|
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 SITE FSNHFGMD GT 1ST 100 SQ CM/1%
|
Facility
|
IP
|
$1,212.00
|
|
|
Service Code
|
CPT 15004
|
| Hospital Charge Code |
20300116
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$330.88 |
| Max. Negotiated Rate |
$1,151.40 |
| Rate for Payer: Cash Price |
$727.20
|
| Rate for Payer: Cigna Commercial |
$1,030.20
|
| Rate for Payer: First Health Commercial |
$1,090.80
|
| Rate for Payer: First Health Workers Compensation |
$467.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,090.80
|
| Rate for Payer: GEHA Commercial |
$848.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,090.80
|
| Rate for Payer: Multiplan All |
$1,102.92
|
| Rate for Payer: OMNI Networks Commercial |
$848.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,090.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,151.40
|
| Rate for Payer: Three Rivers Provider Network All |
$909.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,127.16
|
| Rate for Payer: Zelis Auto |
$484.80
|
| Rate for Payer: Zelis Worker's Compensation |
$330.88
|
|
|
PREP SITE FSNHFGMD GT 1ST 100 SQ CM/1%
|
Facility
|
OP
|
$1,212.00
|
|
|
Service Code
|
CPT 15004
|
| Hospital Charge Code |
20300116
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$330.88 |
| Max. Negotiated Rate |
$1,162.48 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$727.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$355.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$581.24
|
| Rate for Payer: Cash Price |
$727.20
|
| Rate for Payer: Cash Price |
$727.20
|
| Rate for Payer: Cigna Commercial |
$1,030.20
|
| Rate for Payer: First Health Commercial |
$1,090.80
|
| Rate for Payer: First Health Workers Compensation |
$467.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,090.80
|
| Rate for Payer: GEHA Commercial |
$969.60
|
| Rate for Payer: GEHA Medicare |
$581.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,090.80
|
| Rate for Payer: Humana ChoiceCare |
$639.36
|
| Rate for Payer: Humana Medicare Advantage |
$581.24
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$976.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$362.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$581.24
|
| Rate for Payer: Multiplan All |
$1,102.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$988.11
|
| Rate for Payer: OMNI Networks Commercial |
$848.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,090.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$418.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$362.77
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$581.24
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,151.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,162.48
|
| Rate for Payer: Three Rivers Provider Network All |
$909.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$569.62
|
| Rate for Payer: United Healthcare Managed Medicaid |
$362.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$581.24
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,127.16
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$581.24
|
| Rate for Payer: Zelis Auto |
$484.80
|
| Rate for Payer: Zelis Medicare |
$494.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$697.49
|
| Rate for Payer: Zelis Worker's Compensation |
$330.88
|
|
|
PREP SITE FSNHFGMD GT 1ST 100 SQ CM/1%
|
Facility
|
IP
|
$1,124.76
|
|
|
Service Code
|
CPT 15004
|
| Hospital Charge Code |
6115004
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$307.06 |
| Max. Negotiated Rate |
$1,068.52 |
| Rate for Payer: Cash Price |
$674.86
|
| Rate for Payer: Cigna Commercial |
$956.05
|
| Rate for Payer: First Health Commercial |
$1,012.28
|
| Rate for Payer: First Health Workers Compensation |
$434.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,012.28
|
| Rate for Payer: GEHA Commercial |
$787.33
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,012.28
|
| Rate for Payer: Multiplan All |
$1,023.53
|
| Rate for Payer: OMNI Networks Commercial |
$787.33
|
| Rate for Payer: One Health Plan PPO/POS |
$1,012.28
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,068.52
|
| Rate for Payer: Three Rivers Provider Network All |
$843.57
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,046.03
|
| Rate for Payer: Zelis Auto |
$449.90
|
| Rate for Payer: Zelis Worker's Compensation |
$307.06
|
|
|
PREP SITE FSNHFGMD GT 1ST 100 SQ CM/1%
|
Facility
|
IP
|
$5,316.00
|
|
|
Service Code
|
CPT 15004
|
| Hospital Charge Code |
1915004
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,451.27 |
| Max. Negotiated Rate |
$5,050.20 |
| Rate for Payer: Cash Price |
$3,189.60
|
| Rate for Payer: Cigna Commercial |
$4,518.60
|
| Rate for Payer: First Health Commercial |
$4,784.40
|
| Rate for Payer: First Health Workers Compensation |
$2,052.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,784.40
|
| Rate for Payer: GEHA Commercial |
$3,721.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,784.40
|
| Rate for Payer: Multiplan All |
$4,837.56
|
| Rate for Payer: OMNI Networks Commercial |
$3,721.20
|
