|
STREPT PNEUMONIAE AB IGG 26 POP REF
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2300081
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$21.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.99
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$96.00
|
| Rate for Payer: GEHA Medicare |
$14.99
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Humana ChoiceCare |
$16.49
|
| Rate for Payer: Humana Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$25.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.99
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.48
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$25.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.98
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.69
|
| Rate for Payer: United Healthcare Commercial |
$102.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.99
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Medicare |
$12.74
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.99
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 26 POP REF
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2300081
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$84.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 2 POP REF
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2200129
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$84.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 2 POP REF
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2300088
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$21.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.99
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$96.00
|
| Rate for Payer: GEHA Medicare |
$14.99
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Humana ChoiceCare |
$16.49
|
| Rate for Payer: Humana Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$25.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.99
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.48
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$25.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.98
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.69
|
| Rate for Payer: United Healthcare Commercial |
$102.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.99
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Medicare |
$12.74
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.99
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 2 POP REF
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2200129
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$21.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.99
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$96.00
|
| Rate for Payer: GEHA Medicare |
$14.99
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Humana ChoiceCare |
$16.49
|
| Rate for Payer: Humana Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$25.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.99
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.48
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$25.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.98
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.69
|
| Rate for Payer: United Healthcare Commercial |
$102.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.99
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Medicare |
$12.74
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.99
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 2 POP REF
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2300088
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$84.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 34 POP REF
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2300092
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$84.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 34 POP REF
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2200133
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$21.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.99
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$96.00
|
| Rate for Payer: GEHA Medicare |
$14.99
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Humana ChoiceCare |
$16.49
|
| Rate for Payer: Humana Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$25.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.99
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.48
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$25.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.98
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.69
|
| Rate for Payer: United Healthcare Commercial |
$102.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.99
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Medicare |
$12.74
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.99
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 34 POP REF
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2300092
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$21.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.99
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$96.00
|
| Rate for Payer: GEHA Medicare |
$14.99
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Humana ChoiceCare |
$16.49
|
| Rate for Payer: Humana Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$25.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.99
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.48
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$25.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.98
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.69
|
| Rate for Payer: United Healthcare Commercial |
$102.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.99
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Medicare |
$12.74
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.99
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 34 POP REF
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2200133
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$84.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 3 POP REF
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2300075
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$84.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 3 POP REF
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2300075
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$21.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.99
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$96.00
|
| Rate for Payer: GEHA Medicare |
$14.99
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Humana ChoiceCare |
$16.49
|
| Rate for Payer: Humana Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$25.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.99
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.48
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$25.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.98
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.69
|
| Rate for Payer: United Healthcare Commercial |
$102.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.99
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Medicare |
$12.74
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.99
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 3 POP REF
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2200116
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$84.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 3 POP REF
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2200116
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$21.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.99
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$96.00
|
| Rate for Payer: GEHA Medicare |
$14.99
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Humana ChoiceCare |
$16.49
|
| Rate for Payer: Humana Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$25.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.99
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.48
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$25.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.98
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.69
|
| Rate for Payer: United Healthcare Commercial |
$102.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.99
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Medicare |
$12.74
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.99
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 43 POP REF
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2200134
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$21.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.99
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$96.00
|
| Rate for Payer: GEHA Medicare |
$14.99
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Humana ChoiceCare |
$16.49
|
| Rate for Payer: Humana Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$25.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.99
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.48
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$25.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.98
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.69
|
| Rate for Payer: United Healthcare Commercial |
$102.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.99
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Medicare |
$12.74
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.99
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 43 POP REF
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2200134
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$84.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 43 POP REF
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2300093
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$84.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 43 POP REF
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2300093
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$21.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.99
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$96.00
|
| Rate for Payer: GEHA Medicare |
$14.99
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Humana ChoiceCare |
$16.49
|
| Rate for Payer: Humana Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$25.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.99
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.48
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$25.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.98
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.69
|
| Rate for Payer: United Healthcare Commercial |
$102.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.99
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Medicare |
$12.74
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.99
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 4 POP REF
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2200121
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$21.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.99
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$96.00
|
| Rate for Payer: GEHA Medicare |
$14.99
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Humana ChoiceCare |
$16.49
|
| Rate for Payer: Humana Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$25.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.99
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.48
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$25.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.98
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.69
|
| Rate for Payer: United Healthcare Commercial |
$102.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.99
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Medicare |
$12.74
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.99
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 4 POP REF
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2300080
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$84.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 4 POP REF
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2300080
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$21.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.99
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$96.00
|
| Rate for Payer: GEHA Medicare |
$14.99
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Humana ChoiceCare |
$16.49
|
| Rate for Payer: Humana Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$25.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.99
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.48
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$25.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.98
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.69
|
| Rate for Payer: United Healthcare Commercial |
$102.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.99
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Medicare |
$12.74
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.99
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 4 POP REF
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2200121
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$84.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 51 POP REF
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2200120
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$84.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 51 POP REF
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2200120
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$21.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.99
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$96.00
|
| Rate for Payer: GEHA Medicare |
$14.99
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Humana ChoiceCare |
$16.49
|
| Rate for Payer: Humana Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$25.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.99
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$25.48
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$25.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$29.98
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.69
|
| Rate for Payer: United Healthcare Commercial |
$102.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.99
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Medicare |
$12.74
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.99
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
|
STREPT PNEUMONIAE AB IGG 51 POP REF
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2300079
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$26.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$84.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.59
|
|
