|
PREGABALIN 100 MG CAP
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904700161
|
| Hospital Charge Code |
3303018
|
|
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
|
|
|
PREGABALIN 25MG CAP
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 69238131009
|
| Hospital Charge Code |
3300755
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.55 |
| Max. Negotiated Rate |
$33.25 |
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$29.75
|
| Rate for Payer: First Health Commercial |
$31.50
|
| Rate for Payer: First Health Workers Compensation |
$13.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$31.50
|
| Rate for Payer: GEHA Commercial |
$24.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$31.50
|
| Rate for Payer: Multiplan All |
$31.85
|
| Rate for Payer: OMNI Networks Commercial |
$24.50
|
| Rate for Payer: One Health Plan PPO/POS |
$31.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$33.25
|
| Rate for Payer: Three Rivers Provider Network All |
$26.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$32.55
|
| Rate for Payer: Zelis Auto |
$14.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.55
|
|
|
PREGABALIN 25MG CAP
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 69238131009
|
| Hospital Charge Code |
3300755
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$33.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$29.75
|
| Rate for Payer: First Health Commercial |
$31.50
|
| Rate for Payer: First Health Workers Compensation |
$13.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$31.50
|
| Rate for Payer: GEHA Commercial |
$28.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$31.50
|
| Rate for Payer: Humana ChoiceCare |
$9.10
|
| Rate for Payer: Multiplan All |
$31.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$21.00
|
| Rate for Payer: OMNI Networks Commercial |
$24.50
|
| Rate for Payer: One Health Plan PPO/POS |
$31.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$33.25
|
| Rate for Payer: Three Rivers Provider Network All |
$26.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$30.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$32.55
|
| Rate for Payer: Zelis Auto |
$14.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.50
|
| Rate for Payer: Zelis Worker's Compensation |
$9.55
|
|
|
PREGABALIN 50MG CAP
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00071101341
|
| Hospital Charge Code |
3300756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.55 |
| Max. Negotiated Rate |
$33.25 |
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$29.75
|
| Rate for Payer: First Health Commercial |
$31.50
|
| Rate for Payer: First Health Workers Compensation |
$13.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$31.50
|
| Rate for Payer: GEHA Commercial |
$24.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$31.50
|
| Rate for Payer: Multiplan All |
$31.85
|
| Rate for Payer: OMNI Networks Commercial |
$24.50
|
| Rate for Payer: One Health Plan PPO/POS |
$31.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$33.25
|
| Rate for Payer: Three Rivers Provider Network All |
$26.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$32.55
|
| Rate for Payer: Zelis Auto |
$14.00
|
| Rate for Payer: Zelis Worker's Compensation |
$9.55
|
|
|
PREGABALIN 50MG CAP
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00071101341
|
| Hospital Charge Code |
3300756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$33.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$29.75
|
| Rate for Payer: First Health Commercial |
$31.50
|
| Rate for Payer: First Health Workers Compensation |
$13.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$31.50
|
| Rate for Payer: GEHA Commercial |
$28.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$31.50
|
| Rate for Payer: Humana ChoiceCare |
$9.10
|
| Rate for Payer: Multiplan All |
$31.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$21.00
|
| Rate for Payer: OMNI Networks Commercial |
$24.50
|
| Rate for Payer: One Health Plan PPO/POS |
$31.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$33.25
|
| Rate for Payer: Three Rivers Provider Network All |
$26.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$30.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$32.55
|
| Rate for Payer: Zelis Auto |
$14.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17.50
|
| Rate for Payer: Zelis Worker's Compensation |
$9.55
|
|
|
pregnenolone REF140707
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
CPT 84140
|
| Hospital Charge Code |
2200441
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.91 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$36.64
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$117.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: OMNI Networks Commercial |
$117.60
|
| Rate for Payer: One Health Plan PPO/POS |
$151.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Worker's Compensation |
$25.91
|
|
|
pregnenolone REF140707
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
CPT 84140
|
| Hospital Charge Code |
2200441
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.57 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$37.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$100.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$37.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$29.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$20.67
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$36.64
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$134.40
|
| Rate for Payer: GEHA Medicare |
$20.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Humana ChoiceCare |
$22.74
|
| Rate for Payer: Humana Medicare Advantage |
$20.67
