|
CL- PNEUMOCOCCAL 20 CONJ-MEDICARE
|
Facility
|
OP
|
$1,129.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
3350509
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$282.25 |
| Max. Negotiated Rate |
$1,072.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$677.40
|
| Rate for Payer: Cash Price |
$677.40
|
| Rate for Payer: Cash Price |
$677.40
|
| Rate for Payer: Cigna Commercial |
$959.65
|
| Rate for Payer: First Health Commercial |
$1,016.10
|
| Rate for Payer: First Health Workers Compensation |
$435.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,016.10
|
| Rate for Payer: GEHA Commercial |
$344.19
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,016.10
|
| Rate for Payer: Humana ChoiceCare |
$293.54
|
| Rate for Payer: Multiplan All |
$1,027.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$677.40
|
| Rate for Payer: OMNI Networks Commercial |
$790.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,016.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,072.55
|
| Rate for Payer: Three Rivers Provider Network All |
$846.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$993.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$282.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,049.97
|
| Rate for Payer: Zelis Auto |
$451.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$564.50
|
| Rate for Payer: Zelis Worker's Compensation |
$308.22
|
|
|
CL- PNEUMOCOCCAL 20 CONJ-MEDICARE
|
Facility
|
IP
|
$1,129.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
3350509
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$308.22 |
| Max. Negotiated Rate |
$1,072.55 |
| Rate for Payer: Cash Price |
$677.40
|
| Rate for Payer: Cigna Commercial |
$959.65
|
| Rate for Payer: First Health Commercial |
$1,016.10
|
| Rate for Payer: First Health Workers Compensation |
$435.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,016.10
|
| Rate for Payer: GEHA Commercial |
$790.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,016.10
|
| Rate for Payer: Multiplan All |
$1,027.39
|
| Rate for Payer: OMNI Networks Commercial |
$790.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,016.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,072.55
|
| Rate for Payer: Three Rivers Provider Network All |
$846.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,049.97
|
| Rate for Payer: Zelis Auto |
$451.60
|
| Rate for Payer: Zelis Worker's Compensation |
$308.22
|
|
|
CL- PNEUMOCOCCAL 20 CONJ-MEDICARE-AWV
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
3350510
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$344.19 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| 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 |
$344.19
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.00
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$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: TriWest Veterans Administration/VAPC3 |
$0.01
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.01
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- PNEUMOCOCCAL 20 CONJ-MEDICARE-AWV
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
3350510
|
|
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- PNEUMOCOCCAL 20 CONJ-MEDICARE-RHC
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
3350511
|
|
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- PNEUMOCOCCAL 20 CONJ-MEDICARE-RHC
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
3350511
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$344.19 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| 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 |
$344.19
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.00
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$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: TriWest Veterans Administration/VAPC3 |
$0.01
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.01
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
CL- PNEUMOCOCCAL 20 CONJ-NON MEDICARE
|
Facility
|
OP
|
$1,169.40
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
3350512
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$292.35 |
| Max. Negotiated Rate |
$1,110.93 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$701.64
|
| Rate for Payer: Cash Price |
$701.64
|
| Rate for Payer: Cash Price |
$701.64
|
| Rate for Payer: Cigna Commercial |
$993.99
|
| Rate for Payer: First Health Commercial |
$1,052.46
|
| Rate for Payer: First Health Workers Compensation |
$451.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,052.46
|
| Rate for Payer: GEHA Commercial |
$344.19
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,052.46
|
| Rate for Payer: Humana ChoiceCare |
$304.04
|
| Rate for Payer: Multiplan All |
$1,064.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$701.64
|
| Rate for Payer: OMNI Networks Commercial |
$818.58
|
| Rate for Payer: One Health Plan PPO/POS |
$1,052.46
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,110.93
|
| Rate for Payer: Three Rivers Provider Network All |
$877.05
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,029.07
|
| Rate for Payer: United Healthcare Managed Medicaid |
