|
PREPARE FACE/ORAL PROSTHESIS
|
Facility
|
OP
|
$2,930.00
|
|
|
Service Code
|
CPT 21079
|
| Hospital Charge Code |
6121079
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$799.89 |
| Max. Negotiated Rate |
$6,158.84 |
| 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 |
$1,758.00
|
| 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 |
$3,079.42
|
| Rate for Payer: Cash Price |
$1,758.00
|
| 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 |
$2,344.00
|
| Rate for Payer: GEHA Medicare |
$3,079.42
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,637.00
|
| Rate for Payer: Humana ChoiceCare |
$3,387.36
|
| Rate for Payer: Humana Medicare Advantage |
$3,079.42
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,173.43
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,512.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,079.42
|
| Rate for Payer: Multiplan All |
$2,666.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,235.01
|
| Rate for Payer: OMNI Networks Commercial |
$2,051.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,637.00
|
| 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 |
$3,079.42
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,783.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,158.84
|
| Rate for Payer: Three Rivers Provider Network All |
$2,197.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,017.83
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,512.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,079.42
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,724.90
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,079.42
|
| Rate for Payer: Zelis Auto |
$1,172.00
|
| Rate for Payer: Zelis Medicare |
$2,617.51
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,695.30
|
| Rate for Payer: Zelis Worker's Compensation |
$799.89
|
|
|
PREPARE FACE/ORAL PROSTHESIS
|
Facility
|
OP
|
$3,261.00
|
|
|
Service Code
|
CPT 21080
|
| Hospital Charge Code |
6121080
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$890.25 |
| Max. Negotiated Rate |
$6,158.84 |
| 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 |
$1,956.60
|
| 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 |
$3,079.42
|
| Rate for Payer: Cash Price |
$1,956.60
|
| 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 |
$2,608.80
|
| Rate for Payer: GEHA Medicare |
$3,079.42
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,934.90
|
| Rate for Payer: Humana ChoiceCare |
$3,387.36
|
| Rate for Payer: Humana Medicare Advantage |
$3,079.42
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,173.43
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,512.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,079.42
|
| Rate for Payer: Multiplan All |
$2,967.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,235.01
|
| Rate for Payer: OMNI Networks Commercial |
$2,282.70
|
| Rate for Payer: One Health Plan PPO/POS |
$2,934.90
|
| 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 |
$3,079.42
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,097.95
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,158.84
|
| Rate for Payer: Three Rivers Provider Network All |
$2,445.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,017.83
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,512.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,079.42
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,032.73
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,079.42
|
| Rate for Payer: Zelis Auto |
$1,304.40
|
| Rate for Payer: Zelis Medicare |
$2,617.51
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,695.30
|
| Rate for Payer: Zelis Worker's Compensation |
$890.25
|
|
|
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 |
$6,158.84 |
| 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 |
$3,079.42
|
| 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 |
$3,079.42
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,722.50
|
| Rate for Payer: Humana ChoiceCare |
$3,387.36
|
| Rate for Payer: Humana Medicare Advantage |
$3,079.42
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,173.43
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,512.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,079.42
|
| Rate for Payer: Multiplan All |
$2,752.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,235.01
|
| 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 |
$3,079.42
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,873.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,158.84
|
| Rate for Payer: Three Rivers Provider Network All |
$2,268.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,017.83
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,512.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,079.42
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,813.25
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,079.42
|
| Rate for Payer: Zelis Auto |
$1,210.00
|
| Rate for Payer: Zelis Medicare |
$2,617.51
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,695.30
|