| Rate for Payer: One Health Plan PPO/POS |
$4,784.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,050.20
|
| Rate for Payer: Three Rivers Provider Network All |
$3,987.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,943.88
|
| Rate for Payer: Zelis Auto |
$2,126.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1,451.27
|
|
|
PREP SITE FSNHFGMD GT 1ST 100 SQ CM/1%
|
Facility
|
OP
|
$5,316.00
|
|
|
Service Code
|
CPT 15004
|
| Hospital Charge Code |
1915004
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$355.53 |
| Max. Negotiated Rate |
$5,050.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,189.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$355.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$581.24
|
| Rate for Payer: Cash Price |
$3,189.60
|
| Rate for Payer: Cash Price |
$3,189.60
|
| Rate for Payer: Cigna Commercial |
$4,518.60
|
| Rate for Payer: First Health Commercial |
$4,784.40
|
| Rate for Payer: First Health Workers Compensation |
$2,052.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,784.40
|
| Rate for Payer: GEHA Commercial |
$4,252.80
|
| Rate for Payer: GEHA Medicare |
$581.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,784.40
|
| Rate for Payer: Humana ChoiceCare |
$639.36
|
| Rate for Payer: Humana Medicare Advantage |
$581.24
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$976.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$362.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$581.24
|
| Rate for Payer: Multiplan All |
$4,837.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$988.11
|
| Rate for Payer: OMNI Networks Commercial |
$3,721.20
|
| Rate for Payer: One Health Plan PPO/POS |
$4,784.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$418.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$362.77
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$581.24
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,050.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,162.48
|
| Rate for Payer: Three Rivers Provider Network All |
$3,987.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$569.62
|
| Rate for Payer: United Healthcare Managed Medicaid |
$362.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$581.24
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,943.88
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$581.24
|
| Rate for Payer: Zelis Auto |
$2,126.40
|
| Rate for Payer: Zelis Medicare |
$494.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$697.49
|
| Rate for Payer: Zelis Worker's Compensation |
$1,451.27
|
|
|
PREP SITE FSNHFGMD GT 1ST 100 SQ CM/1%
|
Facility
|
OP
|
$1,124.76
|
|
|
Service Code
|
CPT 15004
|
| Hospital Charge Code |
6115004
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$307.06 |
| Max. Negotiated Rate |
$1,162.48 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$674.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$355.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$581.24
|
| Rate for Payer: Cash Price |
$674.86
|
| Rate for Payer: Cash Price |
$674.86
|
| Rate for Payer: Cigna Commercial |
$956.05
|
| Rate for Payer: First Health Commercial |
$1,012.28
|
| Rate for Payer: First Health Workers Compensation |
$434.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,012.28
|
| Rate for Payer: GEHA Commercial |
$899.81
|
| Rate for Payer: GEHA Medicare |
$581.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,012.28
|
| Rate for Payer: Humana ChoiceCare |
$639.36
|
| Rate for Payer: Humana Medicare Advantage |
$581.24
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$976.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$362.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$581.24
|
| Rate for Payer: Multiplan All |
$1,023.53
|
| Rate for Payer: New Mexico Health Connections Medicare |
$988.11
|
| Rate for Payer: OMNI Networks Commercial |
$787.33
|
| Rate for Payer: One Health Plan PPO/POS |
$1,012.28
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$418.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$362.77
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$581.24
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,068.52
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,162.48
|
| Rate for Payer: Three Rivers Provider Network All |
$843.57
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$569.62
|
| Rate for Payer: United Healthcare Managed Medicaid |
$362.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$581.24
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,046.03
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$581.24
|
| Rate for Payer: Zelis Auto |
$449.90
|
| Rate for Payer: Zelis Medicare |
$494.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$697.49
|
| Rate for Payer: Zelis Worker's Compensation |
$307.06
|
|
|
PREP SITE FSNHFGMD GT ADDL 100 SQ CM/1%
|
Facility
|
IP
|
$4,069.00
|
|
|
Service Code
|
CPT 15005
|
| Hospital Charge Code |
1915005
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,110.84 |
| Max. Negotiated Rate |
$3,865.55 |
| Rate for Payer: Cash Price |
$2,441.40
|
| Rate for Payer: Cigna Commercial |