$292.35
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,087.54
|
| Rate for Payer: Zelis Auto |
$467.76
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$584.70
|
| Rate for Payer: Zelis Worker's Compensation |
$319.25
|
|
|
CL- PNEUMOCOCCAL 20 CONJ-NON MEDICARE
|
Facility
|
IP
|
$1,169.40
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
3350512
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$319.25 |
| Max. Negotiated Rate |
$1,110.93 |
| Rate for Payer: Cash Price |
$701.64
|
| Rate for Payer: Cigna Commercial |
$993.99
|
| Rate for Payer: First Health Commercial |
$1,052.46
|
| Rate for Payer: First Health Workers Compensation |
$451.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,052.46
|
| Rate for Payer: GEHA Commercial |
$818.58
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,052.46
|
| Rate for Payer: Multiplan All |
$1,064.15
|
| Rate for Payer: OMNI Networks Commercial |
$818.58
|
| Rate for Payer: One Health Plan PPO/POS |
$1,052.46
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,110.93
|
| Rate for Payer: Three Rivers Provider Network All |
$877.05
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,087.54
|
| Rate for Payer: Zelis Auto |
$467.76
|
| Rate for Payer: Zelis Worker's Compensation |
$319.25
|
|
|
CL- PNEUMOCOCCAL 20CONJ-NON MEDICARE-RHC
|
Facility
|
OP
|
$1,129.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
3350513
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$282.25 |
| Max. Negotiated Rate |
$1,072.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$677.40
|
| Rate for Payer: Cash Price |
$677.40
|
| Rate for Payer: Cash Price |
$677.40
|
| Rate for Payer: Cigna Commercial |
$959.65
|
| Rate for Payer: First Health Commercial |
$1,016.10
|
| Rate for Payer: First Health Workers Compensation |
$435.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,016.10
|
| Rate for Payer: GEHA Commercial |
$344.19
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,016.10
|
| Rate for Payer: Humana ChoiceCare |
$293.54
|
| Rate for Payer: Multiplan All |
$1,027.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$677.40
|
| Rate for Payer: OMNI Networks Commercial |
$790.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,016.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,072.55
|
| Rate for Payer: Three Rivers Provider Network All |
$846.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$993.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$282.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,049.97
|
| Rate for Payer: Zelis Auto |
$451.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$564.50
|
| Rate for Payer: Zelis Worker's Compensation |
$308.22
|
|
|
CL- PNEUMOCOCCAL 20CONJ-NON MEDICARE-RHC
|
Facility
|
IP
|
$1,129.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
3350513
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$308.22 |
| Max. Negotiated Rate |
$1,072.55 |
| Rate for Payer: Cash Price |
$677.40
|
| Rate for Payer: Cigna Commercial |
$959.65
|
| Rate for Payer: First Health Commercial |
$1,016.10
|
| Rate for Payer: First Health Workers Compensation |
$435.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,016.10
|
| Rate for Payer: GEHA Commercial |
$790.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,016.10
|
| Rate for Payer: Multiplan All |
$1,027.39
|
| Rate for Payer: OMNI Networks Commercial |
$790.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,016.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,072.55
|
| Rate for Payer: Three Rivers Provider Network All |
$846.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,049.97
|
| Rate for Payer: Zelis Auto |
$451.60
|
| Rate for Payer: Zelis Worker's Compensation |
$308.22
|
|
|
CL- PNEUMOCOCCAL - HOSPITAL
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3350075
|
|
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
|
|
|
CL- PNEUMOCOCCAL - HOSPITAL
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3350075
|
|
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
|
|
|
CL- Pneumovax 23 - Medicare
|
Facility
|
OP
|
$117.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3350387
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.42 |
| 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 |
$70.20
|
| 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 |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$99.45
|
| Rate for Payer: First Health Commercial |
$105.30
|
| Rate for Payer: First Health Workers Compensation |
$45.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$105.30
|
| Rate for Payer: GEHA Commercial |
$146.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$105.30
|
| Rate for Payer: Humana ChoiceCare |
$30.42
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$119.86
|
| Rate for Payer: Multiplan All |
$106.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$70.20
|
| Rate for Payer: OMNI Networks Commercial |
$81.90
|
| Rate for Payer: One Health Plan PPO/POS |
$105.30
|
| 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 |
$111.15
|
| Rate for Payer: Three Rivers Provider Network All |