| Rate for Payer: Zelis Worker's Compensation |
$825.83
|
|
|
PREPARE FACE/ORAL PROSTHESIS
|
Facility
|
IP
|
$1,187.00
|
|
|
Service Code
|
CPT 21085
|
| Hospital Charge Code |
6121085
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$324.05 |
| Max. Negotiated Rate |
$1,127.65 |
| 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 |
$830.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,068.30
|
| Rate for Payer: Multiplan All |
$1,080.17
|
| Rate for Payer: OMNI Networks Commercial |
$830.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,068.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,127.65
|
| Rate for Payer: Three Rivers Provider Network All |
$890.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,103.91
|
| Rate for Payer: Zelis Auto |
$474.80
|
| Rate for Payer: Zelis Worker's Compensation |
$324.05
|
|
|
PREPARE FACE/ORAL PROSTHESIS
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
CPT 21081
|
| Hospital Charge Code |
6121081
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$819.00 |
| Max. Negotiated Rate |
$11,234.32 |
| 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 |
$1,800.00
|
| 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 |
$5,617.16
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cigna Commercial |
$2,550.00
|
| Rate for Payer: First Health Commercial |
$2,700.00
|
| Rate for Payer: First Health Workers Compensation |
$1,158.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,700.00
|
| Rate for Payer: GEHA Commercial |
$2,400.00
|
| Rate for Payer: GEHA Medicare |
$5,617.16
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,700.00
|
| Rate for Payer: Humana ChoiceCare |
$6,178.88
|
| Rate for Payer: Humana Medicare Advantage |
$5,617.16
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$9,436.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,512.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5,617.16
|
| Rate for Payer: Multiplan All |
$2,730.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9,549.17
|
| Rate for Payer: OMNI Networks Commercial |
$2,100.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,700.00
|
| 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 |
$5,617.16
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,850.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11,234.32
|
| Rate for Payer: Three Rivers Provider Network All |
$2,250.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,504.82
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,512.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,617.16
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,790.00
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5,617.16
|
| Rate for Payer: Zelis Auto |
$1,200.00
|
| Rate for Payer: Zelis Medicare |
$4,774.59
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,740.59
|
| Rate for Payer: Zelis Worker's Compensation |
$819.00
|
|
|
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 |
$6,158.84 |
| 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 |
$3,079.42
|
| 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 |
$3,079.42
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,346.30
|
| Rate for Payer: Humana ChoiceCare |
$3,387.36
|
| Rate for Payer: Humana Medicare Advantage |
$3,079.42
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,173.43
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,512.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,079.42
|
| Rate for Payer: Multiplan All |
$2,372.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,235.01
|
| 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 |
$3,079.42
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,476.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,158.84
|
| Rate for Payer: Three Rivers Provider Network All |
$1,955.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,017.83
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,512.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,079.42
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,424.51
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,079.42
|
| Rate for Payer: Zelis Auto |
$1,042.80
|
| Rate for Payer: Zelis Medicare |
$2,617.51
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,695.30
|
| Rate for Payer: Zelis Worker's Compensation |
$711.71
|
|
|
PREPARE FACE/ORAL PROSTHESIS
|
Facility
|
IP
|
$3,255.00
|
|
|
Service Code
|
CPT 21087
|
| Hospital Charge Code |
6121087
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$888.62 |
| Max. Negotiated Rate |
$3,092.25 |
| Rate for Payer: Cash Price |
$1,953.00
|
| Rate for Payer: Cigna Commercial |
$2,766.75
|
| Rate for Payer: First Health Commercial |
$2,929.50
|
| Rate for Payer: First Health Workers Compensation |
$1,256.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,929.50
|
| Rate for Payer: GEHA Commercial |
$2,278.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,929.50
|
| Rate for Payer: Multiplan All |
$2,962.05
|
| Rate for Payer: OMNI Networks Commercial |
