|
PRQ SKELETAL FIXATION TIBIAL SHAFT FRACT
|
Facility
|
IP
|
$1,167.00
|
|
|
Service Code
|
CPT 27756
|
| Hospital Charge Code |
6127756
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$318.59 |
| Max. Negotiated Rate |
$1,108.65 |
| Rate for Payer: Cash Price |
$700.20
|
| Rate for Payer: Cigna Commercial |
$991.95
|
| Rate for Payer: First Health Commercial |
$1,050.30
|
| Rate for Payer: First Health Workers Compensation |
$450.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,050.30
|
| Rate for Payer: GEHA Commercial |
$816.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,050.30
|
| Rate for Payer: Multiplan All |
$1,061.97
|
| Rate for Payer: OMNI Networks Commercial |
$816.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,050.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,108.65
|
| Rate for Payer: Three Rivers Provider Network All |
$875.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,085.31
|
| Rate for Payer: Zelis Auto |
$466.80
|
| Rate for Payer: Zelis Worker's Compensation |
$318.59
|
|
|
PRQ SKEL FIXJ DSTL PHLNGL FX FNGR/THMB E
|
Facility
|
IP
|
$837.00
|
|
|
Service Code
|
CPT 26756
|
| Hospital Charge Code |
6126756
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$228.50 |
| Max. Negotiated Rate |
$795.15 |
| Rate for Payer: Cash Price |
$502.20
|
| Rate for Payer: Cigna Commercial |
$711.45
|
| Rate for Payer: First Health Commercial |
$753.30
|
| Rate for Payer: First Health Workers Compensation |
$323.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$753.30
|
| Rate for Payer: GEHA Commercial |
$585.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$753.30
|
| Rate for Payer: Multiplan All |
$761.67
|
| Rate for Payer: OMNI Networks Commercial |
$585.90
|
| Rate for Payer: One Health Plan PPO/POS |
$753.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$795.15
|
| Rate for Payer: Three Rivers Provider Network All |
$627.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$778.41
|
| Rate for Payer: Zelis Auto |
$334.80
|
| Rate for Payer: Zelis Worker's Compensation |
$228.50
|
|
|
PRQ SKEL FIXJ DSTL PHLNGL FX FNGR/THMB E
|
Facility
|
OP
|
$837.00
|
|
|
Service Code
|
CPT 26756
|
| Hospital Charge Code |
6126756
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$228.50 |
| Max. Negotiated Rate |
$6,161.78 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,613.12
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,613.12
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2,070.11
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,080.89
|
| Rate for Payer: Cash Price |
$502.20
|
| Rate for Payer: Cash Price |
$502.20
|
| Rate for Payer: Cigna Commercial |
$711.45
|
| Rate for Payer: First Health Commercial |
$753.30
|
| Rate for Payer: First Health Workers Compensation |
$323.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$753.30
|
| Rate for Payer: GEHA Commercial |
$669.60
|
| Rate for Payer: GEHA Medicare |
$3,080.89
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$753.30
|
| Rate for Payer: Humana ChoiceCare |
$3,388.98
|
| Rate for Payer: Humana Medicare Advantage |
$3,080.89
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,175.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,112.27
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,080.89
|
| Rate for Payer: Multiplan All |
$761.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,237.51
|
| Rate for Payer: OMNI Networks Commercial |
$585.90
|
| Rate for Payer: One Health Plan PPO/POS |
$753.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,438.91
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,112.27
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,080.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$795.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,161.78
|
| Rate for Payer: Three Rivers Provider Network All |
$627.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,019.27
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,112.27
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,080.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$778.41
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,080.89
|
| Rate for Payer: Zelis Auto |
$334.80
|
| Rate for Payer: Zelis Medicare |
$2,618.76
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,697.07
|
| Rate for Payer: Zelis Worker's Compensation |
$228.50
|
|
|
PRQ SKEL FIXJ PHLNGL SHFT FX PROX/MID PX
|
Facility
|
IP
|
$945.00
|
|
|
Service Code
|
CPT 26727
|
| Hospital Charge Code |
6126727
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$257.99 |
| Max. Negotiated Rate |
$897.75 |
| Rate for Payer: Cash Price |
$567.00
|
| Rate for Payer: Cigna Commercial |
$803.25
|
| Rate for Payer: First Health Commercial |
$850.50
|
| Rate for Payer: First Health Workers Compensation |
$364.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$850.50
|
| Rate for Payer: GEHA Commercial |
$661.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$850.50
|
| Rate for Payer: Multiplan All |
$859.95
|
| Rate for Payer: OMNI Networks Commercial |
$661.50
|
| Rate for Payer: One Health Plan PPO/POS |
$850.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$897.75
|
| Rate for Payer: Three Rivers Provider Network All |
$708.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$878.85
|
| Rate for Payer: Zelis Auto |
$378.00
|
| Rate for Payer: Zelis Worker's Compensation |
$257.99
|
|
|