$3,458.65
|
| Rate for Payer: First Health Commercial |
$3,662.10
|
| Rate for Payer: First Health Workers Compensation |
$1,571.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,662.10
|
| Rate for Payer: GEHA Commercial |
$2,848.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,662.10
|
| Rate for Payer: Multiplan All |
$3,702.79
|
| Rate for Payer: OMNI Networks Commercial |
$2,848.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,662.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,865.55
|
| Rate for Payer: Three Rivers Provider Network All |
$3,051.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,784.17
|
| Rate for Payer: Zelis Auto |
$1,627.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1,110.84
|
|
|
PREP SITE FSNHFGMD GT ADDL 100 SQ CM/1%
|
Facility
|
IP
|
$381.00
|
|
|
Service Code
|
CPT 15005
|
| Hospital Charge Code |
20300117
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$104.01 |
| Max. Negotiated Rate |
$361.95 |
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Cigna Commercial |
$323.85
|
| Rate for Payer: First Health Commercial |
$342.90
|
| Rate for Payer: First Health Workers Compensation |
$147.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$342.90
|
| Rate for Payer: GEHA Commercial |
$266.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$342.90
|
| Rate for Payer: Multiplan All |
$346.71
|
| Rate for Payer: OMNI Networks Commercial |
$266.70
|
| Rate for Payer: One Health Plan PPO/POS |
$342.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$361.95
|
| Rate for Payer: Three Rivers Provider Network All |
$285.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$354.33
|
| Rate for Payer: Zelis Auto |
$152.40
|
| Rate for Payer: Zelis Worker's Compensation |
$104.01
|
|
|
PREP SITE FSNHFGMD GT ADDL 100 SQ CM/1%
|
Facility
|
OP
|
$4,069.00
|
|
|
Service Code
|
CPT 15005
|
| Hospital Charge Code |
1915005
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$355.53 |
| Max. Negotiated Rate |
$3,865.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,441.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$355.53
|
| Rate for Payer: Cash Price |
$2,441.40
|
| Rate for Payer: Cash Price |
$2,441.40
|
| Rate for Payer: Cigna Commercial |
$3,458.65
|
| Rate for Payer: First Health Commercial |
$3,662.10
|
| Rate for Payer: First Health Workers Compensation |
$1,571.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,662.10
|
| Rate for Payer: GEHA Commercial |
$3,255.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,662.10
|
| Rate for Payer: Humana ChoiceCare |
$1,057.94
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$362.77
|
| Rate for Payer: Multiplan All |
$3,702.79
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,441.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,848.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,662.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$418.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$362.77
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,865.55
|
| Rate for Payer: Three Rivers Provider Network All |
$3,051.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,580.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$362.77
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,784.17
|
| Rate for Payer: Zelis Auto |
$1,627.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,034.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1,110.84
|
|
|
PREP SITE FSNHFGMD GT ADDL 100 SQ CM/1%
|
Facility
|
OP
|
$291.00
|
|
|
Service Code
|
CPT 15005
|
| Hospital Charge Code |
6115005
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$75.66 |
| Max. Negotiated Rate |
$448.79 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$174.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$355.53
|
| Rate for Payer: Cash Price |
$174.60
|
| Rate for Payer: Cash Price |
$174.60
|
| Rate for Payer: Cigna Commercial |
$247.35
|
| Rate for Payer: First Health Commercial |
$261.90
|
| Rate for Payer: First Health Workers Compensation |
$112.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$261.90
|
| Rate for Payer: GEHA Commercial |
$232.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$261.90
|
| Rate for Payer: Humana ChoiceCare |
$75.66
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$362.77
|
| Rate for Payer: Multiplan All |
$264.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$174.60
|
| Rate for Payer: OMNI Networks Commercial |
$203.70
|
| Rate for Payer: One Health Plan PPO/POS |
$261.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$418.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$362.77
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$276.45
|
| Rate for Payer: Three Rivers Provider Network All |
$218.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$256.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$362.77
|
| Rate for Payer: United Payors & United Providers UP&UP |
$270.63
|
| Rate for Payer: Zelis Auto |
$116.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$145.50
|
| Rate for Payer: Zelis Worker's Compensation |