$87.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$102.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$119.86
|
| Rate for Payer: United Payors & United Providers UP&UP |
$108.81
|
| Rate for Payer: Zelis Auto |
$46.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$58.50
|
| Rate for Payer: Zelis Worker's Compensation |
$31.94
|
|
|
CL- Pneumovax 23 - Medicare
|
Facility
|
IP
|
$117.00
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
3350387
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.94 |
| Max. Negotiated Rate |
$111.15 |
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$99.45
|
| Rate for Payer: First Health Commercial |
$105.30
|
| Rate for Payer: First Health Workers Compensation |
$45.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$105.30
|
| Rate for Payer: GEHA Commercial |
$81.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$105.30
|
| Rate for Payer: Multiplan All |
$106.47
|
| Rate for Payer: OMNI Networks Commercial |
$81.90
|
| Rate for Payer: One Health Plan PPO/POS |
$105.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$111.15
|
| Rate for Payer: Three Rivers Provider Network All |
$87.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$108.81
|
| Rate for Payer: Zelis Auto |
$46.80
|
| Rate for Payer: Zelis Worker's Compensation |
$31.94
|
|
|
CL- POTASSIUM CL 2 MEQ (K RIDER)
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
CPT J3480
|
| Hospital Charge Code |
3350348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$0.85
|
| Rate for Payer: First Health Commercial |
$0.90
|
| Rate for Payer: First Health Workers Compensation |
$0.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.90
|
| Rate for Payer: GEHA Commercial |
$0.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.90
|
| Rate for Payer: Multiplan All |
$0.91
|
| Rate for Payer: OMNI Networks Commercial |
$0.70
|
| Rate for Payer: One Health Plan PPO/POS |
$0.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.95
|
| Rate for Payer: Three Rivers Provider Network All |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.93
|
| Rate for Payer: Zelis Auto |
$0.40
|
| Rate for Payer: Zelis Worker's Compensation |
$0.27
|
|
|
CL- POTASSIUM CL 2 MEQ (K RIDER)
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
CPT J3480
|
| Hospital Charge Code |
3350348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$0.85
|
| Rate for Payer: First Health Commercial |
$0.90
|
| Rate for Payer: First Health Workers Compensation |
$0.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.90
|
| Rate for Payer: GEHA Commercial |
$0.12
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.90
|
| Rate for Payer: Humana ChoiceCare |
$0.26
|
| Rate for Payer: Multiplan All |
$0.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.60
|
| Rate for Payer: OMNI Networks Commercial |
$0.70
|
| Rate for Payer: One Health Plan PPO/POS |
$0.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.95
|
| Rate for Payer: Three Rivers Provider Network All |
$0.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.93
|
| Rate for Payer: Zelis Auto |
$0.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.27
|
|
|
CL- POVIDONE-IODINE OINT 10%
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
NDC 00904110231
|
| Hospital Charge Code |
3350096
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.10 |
| Max. Negotiated Rate |
$24.70 |
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$22.10
|
| Rate for Payer: First Health Commercial |
$23.40
|
| Rate for Payer: First Health Workers Compensation |
$10.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$23.40
|
| Rate for Payer: GEHA Commercial |
$18.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$23.40
|
| Rate for Payer: Multiplan All |
$23.66
|
| Rate for Payer: OMNI Networks Commercial |
$18.20
|
| Rate for Payer: One Health Plan PPO/POS |
$23.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$24.70
|
| Rate for Payer: Three Rivers Provider Network All |
$19.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$24.18
|
| Rate for Payer: Zelis Auto |
$10.40
|
| Rate for Payer: Zelis Worker's Compensation |
$7.10
|
|
|
CL- POVIDONE-IODINE OINT 10%
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
NDC 00904110231
|
| Hospital Charge Code |
3350096
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.50 |
| Max. Negotiated Rate |
$24.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$22.10
|
| Rate for Payer: First Health Commercial |
$23.40
|
| Rate for Payer: First Health Workers Compensation |
$10.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$23.40
|
| Rate for Payer: GEHA Commercial |
$20.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$23.40
|
| Rate for Payer: Humana ChoiceCare |
$6.76
|
| Rate for Payer: Multiplan All |
$23.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$15.60
|
| Rate for Payer: OMNI Networks Commercial |
$18.20
|
| Rate for Payer: One Health Plan PPO/POS |
$23.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$24.70
|
| Rate for Payer: Three Rivers Provider Network All |
$19.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$22.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$24.18
|