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$34.73
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$30.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$20.67
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$35.14
|
| Rate for Payer: OMNI Networks Commercial |
$117.60
|
| Rate for Payer: One Health Plan PPO/POS |
$151.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$34.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$30.07
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$20.67
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$41.34
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$20.26
|
| Rate for Payer: United Healthcare Commercial |
$142.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$30.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.67
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$20.67
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Medicare |
$17.57
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$24.80
|
| Rate for Payer: Zelis Worker's Compensation |
$25.91
|
|
|
PREMARIN VAGINAL CREAM
|
Facility
|
OP
|
$1,960.00
|
|
|
Service Code
|
NDC 00046087221
|
| Hospital Charge Code |
3300315
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$490.00 |
| Max. Negotiated Rate |
$1,862.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,176.00
|
| Rate for Payer: Cash Price |
$1,176.00
|
| Rate for Payer: Cigna Commercial |
$1,666.00
|
| Rate for Payer: First Health Commercial |
$1,764.00
|
| Rate for Payer: First Health Workers Compensation |
$756.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,764.00
|
| Rate for Payer: GEHA Commercial |
$1,568.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,764.00
|
| Rate for Payer: Humana ChoiceCare |
$509.60
|
| Rate for Payer: Multiplan All |
$1,783.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,176.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,372.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,764.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,862.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,470.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,724.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$490.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,822.80
|
| Rate for Payer: Zelis Auto |
$784.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$980.00
|
| Rate for Payer: Zelis Worker's Compensation |
$535.08
|
|
|
PREMARIN VAGINAL CREAM
|
Facility
|
IP
|
$1,960.00
|
|
|
Service Code
|
NDC 00046087221
|
| Hospital Charge Code |
3300315
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$535.08 |
| Max. Negotiated Rate |
$1,862.00 |
| Rate for Payer: Cash Price |
$1,176.00
|
| Rate for Payer: Cigna Commercial |
$1,666.00
|
| Rate for Payer: First Health Commercial |
$1,764.00
|
| Rate for Payer: First Health Workers Compensation |
$756.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,764.00
|
| Rate for Payer: GEHA Commercial |
$1,372.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,764.00
|
| Rate for Payer: Multiplan All |
$1,783.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,372.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,764.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,862.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,470.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,822.80
|
| Rate for Payer: Zelis Auto |
$784.00
|
| Rate for Payer: Zelis Worker's Compensation |
$535.08
|
|
|
PREMARIN VAGINAL CREAM - 30GM
|
Facility
|
OP
|
$1,960.00
|
|
|
Service Code
|
NDC 00046087221
|
| Hospital Charge Code |
3301407
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$490.00 |
| Max. Negotiated Rate |
$1,862.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,176.00
|
| Rate for Payer: Cash Price |
$1,176.00
|
| Rate for Payer: Cigna Commercial |
$1,666.00
|
| Rate for Payer: First Health Commercial |
$1,764.00
|
| Rate for Payer: First Health Workers Compensation |
$756.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,764.00
|
| Rate for Payer: GEHA Commercial |
$1,568.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,764.00
|
| Rate for Payer: Humana ChoiceCare |
$509.60
|
| Rate for Payer: Multiplan All |
$1,783.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,176.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,372.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,764.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,862.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,470.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,724.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$490.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,822.80
|
| Rate for Payer: Zelis Auto |
$784.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$980.00
|
| Rate for Payer: Zelis Worker's Compensation |
$535.08
|
|
|
PREMARIN VAGINAL CREAM - 30GM
|
Facility
|
IP
|
$1,960.00
|
|
|
Service Code
|
NDC 00046087221
|
| Hospital Charge Code |
3301407
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$535.08 |
| Max. Negotiated Rate |
$1,862.00 |
| Rate for Payer: Cash Price |
$1,176.00
|
| Rate for Payer: Cigna Commercial |
$1,666.00
|
| Rate for Payer: First Health Commercial |
$1,764.00
|
| Rate for Payer: First Health Workers Compensation |
$756.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,764.00
|
| Rate for Payer: GEHA Commercial |
$1,372.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,764.00
|
| Rate for Payer: Multiplan All |
$1,783.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,372.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,764.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,862.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,470.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,822.80