$79.44
|
|
|
PREP SITE FSNHFGMD GT ADDL 100 SQ CM/1%
|
Facility
|
IP
|
$291.00
|
|
|
Service Code
|
CPT 15005
|
| Hospital Charge Code |
6115005
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$79.44 |
| Max. Negotiated Rate |
$276.45 |
| Rate for Payer: Cash Price |
$174.60
|
| Rate for Payer: Cigna Commercial |
$247.35
|
| Rate for Payer: First Health Commercial |
$261.90
|
| Rate for Payer: First Health Workers Compensation |
$112.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$261.90
|
| Rate for Payer: GEHA Commercial |
$203.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$261.90
|
| Rate for Payer: Multiplan All |
$264.81
|
| Rate for Payer: OMNI Networks Commercial |
$203.70
|
| Rate for Payer: One Health Plan PPO/POS |
$261.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$276.45
|
| Rate for Payer: Three Rivers Provider Network All |
$218.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$270.63
|
| Rate for Payer: Zelis Auto |
$116.40
|
| Rate for Payer: Zelis Worker's Compensation |
$79.44
|
|
|
PREP SITE FSNHFGMD GT ADDL 100 SQ CM/1%
|
Facility
|
OP
|
$381.00
|
|
|
Service Code
|
CPT 15005
|
| Hospital Charge Code |
20300117
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$99.06 |
| Max. Negotiated Rate |
$448.79 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$228.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$355.53
|
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Cigna Commercial |
$323.85
|
| Rate for Payer: First Health Commercial |
$342.90
|
| Rate for Payer: First Health Workers Compensation |
$147.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$342.90
|
| Rate for Payer: GEHA Commercial |
$304.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$342.90
|
| Rate for Payer: Humana ChoiceCare |
$99.06
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$362.77
|
| Rate for Payer: Multiplan All |
$346.71
|
| Rate for Payer: New Mexico Health Connections Medicare |
$228.60
|
| Rate for Payer: OMNI Networks Commercial |
$266.70
|
| Rate for Payer: One Health Plan PPO/POS |
$342.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$418.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$362.77
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$361.95
|
| Rate for Payer: Three Rivers Provider Network All |
$285.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$335.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$362.77
|
| Rate for Payer: United Payors & United Providers UP&UP |
$354.33
|
| Rate for Payer: Zelis Auto |
$152.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$190.50
|
| Rate for Payer: Zelis Worker's Compensation |
$104.01
|
|
|
PREP SITE TRNK/ARM/LEG 1ST 100 SQ CM/1%
|
Facility
|
IP
|
$6,278.00
|
|
|
Service Code
|
CPT 15002
|
| Hospital Charge Code |
1915002
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,713.89 |
| Max. Negotiated Rate |
$5,964.10 |
| Rate for Payer: Cash Price |
$3,766.80
|
| Rate for Payer: Cigna Commercial |
$5,336.30
|
| Rate for Payer: First Health Commercial |
$5,650.20
|
| Rate for Payer: First Health Workers Compensation |
$2,423.94
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,650.20
|
| Rate for Payer: GEHA Commercial |
$4,394.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,650.20
|
| Rate for Payer: Multiplan All |
$5,712.98
|
| Rate for Payer: OMNI Networks Commercial |
$4,394.60
|
| Rate for Payer: One Health Plan PPO/POS |
$5,650.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,964.10
|
| Rate for Payer: Three Rivers Provider Network All |
$4,708.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,838.54
|
| Rate for Payer: Zelis Auto |
$2,511.20
|
| Rate for Payer: Zelis Worker's Compensation |
$1,713.89
|
|
|
PREP SITE TRNK/ARM/LEG 1ST 100 SQ CM/1%
|
Facility
|
IP
|
$708.00
|
|
|
Service Code
|
CPT 15002
|
| Hospital Charge Code |
6115002
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$193.28 |
| Max. Negotiated Rate |
$672.60 |
| Rate for Payer: Cash Price |
$424.80
|
| Rate for Payer: Cigna Commercial |
$601.80
|
| Rate for Payer: First Health Commercial |
$637.20
|
| Rate for Payer: First Health Workers Compensation |
$273.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$637.20
|
| Rate for Payer: GEHA Commercial |
$495.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$637.20
|
| Rate for Payer: Multiplan All |
$644.28
|
| Rate for Payer: OMNI Networks Commercial |
$495.60
|
| Rate for Payer: One Health Plan PPO/POS |
$637.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$672.60
|
| Rate for Payer: Three Rivers Provider Network All |
$531.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$658.44
|
| Rate for Payer: Zelis Auto |
$283.20
|
| Rate for Payer: Zelis Worker's Compensation |
$193.28
|
|
|
PREP SITE TRNK/ARM/LEG 1ST 100 SQ CM/1%
|
Facility
|
OP
|
$1,059.00
|
|
|
Service Code
|
CPT 15002
|
| Hospital Charge Code |
20300114
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$289.11 |
| Max. Negotiated Rate |
$3,473.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$635.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$355.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,736.93