| Rate for Payer: Zelis Auto |
$10.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$13.00
|
| Rate for Payer: Zelis Worker's Compensation |
$7.10
|
|
|
CL- PREDNISOLONE ORAL SOLN 6.7MG/5ML
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
NDC 50383004004
|
| Hospital Charge Code |
3350076
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.00 |
| Max. Negotiated Rate |
$30.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$27.20
|
| Rate for Payer: First Health Commercial |
$28.80
|
| Rate for Payer: First Health Workers Compensation |
$12.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$28.80
|
| Rate for Payer: GEHA Commercial |
$25.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$28.80
|
| Rate for Payer: Humana ChoiceCare |
$8.32
|
| Rate for Payer: Multiplan All |
$29.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$19.20
|
| Rate for Payer: OMNI Networks Commercial |
$22.40
|
| Rate for Payer: One Health Plan PPO/POS |
$28.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$30.40
|
| Rate for Payer: Three Rivers Provider Network All |
$24.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$28.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$29.76
|
| Rate for Payer: Zelis Auto |
$12.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$16.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.74
|
|
|
CL- PREDNISOLONE ORAL SOLN 6.7MG/5ML
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
NDC 50383004004
|
| Hospital Charge Code |
3350076
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$30.40 |
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$27.20
|
| Rate for Payer: First Health Commercial |
$28.80
|
| Rate for Payer: First Health Workers Compensation |
$12.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$28.80
|
| Rate for Payer: GEHA Commercial |
$22.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$28.80
|
| Rate for Payer: Multiplan All |
$29.12
|
| Rate for Payer: OMNI Networks Commercial |
$22.40
|
| Rate for Payer: One Health Plan PPO/POS |
$28.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$30.40
|
| Rate for Payer: Three Rivers Provider Network All |
$24.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$29.76
|
| Rate for Payer: Zelis Auto |
$12.80
|
| Rate for Payer: Zelis Worker's Compensation |
$8.74
|
|
|
CL- PREDNISOLONE SYRUP 15MG/5ML
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
CPT J7510
|
| Hospital Charge Code |
3350077
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$0.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Humana ChoiceCare |
$4.16
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.60
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
CL- PREDNISOLONE SYRUP 15MG/5ML
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
CPT J7510
|
| Hospital Charge Code |
3350077
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$11.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
CL- PREDNISONE 5 MG TABLET
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
CPT J7512
|
| Hospital Charge Code |
3350436
|
|
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- PREDNISONE 5 MG TABLET
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
CPT J7512
|
| Hospital Charge Code |
3350436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| 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: 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 |
$0.01
|
| 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
|
|
|
CL- PREVNAR 13 - HOSPITAL
|
Facility
|
OP
|
$234.00
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
3350119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.84 |
| Max. Negotiated Rate |
$288.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$288.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$140.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$288.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$228.91
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna Commercial |
$198.90
|
| Rate for Payer: First Health Commercial |
$210.60
|
| Rate for Payer: First Health Workers Compensation |
$90.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$210.60
|
| Rate for Payer: GEHA Commercial |
$283.79
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$210.60
|
| Rate for Payer: Humana ChoiceCare |
$60.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$233.58
|
| Rate for Payer: Multiplan All |
$212.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$140.40
|
| Rate for Payer: OMNI Networks Commercial |
$163.80
|
| Rate for Payer: One Health Plan PPO/POS |
$210.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$269.70
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$233.58
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$222.30
|
| Rate for Payer: Three Rivers Provider Network All |
$175.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$205.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$233.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$217.62
|
| Rate for Payer: Zelis Auto |
$93.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$117.00
|
| Rate for Payer: Zelis Worker's Compensation |
$63.88
|
|