|
| Rate for Payer: Zelis Auto |
$784.00
|
| Rate for Payer: Zelis Worker's Compensation |
$535.08
|
|
|
PREPARATION FOR BLADDER XRAY
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
CPT 51605
|
| Hospital Charge Code |
6151605
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$32.21 |
| Max. Negotiated Rate |
$112.10 |
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$100.30
|
| Rate for Payer: First Health Commercial |
$106.20
|
| Rate for Payer: First Health Workers Compensation |
$45.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$106.20
|
| Rate for Payer: GEHA Commercial |
$82.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$106.20
|
| Rate for Payer: Multiplan All |
$107.38
|
| Rate for Payer: OMNI Networks Commercial |
$82.60
|
| Rate for Payer: One Health Plan PPO/POS |
$106.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$112.10
|
| Rate for Payer: Three Rivers Provider Network All |
$88.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$109.74
|
| Rate for Payer: Zelis Auto |
$47.20
|
| Rate for Payer: Zelis Worker's Compensation |
$32.21
|
|
|
PREPARATION FOR BLADDER XRAY
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
CPT 51605
|
| Hospital Charge Code |
6151605
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$29.50 |
| Max. Negotiated Rate |
$112.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$70.80
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$100.30
|
| Rate for Payer: First Health Commercial |
$106.20
|
| Rate for Payer: First Health Workers Compensation |
$45.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$106.20
|
| Rate for Payer: GEHA Commercial |
$94.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$106.20
|
| Rate for Payer: Humana ChoiceCare |
$30.68
|
| Rate for Payer: Multiplan All |
$107.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$70.80
|
| Rate for Payer: OMNI Networks Commercial |
$82.60
|
| Rate for Payer: One Health Plan PPO/POS |
$106.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$112.10
|
| Rate for Payer: Three Rivers Provider Network All |
$88.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$103.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$29.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$109.74
|
| Rate for Payer: Zelis Auto |
$47.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$59.00
|
| Rate for Payer: Zelis Worker's Compensation |
$32.21
|
|
|
PREPARE FACE/ORAL PROSTHESIS
|
Facility
|
IP
|
$4,404.00
|
|
|
Service Code
|
CPT 21077
|
| Hospital Charge Code |
6121077
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,202.29 |
| Max. Negotiated Rate |
$4,183.80 |
| Rate for Payer: Cash Price |
$2,642.40
|
| Rate for Payer: Cigna Commercial |
$3,743.40
|
| Rate for Payer: First Health Commercial |
$3,963.60
|
| Rate for Payer: First Health Workers Compensation |
$1,700.38
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,963.60
|
| Rate for Payer: GEHA Commercial |
$3,082.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,963.60
|
| Rate for Payer: Multiplan All |
$4,007.64
|
| Rate for Payer: OMNI Networks Commercial |
$3,082.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,963.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,183.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3,303.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,095.72
|
| Rate for Payer: Zelis Auto |
$1,761.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1,202.29
|
|
|
PREPARE FACE/ORAL PROSTHESIS
|
Facility
|
OP
|
$1,753.00
|
|
|
Service Code
|
CPT 21076
|
| Hospital Charge Code |
6121076
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$478.57 |
| Max. Negotiated Rate |
$2,870.66 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,524.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,051.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,524.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,999.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,435.33
|
| Rate for Payer: Cash Price |
$1,051.80
|
| Rate for Payer: Cash Price |
$1,051.80
|
| Rate for Payer: Cigna Commercial |
$1,490.05
|
| Rate for Payer: First Health Commercial |
$1,577.70
|
| Rate for Payer: First Health Workers Compensation |
$676.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,577.70
|
| Rate for Payer: GEHA Commercial |
$1,402.40
|
| Rate for Payer: GEHA Medicare |
$1,435.33
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,577.70
|
| Rate for Payer: Humana ChoiceCare |
$1,578.86
|
| Rate for Payer: Humana Medicare Advantage |
$1,435.33
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,411.35
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,040.27
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,435.33
|
| Rate for Payer: Multiplan All |
$1,595.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,440.06
|
| Rate for Payer: OMNI Networks Commercial |
$1,227.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,577.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,355.78
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,040.27
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,435.33
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,665.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$2,870.66
|
| Rate for Payer: Three Rivers Provider Network All |
$1,314.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,406.62
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,040.27
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,435.33
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,630.29
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,435.33
|
| Rate for Payer: Zelis Auto |
$701.20
|