$2,278.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,929.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,092.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,441.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,027.15
|
| Rate for Payer: Zelis Auto |
$1,302.00
|
| Rate for Payer: Zelis Worker's Compensation |
$888.62
|
|
|
PREPARE FACE/ORAL PROSTHESIS
|
Facility
|
OP
|
$1,187.00
|
|
|
Service Code
|
CPT 21085
|
| Hospital Charge Code |
6121085
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$187.43 |
| 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 |
$220.50
|
| 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 |
$220.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,068.30
|
| Rate for Payer: Humana ChoiceCare |
$242.55
|
| Rate for Payer: Humana Medicare Advantage |
$220.50
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$370.44
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,404.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$220.50
|
| Rate for Payer: Multiplan All |
$1,080.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$374.85
|
| 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 |
$220.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,127.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$441.00
|
| Rate for Payer: Three Rivers Provider Network All |
$890.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$216.09
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,404.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$220.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,103.91
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$220.50
|
| Rate for Payer: Zelis Auto |
$474.80
|
| Rate for Payer: Zelis Medicare |
$187.43
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$264.60
|
| Rate for Payer: Zelis Worker's Compensation |
$324.05
|
|
|
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
|
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 SPERM DUCT X-RAY
|
Facility
|
IP
|
$582.00
|
|
|
Service Code
|
CPT 55300
|
| Hospital Charge Code |
6155300
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$158.89 |
| Max. Negotiated Rate |
$552.90 |
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cigna Commercial |
$494.70
|
| Rate for Payer: First Health Commercial |
$523.80
|
| Rate for Payer: First Health Workers Compensation |
$224.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$523.80
|
| Rate for Payer: GEHA Commercial |
$407.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$523.80
|
| Rate for Payer: Multiplan All |
$529.62
|
| Rate for Payer: OMNI Networks Commercial |
$407.40
|
| Rate for Payer: One Health Plan PPO/POS |
$523.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$552.90
|
| Rate for Payer: Three Rivers Provider Network All |
$436.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$541.26
|
| Rate for Payer: Zelis Auto |
$232.80
|
| Rate for Payer: Zelis Worker's Compensation |
$158.89
|
|
|
PREPARE SPERM DUCT X-RAY
|
Facility
|
OP
|
$582.00
|
|
|
Service Code
|
CPT 55300
|
| Hospital Charge Code |
6155300
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$145.50 |
| Max. Negotiated Rate |
$552.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$349.20
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cigna Commercial |
$494.70
|
| Rate for Payer: First Health Commercial |
$523.80
|
| Rate for Payer: First Health Workers Compensation |
$224.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$523.80
|
| Rate for Payer: GEHA Commercial |
$465.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$523.80
|
| Rate for Payer: Humana ChoiceCare |
$151.32
|
| Rate for Payer: Multiplan All |
$529.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$349.20
|
| Rate for Payer: OMNI Networks Commercial |
$407.40
|
| Rate for Payer: One Health Plan PPO/POS |
$523.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$552.90
|
| Rate for Payer: Three Rivers Provider Network All |
$436.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$512.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$145.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$541.26
|
| Rate for Payer: Zelis Auto |
$232.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$291.00
|
| Rate for Payer: Zelis Worker's Compensation |
$158.89
|
|
|
PREP DONOR INTESTINE/ARTERY
|
Facility
|
IP
|
$820.00
|
|
|
Service Code
|
CPT 44721
|
| Hospital Charge Code |
6144721
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$223.86 |
| Max. Negotiated Rate |
$779.00 |
| Rate for Payer: Cash Price |
$492.00
|
| Rate for Payer: Cigna Commercial |
$697.00
|
| Rate for Payer: First Health Commercial |
$738.00
|
| Rate for Payer: First Health Workers Compensation |
$316.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$738.00
|
| Rate for Payer: GEHA Commercial |
$574.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$738.00
|
| Rate for Payer: Multiplan All |
$746.20
|
| Rate for Payer: OMNI Networks Commercial |
$574.00
|
| Rate for Payer: One Health Plan PPO/POS |
$738.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$779.00
|
| Rate for Payer: Three Rivers Provider Network All |