PRQ SKEL FIXJ PHLNGL SHFT FX PROX/MID PX
|
Facility
|
OP
|
$945.00
|
|
|
Service Code
|
CPT 26727
|
| Hospital Charge Code |
6126727
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$257.99 |
| Max. Negotiated Rate |
$6,161.78 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,613.12
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$567.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,613.12
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2,070.11
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,080.89
|
| Rate for Payer: Cash Price |
$567.00
|
| Rate for Payer: Cash Price |
$567.00
|
| Rate for Payer: Cigna Commercial |
$803.25
|
| Rate for Payer: First Health Commercial |
$850.50
|
| Rate for Payer: First Health Workers Compensation |
$364.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$850.50
|
| Rate for Payer: GEHA Commercial |
$756.00
|
| Rate for Payer: GEHA Medicare |
$3,080.89
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$850.50
|
| Rate for Payer: Humana ChoiceCare |
$3,388.98
|
| Rate for Payer: Humana Medicare Advantage |
$3,080.89
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,175.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,112.27
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,080.89
|
| Rate for Payer: Multiplan All |
$859.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,237.51
|
| Rate for Payer: OMNI Networks Commercial |
$661.50
|
| Rate for Payer: One Health Plan PPO/POS |
$850.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,438.91
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,112.27
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,080.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$897.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,161.78
|
| Rate for Payer: Three Rivers Provider Network All |
$708.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,019.27
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,112.27
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,080.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$878.85
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,080.89
|
| Rate for Payer: Zelis Auto |
$378.00
|
| Rate for Payer: Zelis Medicare |
$2,618.76
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,697.07
|
| Rate for Payer: Zelis Worker's Compensation |
$257.99
|
|
|
psa Diagnostic REF 010322
|
Facility
|
OP
|
$216.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
2232278
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.63 |
| Max. Negotiated Rate |
$205.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$33.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$129.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$33.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$26.23
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$18.39
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$183.60
|
| Rate for Payer: First Health Commercial |
$194.40
|
| Rate for Payer: First Health Workers Compensation |
$27.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$194.40
|
| Rate for Payer: GEHA Commercial |
$172.80
|
| Rate for Payer: GEHA Medicare |
$18.39
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$194.40
|
| Rate for Payer: Humana ChoiceCare |
$20.23
|
| Rate for Payer: Humana Medicare Advantage |
$18.39
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$30.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$26.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$18.39
|
| Rate for Payer: Multiplan All |
$196.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.26
|
| Rate for Payer: OMNI Networks Commercial |
$151.20
|
| Rate for Payer: One Health Plan PPO/POS |
$194.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$30.90
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$26.76
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$18.39
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$205.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$36.78
|
| Rate for Payer: Three Rivers Provider Network All |
$162.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.02
|
| Rate for Payer: United Healthcare Commercial |
$183.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.39
|
| Rate for Payer: United Payors & United Providers UP&UP |
$200.88
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$18.39
|
| Rate for Payer: Zelis Auto |
$86.40
|
| Rate for Payer: Zelis Medicare |
$15.63
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.07
|
| Rate for Payer: Zelis Worker's Compensation |
$19.77
|
|
|
psa Diagnostic REF 010322
|
Facility
|
IP
|
$216.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
2232278
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.77 |
| Max. Negotiated Rate |
$205.20 |
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$183.60
|
| Rate for Payer: First Health Commercial |
$194.40
|
| Rate for Payer: First Health Workers Compensation |
$27.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$194.40
|
| Rate for Payer: GEHA Commercial |
$151.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$194.40
|
| Rate for Payer: Multiplan All |
$196.56
|
| Rate for Payer: OMNI Networks Commercial |
$151.20
|
| Rate for Payer: One Health Plan PPO/POS |
$194.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$205.20
|
| Rate for Payer: Three Rivers Provider Network All |
$162.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$200.88