| Rate for Payer: Zelis Medicare |
$1,220.03
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,722.40
|
| Rate for Payer: Zelis Worker's Compensation |
$478.57
|
|
|
PREPARE FACE/ORAL PROSTHESIS
|
Facility
|
OP
|
$4,404.00
|
|
|
Service Code
|
CPT 21077
|
| Hospital Charge Code |
6121077
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,202.29 |
| Max. Negotiated Rate |
$11,464.32 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$4,345.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,642.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$4,345.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3,442.85
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5,732.16
|
| Rate for Payer: Cash Price |
$2,642.40
|
| Rate for Payer: Cash Price |
$2,642.40
|
| Rate for Payer: Cigna Commercial |
$3,743.40
|
| Rate for Payer: First Health Commercial |
$3,963.60
|
| Rate for Payer: First Health Workers Compensation |
$1,700.38
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,963.60
|
| Rate for Payer: GEHA Commercial |
$3,523.20
|
| Rate for Payer: GEHA Medicare |
$5,732.16
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,963.60
|
| Rate for Payer: Humana ChoiceCare |
$6,305.38
|
| Rate for Payer: Humana Medicare Advantage |
$5,732.16
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$9,630.03
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,512.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5,732.16
|
| Rate for Payer: Multiplan All |
$4,007.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9,744.67
|
| Rate for Payer: OMNI Networks Commercial |
$3,082.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,963.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$4,056.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3,512.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5,732.16
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,183.80
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11,464.32
|
| Rate for Payer: Three Rivers Provider Network All |
$3,303.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,617.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,512.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,732.16
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,095.72
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5,732.16
|
| Rate for Payer: Zelis Auto |
$1,761.60
|
| Rate for Payer: Zelis Medicare |
$4,872.34
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,878.59
|
| Rate for Payer: Zelis Worker's Compensation |
$1,202.29
|
|
|
PREPARE FACE/ORAL PROSTHESIS
|
Facility
|
OP
|
$1,187.00
|
|
|
Service Code
|
CPT 21085
|
| Hospital Charge Code |
6121085
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$191.27 |
| Max. Negotiated Rate |
$1,737.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,737.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$712.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,737.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,376.73
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$225.02
|
| Rate for Payer: Cash Price |
$712.20
|
| Rate for Payer: Cash Price |
$712.20
|
| Rate for Payer: Cigna Commercial |
$1,008.95
|
| Rate for Payer: First Health Commercial |
$1,068.30
|
| Rate for Payer: First Health Workers Compensation |
$458.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,068.30
|
| Rate for Payer: GEHA Commercial |
$949.60
|
| Rate for Payer: GEHA Medicare |
$225.02
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,068.30
|
| Rate for Payer: Humana ChoiceCare |
$247.52
|
| Rate for Payer: Humana Medicare Advantage |
$225.02
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$378.03
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,404.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$225.02
|
| Rate for Payer: Multiplan All |
$1,080.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$382.53
|
| Rate for Payer: OMNI Networks Commercial |
$830.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,068.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,622.00
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,404.77
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$225.02
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,127.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$450.04
|
| Rate for Payer: Three Rivers Provider Network All |
$890.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$220.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,404.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$225.02
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,103.91
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$225.02
|
| Rate for Payer: Zelis Auto |
$474.80
|
| Rate for Payer: Zelis Medicare |
$191.27
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$270.02
|
| Rate for Payer: Zelis Worker's Compensation |
$324.05
|
|
|
PREPARE FACE/ORAL PROSTHESIS
|
Facility
|
OP
|
$2,810.00
|
|
|
Service Code
|
CPT 21082
|
| Hospital Charge Code |
6121082
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$767.13 |
| Max. Negotiated Rate |
$6,284.94 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$4,345.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,686.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$4,345.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3,442.85
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,142.47
|
| Rate for Payer: Cash Price |
$1,686.00
|
| Rate for Payer: Cash Price |
$1,686.00
|
| Rate for Payer: Cigna Commercial |
$2,388.50
|
| Rate for Payer: First Health Commercial |
$2,529.00
|
| Rate for Payer: First Health Workers Compensation |
$1,084.94
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,529.00
|