$615.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$762.60
|
| Rate for Payer: Zelis Auto |
$328.00
|
| Rate for Payer: Zelis Worker's Compensation |
$223.86
|
|
|
PREP DONOR INTESTINE/ARTERY
|
Facility
|
OP
|
$820.00
|
|
|
Service Code
|
CPT 44721
|
| Hospital Charge Code |
6144721
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$205.00 |
| Max. Negotiated Rate |
$779.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$492.00
|
| Rate for Payer: Cash Price |
$492.00
|
| Rate for Payer: Cigna Commercial |
$697.00
|
| Rate for Payer: First Health Commercial |
$738.00
|
| Rate for Payer: First Health Workers Compensation |
$316.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$738.00
|
| Rate for Payer: GEHA Commercial |
$656.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$738.00
|
| Rate for Payer: Humana ChoiceCare |
$213.20
|
| Rate for Payer: Multiplan All |
$746.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$492.00
|
| Rate for Payer: OMNI Networks Commercial |
$574.00
|
| Rate for Payer: One Health Plan PPO/POS |
$738.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$779.00
|
| Rate for Payer: Three Rivers Provider Network All |
$615.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$721.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$205.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$762.60
|
| Rate for Payer: Zelis Auto |
$328.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$410.00
|
| Rate for Payer: Zelis Worker's Compensation |
$223.86
|
|
|
PREP DONOR INTESTINE/VENOUS
|
Facility
|
IP
|
$733.00
|
|
|
Service Code
|
CPT 44720
|
| Hospital Charge Code |
6144720
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$200.11 |
| Max. Negotiated Rate |
$696.35 |
| Rate for Payer: Cash Price |
$439.80
|
| Rate for Payer: Cigna Commercial |
$623.05
|
| Rate for Payer: First Health Commercial |
$659.70
|
| Rate for Payer: First Health Workers Compensation |
$283.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$659.70
|
| Rate for Payer: GEHA Commercial |
$513.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$659.70
|
| Rate for Payer: Multiplan All |
$667.03
|
| Rate for Payer: OMNI Networks Commercial |
$513.10
|
| Rate for Payer: One Health Plan PPO/POS |
$659.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$696.35
|
| Rate for Payer: Three Rivers Provider Network All |
$549.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$681.69
|
| Rate for Payer: Zelis Auto |
$293.20
|
| Rate for Payer: Zelis Worker's Compensation |
$200.11
|
|
|
PREP DONOR INTESTINE/VENOUS
|
Facility
|
OP
|
$733.00
|
|
|
Service Code
|
CPT 44720
|
| Hospital Charge Code |
6144720
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$183.25 |
| Max. Negotiated Rate |
$696.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$439.80
|
| Rate for Payer: Cash Price |
$439.80
|
| Rate for Payer: Cigna Commercial |
$623.05
|
| Rate for Payer: First Health Commercial |
$659.70
|
| Rate for Payer: First Health Workers Compensation |
$283.01
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$659.70
|
| Rate for Payer: GEHA Commercial |
$586.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$659.70
|
| Rate for Payer: Humana ChoiceCare |
$190.58
|
| Rate for Payer: Multiplan All |
$667.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$439.80
|
| Rate for Payer: OMNI Networks Commercial |
$513.10
|
| Rate for Payer: One Health Plan PPO/POS |
$659.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$696.35
|
| Rate for Payer: Three Rivers Provider Network All |
$549.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$645.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$183.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$681.69
|
| Rate for Payer: Zelis Auto |
$293.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$366.50
|
| Rate for Payer: Zelis Worker's Compensation |
$200.11
|
|
|
PREP DONOR LIVER/ARTERIAL
|
Facility
|
OP
|
$816.00
|
|
|
Service Code
|
CPT 47147
|
| Hospital Charge Code |
6147147
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$204.00 |
| Max. Negotiated Rate |
$775.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$489.60
|
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Cigna Commercial |
$693.60
|
| Rate for Payer: First Health Commercial |
$734.40
|
| Rate for Payer: First Health Workers Compensation |
$315.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$734.40
|
| Rate for Payer: GEHA Commercial |
$652.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$734.40
|
| Rate for Payer: Humana ChoiceCare |
$212.16
|
| Rate for Payer: Multiplan All |
$742.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$489.60
|
| Rate for Payer: OMNI Networks Commercial |
$571.20
|
| Rate for Payer: One Health Plan PPO/POS |
$734.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$775.20
|
| Rate for Payer: Three Rivers Provider Network All |
$612.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$718.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$204.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$758.88
|