|
| Rate for Payer: Zelis Auto |
$86.40
|
| Rate for Payer: Zelis Worker's Compensation |
$19.77
|
|
|
PSA DIAG (Vitros)
|
Facility
|
IP
|
$216.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
2232252
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.77 |
| Max. Negotiated Rate |
$205.20 |
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$183.60
|
| Rate for Payer: First Health Commercial |
$194.40
|
| Rate for Payer: First Health Workers Compensation |
$27.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$194.40
|
| Rate for Payer: GEHA Commercial |
$151.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$194.40
|
| Rate for Payer: Multiplan All |
$196.56
|
| Rate for Payer: OMNI Networks Commercial |
$151.20
|
| Rate for Payer: One Health Plan PPO/POS |
$194.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$205.20
|
| Rate for Payer: Three Rivers Provider Network All |
$162.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$200.88
|
| Rate for Payer: Zelis Auto |
$86.40
|
| Rate for Payer: Zelis Worker's Compensation |
$19.77
|
|
|
PSA DIAG (Vitros)
|
Facility
|
OP
|
$216.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
2232252
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.63 |
| Max. Negotiated Rate |
$205.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$33.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$129.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$33.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$26.23
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$18.39
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$183.60
|
| Rate for Payer: First Health Commercial |
$194.40
|
| Rate for Payer: First Health Workers Compensation |
$27.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$194.40
|
| Rate for Payer: GEHA Commercial |
$172.80
|
| Rate for Payer: GEHA Medicare |
$18.39
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$194.40
|
| Rate for Payer: Humana ChoiceCare |
$20.23
|
| Rate for Payer: Humana Medicare Advantage |
$18.39
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$30.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$26.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$18.39
|
| Rate for Payer: Multiplan All |
$196.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.26
|
| Rate for Payer: OMNI Networks Commercial |
$151.20
|
| Rate for Payer: One Health Plan PPO/POS |
$194.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$30.90
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$26.76
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$18.39
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$205.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$36.78
|
| Rate for Payer: Three Rivers Provider Network All |
$162.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.02
|
| Rate for Payer: United Healthcare Commercial |
$183.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.39
|
| Rate for Payer: United Payors & United Providers UP&UP |
$200.88
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$18.39
|
| Rate for Payer: Zelis Auto |
$86.40
|
| Rate for Payer: Zelis Medicare |
$15.63
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.07
|
| Rate for Payer: Zelis Worker's Compensation |
$19.77
|
|
|
PSA FREE AGH
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
CPT 84154
|
| Hospital Charge Code |
2232169
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.63 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$33.10
|
| 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 |
$33.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$26.23
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$18.39
|
| 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 |
$27.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$134.40
|
| Rate for Payer: GEHA Medicare |
$18.39
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Humana ChoiceCare |
$20.23
|
| Rate for Payer: Humana Medicare Advantage |
$18.39
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$30.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$26.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$18.39
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.26
|
| 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 |
$30.90
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$26.76
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$18.39
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$36.78
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.02
|
| Rate for Payer: United Healthcare Commercial |
$142.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.39
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$18.39
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Medicare |
$15.63
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.07
|
| Rate for Payer: Zelis Worker's Compensation |
$19.77
|
|
|
PSA FREE AGH
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
CPT 84154
|
| Hospital Charge Code |
2232169
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.77 |
| 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 |
$27.96
|
| 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 |
$19.77
|
|
|
PSA SCREENING (Vitros)
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT G0103
|
| Hospital Charge Code |
2232253