| Rate for Payer: GEHA Commercial |
$2,248.00
|
| Rate for Payer: GEHA Medicare |
$3,142.47
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,529.00
|
| Rate for Payer: Humana ChoiceCare |
$3,456.72
|
| Rate for Payer: Humana Medicare Advantage |
$3,142.47
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,279.35
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,512.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,142.47
|
| Rate for Payer: Multiplan All |
$2,557.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,342.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,967.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,529.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$4,056.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3,512.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,142.47
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,669.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,284.94
|
| Rate for Payer: Three Rivers Provider Network All |
$2,107.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,079.62
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,512.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,142.47
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,613.30
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,142.47
|
| Rate for Payer: Zelis Auto |
$1,124.00
|
| Rate for Payer: Zelis Medicare |
$2,671.10
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,770.96
|
| Rate for Payer: Zelis Worker's Compensation |
$767.13
|
|
|
PREPARE FACE/ORAL PROSTHESIS
|
Facility
|
IP
|
$2,930.00
|
|
|
Service Code
|
CPT 21079
|
| Hospital Charge Code |
6121079
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$799.89 |
| Max. Negotiated Rate |
$2,783.50 |
| Rate for Payer: Cash Price |
$1,758.00
|
| Rate for Payer: Cigna Commercial |
$2,490.50
|
| Rate for Payer: First Health Commercial |
$2,637.00
|
| Rate for Payer: First Health Workers Compensation |
$1,131.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,637.00
|
| Rate for Payer: GEHA Commercial |
$2,051.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,637.00
|
| Rate for Payer: Multiplan All |
$2,666.30
|
| Rate for Payer: OMNI Networks Commercial |
$2,051.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,637.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,783.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,197.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,724.90
|
| Rate for Payer: Zelis Auto |
$1,172.00
|
| Rate for Payer: Zelis Worker's Compensation |
$799.89
|
|
|
PREPARE FACE/ORAL PROSTHESIS
|
Facility
|
IP
|
$3,261.00
|
|
|
Service Code
|
CPT 21080
|
| Hospital Charge Code |
6121080
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$890.25 |
| Max. Negotiated Rate |
$3,097.95 |
| Rate for Payer: Cash Price |
$1,956.60
|
| Rate for Payer: Cigna Commercial |
$2,771.85
|
| Rate for Payer: First Health Commercial |
$2,934.90
|
| Rate for Payer: First Health Workers Compensation |
$1,259.07
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,934.90
|
| Rate for Payer: GEHA Commercial |
$2,282.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,934.90
|
| Rate for Payer: Multiplan All |
$2,967.51
|
| Rate for Payer: OMNI Networks Commercial |
$2,282.70
|
| Rate for Payer: One Health Plan PPO/POS |
$2,934.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,097.95
|
| Rate for Payer: Three Rivers Provider Network All |
$2,445.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,032.73
|
| Rate for Payer: Zelis Auto |
$1,304.40
|
| Rate for Payer: Zelis Worker's Compensation |
$890.25
|
|
|
PREPARE FACE/ORAL PROSTHESIS
|
Facility
|
OP
|
$2,607.00
|
|
|
Service Code
|
CPT 21083
|
| Hospital Charge Code |
6121083
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$711.71 |
| Max. Negotiated Rate |
$6,284.94 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$4,345.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,564.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$4,345.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3,442.85
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,142.47
|
| Rate for Payer: Cash Price |
$1,564.20
|
| Rate for Payer: Cash Price |
$1,564.20
|
| Rate for Payer: Cigna Commercial |
$2,215.95
|
| Rate for Payer: First Health Commercial |
$2,346.30
|
| Rate for Payer: First Health Workers Compensation |
$1,006.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,346.30
|
| Rate for Payer: GEHA Commercial |
$2,085.60
|
| Rate for Payer: GEHA Medicare |
$3,142.47
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,346.30
|
| Rate for Payer: Humana ChoiceCare |
$3,456.72
|
| Rate for Payer: Humana Medicare Advantage |
$3,142.47
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,279.35
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,512.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,142.47
|
| Rate for Payer: Multiplan All |
$2,372.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,342.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,824.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,346.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$4,056.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3,512.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,142.47
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,476.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,284.94
|
| Rate for Payer: Three Rivers Provider Network All |
$1,955.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,079.62
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,512.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,142.47
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,424.51
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,142.47