| Rate for Payer: Zelis Auto |
$326.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$408.00
|
| Rate for Payer: Zelis Worker's Compensation |
$222.77
|
|
|
PREP DONOR LIVER/ARTERIAL
|
Facility
|
IP
|
$816.00
|
|
|
Service Code
|
CPT 47147
|
| Hospital Charge Code |
6147147
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$222.77 |
| Max. Negotiated Rate |
$775.20 |
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Cigna Commercial |
$693.60
|
| Rate for Payer: First Health Commercial |
$734.40
|
| Rate for Payer: First Health Workers Compensation |
$315.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$734.40
|
| Rate for Payer: GEHA Commercial |
$571.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$734.40
|
| Rate for Payer: Multiplan All |
$742.56
|
| Rate for Payer: OMNI Networks Commercial |
$571.20
|
| Rate for Payer: One Health Plan PPO/POS |
$734.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$775.20
|
| Rate for Payer: Three Rivers Provider Network All |
$612.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$758.88
|
| Rate for Payer: Zelis Auto |
$326.40
|
| Rate for Payer: Zelis Worker's Compensation |
$222.77
|
|
|
PREP DONOR PANCREAS/VENOUS
|
Facility
|
IP
|
$622.00
|
|
|
Service Code
|
CPT 48552
|
| Hospital Charge Code |
6148552
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$169.81 |
| Max. Negotiated Rate |
$590.90 |
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cigna Commercial |
$528.70
|
| Rate for Payer: First Health Commercial |
$559.80
|
| Rate for Payer: First Health Workers Compensation |
$240.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$559.80
|
| Rate for Payer: GEHA Commercial |
$435.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$559.80
|
| Rate for Payer: Multiplan All |
$566.02
|
| Rate for Payer: OMNI Networks Commercial |
$435.40
|
| Rate for Payer: One Health Plan PPO/POS |
$559.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$590.90
|
| Rate for Payer: Three Rivers Provider Network All |
$466.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$578.46
|
| Rate for Payer: Zelis Auto |
$248.80
|
| Rate for Payer: Zelis Worker's Compensation |
$169.81
|
|
|
PREP DONOR PANCREAS/VENOUS
|
Facility
|
OP
|
$622.00
|
|
|
Service Code
|
CPT 48552
|
| Hospital Charge Code |
6148552
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$155.50 |
| Max. Negotiated Rate |
$590.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$373.20
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cigna Commercial |
$528.70
|
| Rate for Payer: First Health Commercial |
$559.80
|
| Rate for Payer: First Health Workers Compensation |
$240.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$559.80
|
| Rate for Payer: GEHA Commercial |
$497.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$559.80
|
| Rate for Payer: Humana ChoiceCare |
$161.72
|
| Rate for Payer: Multiplan All |
$566.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$373.20
|
| Rate for Payer: OMNI Networks Commercial |
$435.40
|
| Rate for Payer: One Health Plan PPO/POS |
$559.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$590.90
|
| Rate for Payer: Three Rivers Provider Network All |
$466.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$547.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$155.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$578.46
|
| Rate for Payer: Zelis Auto |
$248.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$311.00
|
| Rate for Payer: Zelis Worker's Compensation |
$169.81
|
|
|
PREP RENAL GRAFT/VENOUS
|
Facility
|
OP
|
$576.00
|
|
|
Service Code
|
CPT 50327
|
| Hospital Charge Code |
6150327
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$144.00 |
| Max. Negotiated Rate |
$547.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$345.60
|
| Rate for Payer: Cash Price |
$345.60
|
| Rate for Payer: Cigna Commercial |
$489.60
|
| Rate for Payer: First Health Commercial |
$518.40
|
| Rate for Payer: First Health Workers Compensation |
$222.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$518.40
|
| Rate for Payer: GEHA Commercial |
$460.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$518.40
|
| Rate for Payer: Humana ChoiceCare |
$149.76
|
| Rate for Payer: Multiplan All |
$524.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$345.60
|
| Rate for Payer: OMNI Networks Commercial |
$403.20
|
| Rate for Payer: One Health Plan PPO/POS |
$518.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$547.20
|
| Rate for Payer: Three Rivers Provider Network All |
$432.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$506.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$144.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$535.68
|
| Rate for Payer: Zelis Auto |
$230.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$288.00
|
| Rate for Payer: Zelis Worker's Compensation |
$157.25
|
|
|
PREP RENAL GRAFT/VENOUS
|
Facility
|
IP
|
$576.00
|
|
|
Service Code
|
CPT 50327
|
| Hospital Charge Code |
6150327
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$157.25 |
| Max. Negotiated Rate |
