|
CL- FERRIC CARBOXYMALTOSE 750 MG
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
CPT J1439
|
| Hospital Charge Code |
3350316
|
|
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
|
|
|
CL- FERRIC CARBOXYMALTOSE 750 MG
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
CPT J1439
|
| Hospital Charge Code |
3350316
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1.27
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1.11
|
| Rate for Payer: Cash Price |
$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 |
$1.22
|
| Rate for Payer: GEHA Medicare |
$1.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$1.22
|
| Rate for Payer: Humana Medicare Advantage |
$1.11
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1.86
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1.30
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1.11
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.89
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1.50
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1.30
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$2.22
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1.09
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1.11
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Medicare |
$0.94
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.33
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
CL- Filgrastim 1 MCG
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
CPT J1442
|
| Hospital Charge Code |
3350333
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1.18
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1.00
|
| Rate for Payer: Cash Price |
$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 |
$1.10
|
| Rate for Payer: GEHA Medicare |
$1.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$1.10
|
| Rate for Payer: Humana Medicare Advantage |
$1.00
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1.68
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1.20
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1.00
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.70
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1.39
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1.20
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$2.00
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.98
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1.00
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Medicare |
$0.85
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
CL- Filgrastim 1 MCG
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
CPT J1442
|
| Hospital Charge Code |
3350333
|
|
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
|
|
|
CL- FIRMAGON 1 MG -- PT OWNED
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J9155
|
| Hospital Charge Code |
3350417
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- FIRMAGON 1 MG -- PT OWNED
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J9155
|
| Hospital Charge Code |
3350417
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$8.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$5.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$5.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$4.14
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$4.45
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$4.89
|
| Rate for Payer: GEHA Medicare |
$4.45
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$4.89
|
| Rate for Payer: Humana Medicare Advantage |
$4.45
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$7.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$4.22
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$4.45
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.57
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$4.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$4.22
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$4.45
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$8.90
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$4.45
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Medicare |
$3.78
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.34
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- FIRMAGON 80 MG INJ
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
CPT J9155
|
| Hospital Charge Code |
3350445
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$8.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$5.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$5.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$4.14
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$4.45
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$4.89
|
| Rate for Payer: GEHA Medicare |
$4.45
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Humana ChoiceCare |
$4.89
|
| Rate for Payer: Humana Medicare Advantage |
$4.45
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$7.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$4.22
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$4.45
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.57
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$4.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$4.22
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$4.45
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$8.90
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$4.45
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Medicare |
$3.78
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.34
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
CL- FIRMAGON 80 MG INJ
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
CPT J9155
|
| Hospital Charge Code |
3350445
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
CL- FIRMAGON 80 MG INJ - PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J9155
|
| Hospital Charge Code |
3350371
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$8.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$5.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$5.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$4.14
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$4.45
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$4.89
|
| Rate for Payer: GEHA Medicare |
$4.45
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$4.89
|
| Rate for Payer: Humana Medicare Advantage |
$4.45
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$7.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$4.22
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$4.45
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7.57
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$4.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$4.22
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$4.45
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$8.90
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$4.45
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Medicare |
$3.78
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.34
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- FIRMAGON 80 MG INJ - PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J9155
|
| Hospital Charge Code |
3350371
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- FLUCELVAX- HOSPITAL********ARCHIVED
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
CPT 90674
|
| Hospital Charge Code |
