40
|
|
|
POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PAR
|
Facility
|
OP
|
$1,869.00
|
|
|
Service Code
|
CPT 95811
|
| Hospital Charge Code |
21800002
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$510.24 |
| Max. Negotiated Rate |
$1,932.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,155.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,121.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,155.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$915.64
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$966.05
|
| Rate for Payer: Cash Price |
$1,121.40
|
| Rate for Payer: Cash Price |
$1,121.40
|
| Rate for Payer: Cigna Commercial |
$1,588.65
|
| Rate for Payer: First Health Commercial |
$1,682.10
|
| Rate for Payer: First Health Workers Compensation |
$721.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,682.10
|
| Rate for Payer: GEHA Commercial |
$1,495.20
|
| Rate for Payer: GEHA Medicare |
$966.05
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,682.10
|
| Rate for Payer: Humana ChoiceCare |
$1,062.65
|
| Rate for Payer: Humana Medicare Advantage |
$966.05
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,622.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$934.29
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$966.05
|
| Rate for Payer: Multiplan All |
$1,700.79
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,642.29
|
| Rate for Payer: OMNI Networks Commercial |
$1,308.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,682.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,078.77
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$934.29
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$966.05
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,775.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,932.10
|
| Rate for Payer: Three Rivers Provider Network All |
$1,401.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$946.73
|
| Rate for Payer: United Healthcare Managed Medicaid |
$934.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$966.05
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,738.17
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$966.05
|
| Rate for Payer: Zelis Auto |
$747.60
|
| Rate for Payer: Zelis Medicare |
$821.14
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,159.26
|
| Rate for Payer: Zelis Worker's Compensation |
$510.24
|
|
|
POLYVINYL ALCOHOL 1.4% EYE DROP UD
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00023050650
|
| Hospital Charge Code |
3300732
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
POLYVINYL ALCOHOL 1.4% EYE DROP UD
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00023050650
|
| Hospital Charge Code |
3300732
|
|
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
|
|