$547.20 |
| Rate for Payer: Cash Price |
$345.60
|
| Rate for Payer: Cigna Commercial |
$489.60
|
| Rate for Payer: First Health Commercial |
$518.40
|
| Rate for Payer: First Health Workers Compensation |
$222.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$518.40
|
| Rate for Payer: GEHA Commercial |
$403.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$518.40
|
| Rate for Payer: Multiplan All |
$524.16
|
| Rate for Payer: OMNI Networks Commercial |
$403.20
|
| Rate for Payer: One Health Plan PPO/POS |
$518.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$547.20
|
| Rate for Payer: Three Rivers Provider Network All |
$432.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$535.68
|
| Rate for Payer: Zelis Auto |
$230.40
|
| Rate for Payer: Zelis Worker's Compensation |
$157.25
|
|
|
PREP REPORT PT PSYCH STATUS AGENCY/PAYER
|
Facility
|
IP
|
$217.00
|
|
|
Service Code
|
CPT 90889
|
| Hospital Charge Code |
9599250
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$59.24 |
| Max. Negotiated Rate |
$206.15 |
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$184.45
|
| Rate for Payer: First Health Commercial |
$195.30
|
| Rate for Payer: First Health Workers Compensation |
$83.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$195.30
|
| Rate for Payer: GEHA Commercial |
$151.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$195.30
|
| Rate for Payer: Multiplan All |
$197.47
|
| Rate for Payer: OMNI Networks Commercial |
$151.90
|
| Rate for Payer: One Health Plan PPO/POS |
$195.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$206.15
|
| Rate for Payer: Three Rivers Provider Network All |
$162.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$201.81
|
| Rate for Payer: Zelis Auto |
$86.80
|
| Rate for Payer: Zelis Worker's Compensation |
$59.24
|
|
|
PREP REPORT PT PSYCH STATUS AGENCY/PAYER
|
Facility
|
OP
|
$217.00
|
|
|
Service Code
|
CPT 90889
|
| Hospital Charge Code |
8499248
|
|
Hospital Revenue Code
|
513
|
| Min. Negotiated Rate |
$50.86 |
| Max. Negotiated Rate |
$206.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$64.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$64.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$50.86
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$184.45
|
| Rate for Payer: First Health Commercial |
$195.30
|
| Rate for Payer: First Health Workers Compensation |
$83.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$195.30
|
| Rate for Payer: GEHA Commercial |
$173.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$195.30
|
| Rate for Payer: Humana ChoiceCare |
$56.42
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$51.90
|
| Rate for Payer: Multiplan All |
$197.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$130.20
|
| Rate for Payer: OMNI Networks Commercial |
$151.90
|
| Rate for Payer: One Health Plan PPO/POS |
$195.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$59.92
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$80.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$206.15
|
| Rate for Payer: Three Rivers Provider Network All |
$162.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$190.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$51.90
|
| Rate for Payer: United Payors & United Providers UP&UP |
$201.81
|
| Rate for Payer: Zelis Auto |
$86.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$108.50
|
| Rate for Payer: Zelis Worker's Compensation |
$59.24
|
|
|
PREP REPORT PT PSYCH STATUS AGENCY/PAYER
|
Facility
|
OP
|
$217.00
|
|
|
Service Code
|
CPT 90889
|
| Hospital Charge Code |
9599250
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$50.86 |
| Max. Negotiated Rate |
$206.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$64.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$64.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$50.86
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$184.45
|
| Rate for Payer: First Health Commercial |
$195.30
|
| Rate for Payer: First Health Workers Compensation |
$83.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$195.30
|
| Rate for Payer: GEHA Commercial |
$173.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$195.30
|
| Rate for Payer: Humana ChoiceCare |
$56.42
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$51.90
|
| Rate for Payer: Multiplan All |
$197.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$130.20
|
| Rate for Payer: OMNI Networks Commercial |
$151.90
|
| Rate for Payer: One Health Plan PPO/POS |
$195.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$59.92
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$51.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$206.15
|
| Rate for Payer: Three Rivers Provider Network All |
$162.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$190.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$51.90
|
| Rate for Payer: United Payors & United Providers UP&UP |
$201.81
|
| Rate for Payer: Zelis Auto |
$86.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$108.50
|
| Rate for Payer: Zelis Worker's Compensation |
$59.24
|
|