|
| Rate for Payer: Cash Price |
$635.40
|
| Rate for Payer: Cash Price |
$635.40
|
| Rate for Payer: Cigna Commercial |
$900.15
|
| Rate for Payer: First Health Commercial |
$953.10
|
| Rate for Payer: First Health Workers Compensation |
$408.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$953.10
|
| Rate for Payer: GEHA Commercial |
$847.20
|
| Rate for Payer: GEHA Medicare |
$1,736.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$953.10
|
| Rate for Payer: Humana ChoiceCare |
$1,910.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,736.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,918.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$362.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,736.93
|
| Rate for Payer: Multiplan All |
$963.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,952.78
|
| Rate for Payer: OMNI Networks Commercial |
$741.30
|
| Rate for Payer: One Health Plan PPO/POS |
$953.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$418.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$362.77
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,736.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,006.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,473.86
|
| Rate for Payer: Three Rivers Provider Network All |
$794.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,702.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$362.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,736.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$984.87
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,736.93
|
| Rate for Payer: Zelis Auto |
$423.60
|
| Rate for Payer: Zelis Medicare |
$1,476.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,084.32
|
| Rate for Payer: Zelis Worker's Compensation |
$289.11
|
|
|
PREP SITE TRNK/ARM/LEG 1ST 100 SQ CM/1%
|
Facility
|
IP
|
$1,059.00
|
|
|
Service Code
|
CPT 15002
|
| Hospital Charge Code |
20300114
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$289.11 |
| Max. Negotiated Rate |
$1,006.05 |
| Rate for Payer: Cash Price |
$635.40
|
| Rate for Payer: Cigna Commercial |
$900.15
|
| Rate for Payer: First Health Commercial |
$953.10
|
| Rate for Payer: First Health Workers Compensation |
$408.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$953.10
|
| Rate for Payer: GEHA Commercial |
$741.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$953.10
|
| Rate for Payer: Multiplan All |
$963.69
|
| Rate for Payer: OMNI Networks Commercial |
$741.30
|
| Rate for Payer: One Health Plan PPO/POS |
$953.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,006.05
|
| Rate for Payer: Three Rivers Provider Network All |
$794.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$984.87
|
| Rate for Payer: Zelis Auto |
$423.60
|
| Rate for Payer: Zelis Worker's Compensation |
$289.11
|
|
|
PREP SITE TRNK/ARM/LEG 1ST 100 SQ CM/1%
|
Facility
|
OP
|
$6,278.00
|
|
|
Service Code
|
CPT 15002
|
| Hospital Charge Code |
1915002
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$355.53 |
| Max. Negotiated Rate |
$5,964.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,766.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$355.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,736.93
|
| Rate for Payer: Cash Price |
$3,766.80
|
| Rate for Payer: Cash Price |
$3,766.80
|
| Rate for Payer: Cigna Commercial |
$5,336.30
|
| Rate for Payer: First Health Commercial |
$5,650.20
|
| Rate for Payer: First Health Workers Compensation |
$2,423.94
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,650.20
|
| Rate for Payer: GEHA Commercial |
$5,022.40
|
| Rate for Payer: GEHA Medicare |
$1,736.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,650.20
|
| Rate for Payer: Humana ChoiceCare |
$1,910.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,736.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,918.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$362.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,736.93
|
| Rate for Payer: Multiplan All |
$5,712.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,952.78
|
| Rate for Payer: OMNI Networks Commercial |
$4,394.60
|
| Rate for Payer: One Health Plan PPO/POS |
$5,650.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$418.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$362.77
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,736.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,964.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,473.86
|
| Rate for Payer: Three Rivers Provider Network All |
$4,708.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,702.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$362.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,736.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,838.54
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,736.93
|
| Rate for Payer: Zelis Auto |
$2,511.20
|
| Rate for Payer: Zelis Medicare |
$1,476.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,084.32
|
| Rate for Payer: Zelis Worker's Compensation |