3350109
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.74 |
| Max. Negotiated Rate |
$51.30 |
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$45.90
|
| Rate for Payer: First Health Commercial |
$48.60
|
| Rate for Payer: First Health Workers Compensation |
$20.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$48.60
|
| Rate for Payer: GEHA Commercial |
$37.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$48.60
|
| Rate for Payer: Multiplan All |
$49.14
|
| Rate for Payer: OMNI Networks Commercial |
$37.80
|
| Rate for Payer: One Health Plan PPO/POS |
$48.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$51.30
|
| Rate for Payer: Three Rivers Provider Network All |
$40.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$50.22
|
| Rate for Payer: Zelis Auto |
$21.60
|
| Rate for Payer: Zelis Worker's Compensation |
$14.74
|
|
|
CL- FLUCELVAX- HOSPITAL********ARCHIVED
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
CPT 90674
|
| Hospital Charge Code |
3350109
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.04 |
| Max. Negotiated Rate |
$51.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$36.08
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$32.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$36.08
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$28.58
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$45.90
|
| Rate for Payer: First Health Commercial |
$48.60
|
| Rate for Payer: First Health Workers Compensation |
$20.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$48.60
|
| Rate for Payer: GEHA Commercial |
$43.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$48.60
|
| Rate for Payer: Humana ChoiceCare |
$14.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$29.16
|
| Rate for Payer: Multiplan All |
$49.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$32.40
|
| Rate for Payer: OMNI Networks Commercial |
$37.80
|
| Rate for Payer: One Health Plan PPO/POS |
$48.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$33.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$29.16
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$51.30
|
| Rate for Payer: Three Rivers Provider Network All |
$40.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$47.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$29.16
|
| Rate for Payer: United Payors & United Providers UP&UP |
$50.22
|
| Rate for Payer: Zelis Auto |
$21.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$27.00
|
| Rate for Payer: Zelis Worker's Compensation |
$14.74
|
|
|
CL- FLUORESCEIN OPTH STRIPS 1MG
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 17478040401
|
| Hospital Charge Code |
3350120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
CL- FLUORESCEIN OPTH STRIPS 1MG
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 17478040401
|
| Hospital Charge Code |
3350120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
CL- FLUOROURACIL 500 MG/10 ML
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
CPT J9190
|
| Hospital Charge Code |
3350303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
CL- FLUOROURACIL 500 MG/10 ML
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
CPT J9190
|
| Hospital Charge Code |
3350303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$2.19
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Humana ChoiceCare |
$1.30
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.00
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
CL- Flu Vaccine HD - Medicare
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
3350392
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.72 |
| Max. Negotiated Rate |
$107.98 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$73.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$43.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$73.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$58.26
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$61.20
|
| Rate for Payer: First Health Commercial |
$64.80
|
| Rate for Payer: First Health Workers Compensation |
$27.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$64.80
|
| Rate for Payer: GEHA Commercial |
$107.98
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$64.80
|
| Rate for Payer: Humana ChoiceCare |
$18.72
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$59.45
|
| Rate for Payer: Multiplan All |
$65.52
|
| Rate for Payer: New Mexico Health Connections Medicare |
$43.20
|
| Rate for Payer: OMNI Networks Commercial |
$50.40
|
| Rate for Payer: One Health Plan PPO/POS |
$64.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$68.64
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$59.45
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$68.40
|
| Rate for Payer: Three Rivers Provider Network All |
$54.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$63.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$59.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$66.96
|
| Rate for Payer: Zelis Auto |
$28.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$36.00
|
| Rate for Payer: Zelis Worker's Compensation |
$19.66
|
|
|
CL- Flu Vaccine HD - Medicare
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
3350392
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.66 |
| Max. Negotiated Rate |
$68.40 |
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$61.20
|
| Rate for Payer: First Health Commercial |
$64.80
|
| Rate for Payer: First Health Workers Compensation |
$27.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$64.80
|
| Rate for Payer: GEHA Commercial |
$50.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$64.80
|
| Rate for Payer: Multiplan All |
$65.52
|
| Rate for Payer: OMNI Networks Commercial |
$50.40
|
| Rate for Payer: One Health Plan PPO/POS |
$64.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$68.40
|
| Rate for Payer: Three Rivers Provider Network All |
$54.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$66.96
|
| Rate for Payer: Zelis Auto |
$28.80
|
| Rate for Payer: Zelis Worker's Compensation |
$19.66
|
|
|
CL- Flu Vaccine HD - Non Medicare
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
3350393
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.02 |
| Max. Negotiated Rate |
$52.25 |
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$46.75
|
| Rate for Payer: First Health Commercial |
$49.50
|
| Rate for Payer: First Health Workers Compensation |
$21.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$49.50
|
| Rate for Payer: GEHA Commercial |
$38.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$49.50
|
| Rate for Payer: Multiplan All |
$50.05
|
| Rate for Payer: OMNI Networks Commercial |
$38.50
|
| Rate for Payer: One Health Plan PPO/POS |
$49.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$52.25
|
| Rate for Payer: Three Rivers Provider Network All |
$41.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$51.15
|
| Rate for Payer: Zelis Auto |
$22.00
|
| Rate for Payer: Zelis Worker's Compensation |
$15.02
|
|
|
CL- Flu Vaccine HD - Non Medicare
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
3350393
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.30 |
| Max. Negotiated Rate |
$107.98 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$73.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$73.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$58.26