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$16.41 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$34.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$34.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$27.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$19.31
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$174.40
|
| Rate for Payer: GEHA Medicare |
$19.31
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Humana ChoiceCare |
$21.24
|
| Rate for Payer: Humana Medicare Advantage |
$19.31
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$32.44
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$28.09
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$19.31
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$32.83
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$32.44
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$28.09
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$19.31
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$38.62
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.92
|
| Rate for Payer: United Healthcare Commercial |
$185.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$28.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.31
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$19.31
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Medicare |
$16.41
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$23.17
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
PSA SCREENING (Vitros)
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT G0103
|
| Hospital Charge Code |
2232253
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$152.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
psa screen REF 010322
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT G0103
|
| Hospital Charge Code |
2232279
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$152.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
psa screen REF 010322
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT G0103
|
| Hospital Charge Code |
2232279
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$16.41 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$34.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$34.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$27.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$19.31
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$174.40
|
| Rate for Payer: GEHA Medicare |
$19.31
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Humana ChoiceCare |
$21.24
|
| Rate for Payer: Humana Medicare Advantage |
$19.31
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$32.44
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$28.09
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$19.31
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$32.83
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$32.44
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$28.09
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$19.31
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$38.62
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.92
|
| Rate for Payer: United Healthcare Commercial |
$185.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$28.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.31
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$19.31
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Medicare |
$16.41
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$23.17
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
psa ultrasensitive serial monitREF140723
|
Facility
|
IP
|
$216.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
2200683
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.77 |
| Max. Negotiated Rate |
$205.20 |
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$183.60
|
| Rate for Payer: First Health Commercial |
$194.40
|
| Rate for Payer: First Health Workers Compensation |
$27.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$194.40
|
| Rate for Payer: GEHA Commercial |
$151.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$194.40
|
| Rate for Payer: Multiplan All |
$196.56
|
| Rate for Payer: OMNI Networks Commercial |
$151.20
|
| Rate for Payer: One Health Plan PPO/POS |
$194.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$205.20
|
| Rate for Payer: Three Rivers Provider Network All |
$162.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$200.88
|
| Rate for Payer: Zelis Auto |
$86.40
|
| Rate for Payer: Zelis Worker's Compensation |
$19.77
|
|
|
psa ultrasensitive serial monitREF140723
|
Facility
|
OP
|
$216.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
2200683
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.63 |
| Max. Negotiated Rate |
$205.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$33.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$129.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$33.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$26.23
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$18.39
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$183.60
|
| Rate for Payer: First Health Commercial |
$194.40
|
| Rate for Payer: First Health Workers Compensation |
$27.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$194.40
|
| Rate for Payer: GEHA Commercial |
$172.80
|
| Rate for Payer: GEHA Medicare |
$18.39
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$194.40
|
| Rate for Payer: Humana ChoiceCare |
$20.23
|
| Rate for Payer: Humana Medicare Advantage |
$18.39