$1,713.89
|
|
|
PREP SITE TRNK/ARM/LEG 1ST 100 SQ CM/1%
|
Facility
|
OP
|
$708.00
|
|
|
Service Code
|
CPT 15002
|
| Hospital Charge Code |
6115002
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$193.28 |
| Max. Negotiated Rate |
$3,473.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$424.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$355.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,736.93
|
| Rate for Payer: Cash Price |
$424.80
|
| Rate for Payer: Cash Price |
$424.80
|
| Rate for Payer: Cigna Commercial |
$601.80
|
| Rate for Payer: First Health Commercial |
$637.20
|
| Rate for Payer: First Health Workers Compensation |
$273.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$637.20
|
| Rate for Payer: GEHA Commercial |
$566.40
|
| Rate for Payer: GEHA Medicare |
$1,736.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$637.20
|
| Rate for Payer: Humana ChoiceCare |
$1,910.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,736.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,918.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$362.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,736.93
|
| Rate for Payer: Multiplan All |
$644.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,952.78
|
| Rate for Payer: OMNI Networks Commercial |
$495.60
|
| Rate for Payer: One Health Plan PPO/POS |
$637.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$418.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$362.77
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,736.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$672.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,473.86
|
| Rate for Payer: Three Rivers Provider Network All |
$531.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,702.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$362.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,736.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$658.44
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,736.93
|
| Rate for Payer: Zelis Auto |
$283.20
|
| Rate for Payer: Zelis Medicare |
$1,476.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,084.32
|
| Rate for Payer: Zelis Worker's Compensation |
$193.28
|
|
|
PREP SITE TRNK/ARM/LEG ADDL 100 SQ CM/1%
|
Facility
|
IP
|
$226.00
|
|
|
Service Code
|
CPT 15003
|
| Hospital Charge Code |
20300115
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.70 |
| Max. Negotiated Rate |
$214.70 |
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$192.10
|
| Rate for Payer: First Health Commercial |
$203.40
|
| Rate for Payer: First Health Workers Compensation |
$87.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$203.40
|
| Rate for Payer: GEHA Commercial |
$158.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$203.40
|
| Rate for Payer: Multiplan All |
$205.66
|
| Rate for Payer: OMNI Networks Commercial |
$158.20
|
| Rate for Payer: One Health Plan PPO/POS |
$203.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$214.70
|
| Rate for Payer: Three Rivers Provider Network All |
$169.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$210.18
|
| Rate for Payer: Zelis Auto |
$90.40
|
| Rate for Payer: Zelis Worker's Compensation |
$61.70
|
|
|
PREP SITE TRNK/ARM/LEG ADDL 100 SQ CM/1%
|
Facility
|
OP
|
$3,127.00
|
|
|
Service Code
|
CPT 15003
|
| Hospital Charge Code |
1915003
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$355.53 |
| Max. Negotiated Rate |
$2,970.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,876.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$355.53
|
| Rate for Payer: Cash Price |
$1,876.20
|
| Rate for Payer: Cash Price |
$1,876.20
|
| Rate for Payer: Cigna Commercial |
$2,657.95
|
| Rate for Payer: First Health Commercial |
$2,814.30
|
| Rate for Payer: First Health Workers Compensation |
$1,207.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,814.30
|
| Rate for Payer: GEHA Commercial |
$2,501.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,814.30
|
| Rate for Payer: Humana ChoiceCare |
$813.02
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$362.77
|
| Rate for Payer: Multiplan All |
$2,845.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,876.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,188.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,814.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$418.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$362.77
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,970.65
|
| Rate for Payer: Three Rivers Provider Network All |
$2,345.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,751.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$362.77
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,908.11
|
| Rate for Payer: Zelis Auto |
$1,250.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,563.50
|
| Rate for Payer: Zelis Worker's Compensation |
$853.67
|
|
|
PREP SITE TRNK/ARM/LEG ADDL 100 SQ CM/1%
|
Facility
|
IP
|
$3,127.00
|
|
|
Service Code
|
CPT 15003
|
| Hospital Charge Code |
1915003
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$853.67 |