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$46.75
|
| Rate for Payer: First Health Commercial |
$49.50
|
| Rate for Payer: First Health Workers Compensation |
$21.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$49.50
|
| Rate for Payer: GEHA Commercial |
$107.98
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$49.50
|
| Rate for Payer: Humana ChoiceCare |
$14.30
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$59.45
|
| Rate for Payer: Multiplan All |
$50.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$33.00
|
| Rate for Payer: OMNI Networks Commercial |
$38.50
|
| Rate for Payer: One Health Plan PPO/POS |
$49.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$68.64
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$59.45
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$52.25
|
| Rate for Payer: Three Rivers Provider Network All |
$41.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$48.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$59.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$51.15
|
| Rate for Payer: Zelis Auto |
$22.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$27.50
|
| Rate for Payer: Zelis Worker's Compensation |
$15.02
|
|
|
CL- Flu Vaccine HD - Non Medicare - RHC
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
3350385
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.66 |
| Max. Negotiated Rate |
$68.40 |
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$61.20
|
| Rate for Payer: First Health Commercial |
$64.80
|
| Rate for Payer: First Health Workers Compensation |
$27.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$64.80
|
| Rate for Payer: GEHA Commercial |
$50.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$64.80
|
| Rate for Payer: Multiplan All |
$65.52
|
| Rate for Payer: OMNI Networks Commercial |
$50.40
|
| Rate for Payer: One Health Plan PPO/POS |
$64.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$68.40
|
| Rate for Payer: Three Rivers Provider Network All |
$54.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$66.96
|
| Rate for Payer: Zelis Auto |
$28.80
|
| Rate for Payer: Zelis Worker's Compensation |
$19.66
|
|
|
CL- Flu Vaccine HD - Non Medicare - RHC
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
3350385
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.72 |
| Max. Negotiated Rate |
$107.98 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$73.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$43.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$73.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$58.26
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$61.20
|
| Rate for Payer: First Health Commercial |
$64.80
|
| Rate for Payer: First Health Workers Compensation |
$27.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$64.80
|
| Rate for Payer: GEHA Commercial |
$107.98
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$64.80
|
| Rate for Payer: Humana ChoiceCare |
$18.72
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$59.45
|
| Rate for Payer: Multiplan All |
$65.52
|
| Rate for Payer: New Mexico Health Connections Medicare |
$43.20
|
| Rate for Payer: OMNI Networks Commercial |
$50.40
|
| Rate for Payer: One Health Plan PPO/POS |
$64.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$68.64
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$59.45
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$68.40
|
| Rate for Payer: Three Rivers Provider Network All |
$54.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$63.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$59.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$66.96
|
| Rate for Payer: Zelis Auto |
$28.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$36.00
|
| Rate for Payer: Zelis Worker's Compensation |
$19.66
|
|
|
CL- Flu Vaccine Quad- Medicare
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT 90656
|
| Hospital Charge Code |
3350390
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.92 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$43.35
|
| Rate for Payer: First Health Commercial |
$45.90
|
| Rate for Payer: First Health Workers Compensation |
$19.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.90
|
| Rate for Payer: GEHA Commercial |
$35.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.90
|
| Rate for Payer: Multiplan All |
$46.41
|
| Rate for Payer: OMNI Networks Commercial |
$35.70
|
| Rate for Payer: One Health Plan PPO/POS |
$45.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$48.45
|
| Rate for Payer: Three Rivers Provider Network All |
$38.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$47.43
|
| Rate for Payer: Zelis Auto |
$20.40
|
| Rate for Payer: Zelis Worker's Compensation |
$13.92
|
|
|
CL- Flu Vaccine Quad- Medicare
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
CPT 90656
|
| Hospital Charge Code |
3350390
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.26 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$36.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$36.36
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$28.80
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$43.35
|
| Rate for Payer: First Health Commercial |
$45.90
|
| Rate for Payer: First Health Workers Compensation |
$19.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.90
|
| Rate for Payer: GEHA Commercial |
$25.54
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.90
|
| Rate for Payer: Humana ChoiceCare |
$13.26
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$29.39
|
| Rate for Payer: Multiplan All |
$46.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.60
|
| Rate for Payer: OMNI Networks Commercial |
$35.70
|
| Rate for Payer: One Health Plan PPO/POS |
$45.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$33.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$29.39
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$48.45
|
| Rate for Payer: Three Rivers Provider Network All |
$38.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$44.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$29.39
|
| Rate for Payer: United Payors & United Providers UP&UP |
$47.43
|
| Rate for Payer: Zelis Auto |
$20.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$25.50
|
| Rate for Payer: Zelis Worker's Compensation |
$13.92
|
|
|
CL- Flu Vaccine Quad- Non Medicare
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT 90656
|
| Hospital Charge Code |
3350391
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.92 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$43.35
|
| Rate for Payer: First Health Commercial |
$45.90
|
| Rate for Payer: First Health Workers Compensation |
$19.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.90
|
| Rate for Payer: GEHA Commercial |
$35.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.90
|
| Rate for Payer: Multiplan All |
$46.41
|
| Rate for Payer: OMNI Networks Commercial |
$35.70
|
| Rate for Payer: One Health Plan PPO/POS |
$45.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$48.45
|
| Rate for Payer: Three Rivers Provider Network All |
$38.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$47.43
|
| Rate for Payer: Zelis Auto |
$20.40
|
| Rate for Payer: Zelis Worker's Compensation |
$13.92
|
|