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$30.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$26.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$18.39
|
| Rate for Payer: Multiplan All |
$196.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.26
|
| Rate for Payer: OMNI Networks Commercial |
$151.20
|
| Rate for Payer: One Health Plan PPO/POS |
$194.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$30.90
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$26.76
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$18.39
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$205.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$36.78
|
| Rate for Payer: Three Rivers Provider Network All |
$162.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.02
|
| Rate for Payer: United Healthcare Commercial |
$183.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.39
|
| Rate for Payer: United Payors & United Providers UP&UP |
$200.88
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$18.39
|
| Rate for Payer: Zelis Auto |
$86.40
|
| Rate for Payer: Zelis Medicare |
$15.63
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.07
|
| Rate for Payer: Zelis Worker's Compensation |
$19.77
|
|
|
PSN 2.5MM FEMALE SCREW
|
Facility
|
IP
|
$1,019.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
70090020
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$407.60 |
| Max. Negotiated Rate |
$968.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$815.20
|
| Rate for Payer: Cash Price |
$611.40
|
| Rate for Payer: Cash Price |
$611.40
|
| Rate for Payer: Cigna Commercial |
$866.15
|
| Rate for Payer: First Health Commercial |
$917.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$917.10
|
| Rate for Payer: GEHA Commercial |
$713.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$917.10
|
| Rate for Payer: Multiplan All |
$927.29
|
| Rate for Payer: OMNI Networks Commercial |
$713.30
|
| Rate for Payer: One Health Plan PPO/POS |
$917.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$968.05
|
| Rate for Payer: Three Rivers Provider Network All |
$764.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$947.67
|
| Rate for Payer: Zelis Auto |
$407.60
|
|
|
PSN 2.5MM FEMALE SCREW
|
Facility
|
OP
|
$1,019.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
70090020
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$254.75 |
| Max. Negotiated Rate |
$968.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$611.40
|
| Rate for Payer: Cash Price |
$611.40
|
| Rate for Payer: Cash Price |
$611.40
|
| Rate for Payer: Cigna Commercial |
$866.15
|
| Rate for Payer: First Health Commercial |
$917.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$917.10
|
| Rate for Payer: GEHA Commercial |
$815.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$917.10
|
| Rate for Payer: Humana ChoiceCare |
$264.94
|
| Rate for Payer: Multiplan All |
$927.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$611.40
|
| Rate for Payer: OMNI Networks Commercial |
$713.30
|
| Rate for Payer: One Health Plan PPO/POS |
$917.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$968.05
|
| Rate for Payer: Three Rivers Provider Network All |
$764.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$896.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$254.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$947.67
|
| Rate for Payer: Zelis Auto |
$407.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$509.50
|
|
|
PSN MC VE ASF R 10MM 8-11 GH
|
Facility
|
IP
|
$99.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
70090021
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$39.60 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$79.20
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$84.15
|
| Rate for Payer: First Health Commercial |
$89.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$89.10
|
| Rate for Payer: GEHA Commercial |
$69.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$89.10
|
| Rate for Payer: Multiplan All |
$90.09
|
| Rate for Payer: OMNI Networks Commercial |
$69.30
|
| Rate for Payer: One Health Plan PPO/POS |
$89.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$94.05
|
| Rate for Payer: Three Rivers Provider Network All |
$74.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$92.07
|
| Rate for Payer: Zelis Auto |
$39.60
|
|
|
PSN MC VE ASF R 10MM 8-11 GH
|
Facility
|
OP
|
$99.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
70090021
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$84.15
|
| Rate for Payer: First Health Commercial |
$89.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$89.10
|
| Rate for Payer: GEHA Commercial |
$79.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$89.10
|
| Rate for Payer: Humana ChoiceCare |
$25.74
|
| Rate for Payer: Multiplan All |
$90.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$59.40
|
| Rate for Payer: OMNI Networks Commercial |
$69.30
|
| Rate for Payer: One Health Plan PPO/POS |
$89.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$94.05
|
| Rate for Payer: Three Rivers Provider Network All |
$74.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$87.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$24.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$92.07
|
| Rate for Payer: Zelis Auto |
$39.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$49.50
|
|
|
PSYCH DIAG EVAL W/MED SRV
|