|
| Rate for Payer: Zelis Auto |
$1,042.80
|
| Rate for Payer: Zelis Medicare |
$2,671.10
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,770.96
|
| Rate for Payer: Zelis Worker's Compensation |
$711.71
|
|
|
PREPARE FACE/ORAL PROSTHESIS
|
Facility
|
IP
|
$2,607.00
|
|
|
Service Code
|
CPT 21083
|
| Hospital Charge Code |
6121083
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$711.71 |
| Max. Negotiated Rate |
$2,476.65 |
| Rate for Payer: Cash Price |
$1,564.20
|
| Rate for Payer: Cigna Commercial |
$2,215.95
|
| Rate for Payer: First Health Commercial |
$2,346.30
|
| Rate for Payer: First Health Workers Compensation |
$1,006.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,346.30
|
| Rate for Payer: GEHA Commercial |
$1,824.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,346.30
|
| Rate for Payer: Multiplan All |
$2,372.37
|
| Rate for Payer: OMNI Networks Commercial |
$1,824.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,346.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,476.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,955.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,424.51
|
| Rate for Payer: Zelis Auto |
$1,042.80
|
| Rate for Payer: Zelis Worker's Compensation |
$711.71
|
|
|
PREPARE FACE/ORAL PROSTHESIS
|
Facility
|
IP
|
$1,753.00
|
|
|
Service Code
|
CPT 21076
|
| Hospital Charge Code |
6121076
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$478.57 |
| Max. Negotiated Rate |
$1,665.35 |
| Rate for Payer: Cash Price |
$1,051.80
|
| Rate for Payer: Cigna Commercial |
$1,490.05
|
| Rate for Payer: First Health Commercial |
$1,577.70
|
| Rate for Payer: First Health Workers Compensation |
$676.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,577.70
|
| Rate for Payer: GEHA Commercial |
$1,227.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,577.70
|
| Rate for Payer: Multiplan All |
$1,595.23
|
| Rate for Payer: OMNI Networks Commercial |
$1,227.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,577.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,665.35
|
| Rate for Payer: Three Rivers Provider Network All |
$1,314.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,630.29
|
| Rate for Payer: Zelis Auto |
$701.20
|
| Rate for Payer: Zelis Worker's Compensation |
$478.57
|
|
|
PREPARE FACE/ORAL PROSTHESIS
|
Facility
|
OP
|
$3,025.00
|
|
|
Service Code
|
CPT 21084
|
| Hospital Charge Code |
6121084
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$825.83 |
| Max. Negotiated Rate |
$6,284.94 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$4,345.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,815.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$4,345.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3,442.85
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,142.47
|
| Rate for Payer: Cash Price |
$1,815.00
|
| Rate for Payer: Cash Price |
$1,815.00
|
| Rate for Payer: Cigna Commercial |
$2,571.25
|
| Rate for Payer: First Health Commercial |
$2,722.50
|
| Rate for Payer: First Health Workers Compensation |
$1,167.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,722.50
|
| Rate for Payer: GEHA Commercial |
$2,420.00
|
| Rate for Payer: GEHA Medicare |
$3,142.47
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,722.50
|
| Rate for Payer: Humana ChoiceCare |
$3,456.72
|
| Rate for Payer: Humana Medicare Advantage |
$3,142.47
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,279.35
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,512.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,142.47
|
| Rate for Payer: Multiplan All |
$2,752.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,342.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,117.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,722.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$4,056.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3,512.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,142.47
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,873.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,284.94
|
| Rate for Payer: Three Rivers Provider Network All |
$2,268.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,079.62
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,512.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,142.47
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,813.25
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,142.47
|
| Rate for Payer: Zelis Auto |
$1,210.00
|
| Rate for Payer: Zelis Medicare |
$2,671.10
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,770.96
|
| Rate for Payer: Zelis Worker's Compensation |
$825.83
|
|
|
PREPARE FACE/ORAL PROSTHESIS
|
Facility
|
IP
|
$3,262.00
|
|
|
Service Code
|
CPT 21086
|
| Hospital Charge Code |
6121086
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$890.53 |
| Max. Negotiated Rate |
$3,098.90 |
| Rate for Payer: Cash Price |
$1,957.20
|
| Rate for Payer: Cigna Commercial |
$2,772.70
|
| Rate for Payer: First Health Commercial |
$2,935.80
|
| Rate for Payer: First Health Workers Compensation |
$1,259.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,935.80
|
| Rate for Payer: GEHA Commercial |
$2,283.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,935.80
|
| Rate for Payer: Multiplan All |
$2,968.42
|
| Rate for Payer: OMNI Networks Commercial |
$2,283.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,935.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,098.90
|
| Rate for Payer: Three Rivers Provider Network All |
$2,446.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,033.66
|
| Rate for Payer: Zelis Auto |
$1,304.80
|
| Rate for Payer: Zelis Worker's Compensation |
$890.53
|
|