| Max. Negotiated Rate |
$2,970.65 |
| Rate for Payer: Cash Price |
$1,876.20
|
| Rate for Payer: Cigna Commercial |
$2,657.95
|
| Rate for Payer: First Health Commercial |
$2,814.30
|
| Rate for Payer: First Health Workers Compensation |
$1,207.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,814.30
|
| Rate for Payer: GEHA Commercial |
$2,188.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,814.30
|
| Rate for Payer: Multiplan All |
$2,845.57
|
| Rate for Payer: OMNI Networks Commercial |
$2,188.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,814.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,970.65
|
| Rate for Payer: Three Rivers Provider Network All |
$2,345.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,908.11
|
| Rate for Payer: Zelis Auto |
$1,250.80
|
| Rate for Payer: Zelis Worker's Compensation |
$853.67
|
|
|
PREP SITE TRNK/ARM/LEG ADDL 100 SQ CM/1%
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
CPT 15003
|
| Hospital Charge Code |
6115003
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$37.96 |
| Max. Negotiated Rate |
$448.79 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$87.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$355.53
|
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cigna Commercial |
$124.10
|
| Rate for Payer: First Health Commercial |
$131.40
|
| Rate for Payer: First Health Workers Compensation |
$56.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$131.40
|
| Rate for Payer: GEHA Commercial |
$116.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$131.40
|
| Rate for Payer: Humana ChoiceCare |
$37.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$362.77
|
| Rate for Payer: Multiplan All |
$132.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$87.60
|
| Rate for Payer: OMNI Networks Commercial |
$102.20
|
| Rate for Payer: One Health Plan PPO/POS |
$131.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$418.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$362.77
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$138.70
|
| Rate for Payer: Three Rivers Provider Network All |
$109.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$128.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$362.77
|
| Rate for Payer: United Payors & United Providers UP&UP |
$135.78
|
| Rate for Payer: Zelis Auto |
$58.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$73.00
|
| Rate for Payer: Zelis Worker's Compensation |
$39.86
|
|
|
PREP SITE TRNK/ARM/LEG ADDL 100 SQ CM/1%
|
Facility
|
OP
|
$226.00
|
|
|
Service Code
|
CPT 15003
|
| Hospital Charge Code |
20300115
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$58.76 |
| Max. Negotiated Rate |
$448.79 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$135.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$355.53
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$192.10
|
| Rate for Payer: First Health Commercial |
$203.40
|
| Rate for Payer: First Health Workers Compensation |
$87.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$203.40
|
| Rate for Payer: GEHA Commercial |
$180.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$203.40
|
| Rate for Payer: Humana ChoiceCare |
$58.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$362.77
|
| Rate for Payer: Multiplan All |
$205.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$135.60
|
| Rate for Payer: OMNI Networks Commercial |
$158.20
|
| Rate for Payer: One Health Plan PPO/POS |
$203.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$418.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$362.77
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$214.70
|
| Rate for Payer: Three Rivers Provider Network All |
$169.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$198.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$362.77
|
| Rate for Payer: United Payors & United Providers UP&UP |
$210.18
|
| Rate for Payer: Zelis Auto |
$90.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$113.00
|
| Rate for Payer: Zelis Worker's Compensation |
$61.70
|
|
|
PREP SITE TRNK/ARM/LEG ADDL 100 SQ CM/1%
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
CPT 15003
|
| Hospital Charge Code |
6115003
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$39.86 |
| Max. Negotiated Rate |
$138.70 |
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cigna Commercial |
$124.10
|
| Rate for Payer: First Health Commercial |
$131.40
|
| Rate for Payer: First Health Workers Compensation |
$56.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$131.40
|
| Rate for Payer: GEHA Commercial |
$102.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$131.40
|
| Rate for Payer: Multiplan All |
$132.86
|
| Rate for Payer: OMNI Networks Commercial |
$102.20
|
| Rate for Payer: One Health Plan PPO/POS |
$131.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$138.70
|
| Rate for Payer: Three Rivers Provider Network All |
$109.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$135.78
|
| Rate for Payer: Zelis Auto |
$58.40
|
| Rate for Payer: Zelis Worker's Compensation |
$39.86
|
|