Facility
|
OP
|
$445.00
|
|
|
Service Code
|
CPT 90792
|
| Hospital Charge Code |
5090792
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$121.48 |
| Max. Negotiated Rate |
$422.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$156.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$267.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$156.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$123.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$152.56
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cigna Commercial |
$378.25
|
| Rate for Payer: First Health Commercial |
$400.50
|
| Rate for Payer: First Health Workers Compensation |
$171.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$400.50
|
| Rate for Payer: GEHA Commercial |
$356.00
|
| Rate for Payer: GEHA Medicare |
$152.56
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$400.50
|
| Rate for Payer: Humana ChoiceCare |
$167.82
|
| Rate for Payer: Humana Medicare Advantage |
$152.56
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$256.30
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$126.26
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$152.56
|
| Rate for Payer: Multiplan All |
$404.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$259.35
|
| Rate for Payer: OMNI Networks Commercial |
$311.50
|
| Rate for Payer: One Health Plan PPO/POS |
$400.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$145.78
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$126.26
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$152.56
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$422.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$305.12
|
| Rate for Payer: Three Rivers Provider Network All |
$333.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$149.51
|
| Rate for Payer: United Healthcare Commercial |
$378.25
|
| Rate for Payer: United Healthcare Managed Medicaid |
$126.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$152.56
|
| Rate for Payer: United Payors & United Providers UP&UP |
$413.85
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$152.56
|
| Rate for Payer: Zelis Auto |
$178.00
|
| Rate for Payer: Zelis Medicare |
$129.68
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$183.07
|
| Rate for Payer: Zelis Worker's Compensation |
$121.48
|
|
|
PSYCH DIAG EVAL W/MED SRV
|
Facility
|
IP
|
$445.00
|
|
|
Service Code
|
CPT 90792
|
| Hospital Charge Code |
5090792
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$121.48 |
| Max. Negotiated Rate |
$422.75 |
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cigna Commercial |
$378.25
|
| Rate for Payer: First Health Commercial |
$400.50
|
| Rate for Payer: First Health Workers Compensation |
$171.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$400.50
|
| Rate for Payer: GEHA Commercial |
$311.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$400.50
|
| Rate for Payer: Multiplan All |
$404.95
|
| Rate for Payer: OMNI Networks Commercial |
$311.50
|
| Rate for Payer: One Health Plan PPO/POS |
$400.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$422.75
|
| Rate for Payer: Three Rivers Provider Network All |
$333.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$413.85
|
| Rate for Payer: Zelis Auto |
$178.00
|
| Rate for Payer: Zelis Worker's Compensation |
$121.48
|
|
|
PSYCH DIAGNOSTIC EVALUATION
|
Facility
|
IP
|
$217.00
|
|
|
Service Code
|
CPT 90791
|
| Hospital Charge Code |
5090791
|
|
Hospital Revenue Code
|
987
|
| 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
|
|
|
PSYCH DIAGNOSTIC EVALUATION
|
Facility
|
OP
|
$217.00
|
|
|
Service Code
|
CPT 90791
|
| Hospital Charge Code |
5090791
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$59.24 |
| Max. Negotiated Rate |
$305.12 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$156.19
|
| 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 |
$156.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$123.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$152.56
|
| 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: GEHA Medicare |
$152.56
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$195.30
|
| Rate for Payer: Humana ChoiceCare |
$167.82
|
| Rate for Payer: Humana Medicare Advantage |
$152.56
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$256.30
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$126.26
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$152.56
|
| Rate for Payer: Multiplan All |
$197.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$259.35
|
| 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 |
$145.78
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$126.26
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$152.56
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$206.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$305.12
|
| Rate for Payer: Three Rivers Provider Network All |
$162.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$149.51
|
| Rate for Payer: United Healthcare Managed Medicaid |
$126.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$152.56
|
| Rate for Payer: United Payors & United Providers UP&UP |
$201.81
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$152.56
|
| Rate for Payer: Zelis Auto |
$86.80
|
| Rate for Payer: Zelis Medicare |
$129.68
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$183.07
|
| Rate for Payer: Zelis Worker's Compensation |
$59.24
|
|
