|
RIVAROXABAN 10MG TAB
|
Facility
|
IP
|
$91.00
|
|
|
Service Code
|
NDC 50458058030
|
| Hospital Charge Code |
3300799
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.84 |
| Max. Negotiated Rate |
$86.45 |
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$77.35
|
| Rate for Payer: First Health Commercial |
$81.90
|
| Rate for Payer: First Health Workers Compensation |
$35.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.90
|
| Rate for Payer: GEHA Commercial |
$63.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.90
|
| Rate for Payer: Multiplan All |
$82.81
|
| Rate for Payer: OMNI Networks Commercial |
$63.70
|
| Rate for Payer: One Health Plan PPO/POS |
$81.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$86.45
|
| Rate for Payer: Three Rivers Provider Network All |
$68.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$84.63
|
| Rate for Payer: Zelis Auto |
$36.40
|
| Rate for Payer: Zelis Worker's Compensation |
$24.84
|
|
|
RIVAROXABAN 10MG TAB
|
Facility
|
OP
|
$91.00
|
|
|
Service Code
|
NDC 50458058030
|
| Hospital Charge Code |
3300799
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$86.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$77.35
|
| Rate for Payer: First Health Commercial |
$81.90
|
| Rate for Payer: First Health Workers Compensation |
$35.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.90
|
| Rate for Payer: GEHA Commercial |
$72.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.90
|
| Rate for Payer: Humana ChoiceCare |
$23.66
|
| Rate for Payer: Multiplan All |
$82.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$54.60
|
| Rate for Payer: OMNI Networks Commercial |
$63.70
|
| Rate for Payer: One Health Plan PPO/POS |
$81.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$86.45
|
| Rate for Payer: Three Rivers Provider Network All |
$68.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$80.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$22.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$84.63
|
| Rate for Payer: Zelis Auto |
$36.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$45.50
|
| Rate for Payer: Zelis Worker's Compensation |
$24.84
|
|
|
RIVAROXABAN 15MG TAB
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$74.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$46.80
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$66.30
|
| Rate for Payer: First Health Commercial |
$70.20
|
| Rate for Payer: First Health Workers Compensation |
$30.12
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$70.20
|
| Rate for Payer: GEHA Commercial |
$62.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$70.20
|
| Rate for Payer: Humana ChoiceCare |
$20.28
|
| Rate for Payer: Multiplan All |
$70.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$46.80
|
| Rate for Payer: OMNI Networks Commercial |
$54.60
|
| Rate for Payer: One Health Plan PPO/POS |
$70.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$74.10
|
| Rate for Payer: Three Rivers Provider Network All |
$58.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$68.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$19.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$72.54
|
| Rate for Payer: Zelis Auto |
$31.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$39.00
|
| Rate for Payer: Zelis Worker's Compensation |
$21.29
|
|
|
RIVAROXABAN 15MG TAB
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3300800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.29 |
| Max. Negotiated Rate |
$74.10 |
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$66.30
|
| Rate for Payer: First Health Commercial |
$70.20
|
| Rate for Payer: First Health Workers Compensation |
$30.12
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$70.20
|
| Rate for Payer: GEHA Commercial |
$54.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$70.20
|
| Rate for Payer: Multiplan All |
$70.98
|
| Rate for Payer: OMNI Networks Commercial |
$54.60
|
| Rate for Payer: One Health Plan PPO/POS |
$70.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$74.10
|
| Rate for Payer: Three Rivers Provider Network All |
$58.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$72.54
|
| Rate for Payer: Zelis Auto |
$31.20
|
| Rate for Payer: Zelis Worker's Compensation |
$21.29
|
|
|
RMVL DEVITAL TISS N-SLCTV DBRDMT W/O AN
|
Facility
|
OP
|
$537.00
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
20300007
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$70.39 |
| Max. Negotiated Rate |
$510.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$88.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$322.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$88.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$70.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$188.67
|
| Rate for Payer: Cash Price |
$322.20
|
| Rate for Payer: Cash Price |
$322.20
|
| Rate for Payer: Cigna Commercial |
$456.45
|
| Rate for Payer: First Health Commercial |
$483.30
|
| Rate for Payer: First Health Workers Compensation |
$207.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$483.30
|
| Rate for Payer: GEHA Commercial |
$429.60
|
| Rate for Payer: GEHA Medicare |
$188.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$483.30
|
| Rate for Payer: Humana ChoiceCare |
$207.54
|
| Rate for Payer: Humana Medicare Advantage |
$188.67
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$316.97
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$71.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$188.67
|
| Rate for Payer: Multiplan All |
$488.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$320.74
|
| Rate for Payer: OMNI Networks Commercial |
$375.90
|
| Rate for Payer: One Health Plan PPO/POS |
$483.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$82.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$71.83
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$188.67
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$510.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$377.34
|
| Rate for Payer: Three Rivers Provider Network All |
$402.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$184.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$71.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$188.67
|
| Rate for Payer: United Payors & United Providers UP&UP |
$499.41
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$188.67
|
| Rate for Payer: Zelis Auto |
$214.80
|
| Rate for Payer: Zelis Medicare |
$160.37
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$226.40
|
| Rate for Payer: Zelis Worker's Compensation |
$146.60
|
|
|
RMVL DEVITAL TISS N-SLCTV DBRDMT W/O AN
|
Facility
|
IP
|
$537.00
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
20300007
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$146.60 |
| Max. Negotiated Rate |
$510.15 |
| Rate for Payer: Cash Price |
$322.20
|
| Rate for Payer: Cigna Commercial |
$456.45
|
| Rate for Payer: First Health Commercial |
$483.30
|
| Rate for Payer: First Health Workers Compensation |
$207.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$483.30
|
| Rate for Payer: GEHA Commercial |
$375.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$483.30
|
| Rate for Payer: Multiplan All |
$488.67
|
| Rate for Payer: OMNI Networks Commercial |
$375.90
|
| Rate for Payer: One Health Plan PPO/POS |
$483.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$510.15
|
| Rate for Payer: Three Rivers Provider Network All |
$402.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$499.41
|
| Rate for Payer: Zelis Auto |
$214.80
|
| Rate for Payer: Zelis Worker's Compensation |
$146.60
|
|
|
RMVL DEVITAL TISS N-SLCTV DBRDMT W/O ANE
|
Facility
|
OP
|
$537.00
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
1997604
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.39 |
| Max. Negotiated Rate |
$510.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$88.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$322.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$88.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$70.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$188.67
|
| Rate for Payer: Cash Price |
$322.20
|
| Rate for Payer: Cash Price |
$322.20
|
| Rate for Payer: Cigna Commercial |
$456.45
|
| Rate for Payer: First Health Commercial |
$483.30
|
| Rate for Payer: First Health Workers Compensation |
$207.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$483.30
|
| Rate for Payer: GEHA Commercial |
$429.60
|
| Rate for Payer: GEHA Medicare |
$188.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$483.30
|
| Rate for Payer: Humana ChoiceCare |
$207.54
|
| Rate for Payer: Humana Medicare Advantage |
$188.67
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$316.97
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$71.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$188.67
|
| Rate for Payer: Multiplan All |
$488.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$320.74
|
| Rate for Payer: OMNI Networks Commercial |
$375.90
|
| Rate for Payer: One Health Plan PPO/POS |
$483.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$82.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$71.83
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$188.67
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$510.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$377.34
|
| Rate for Payer: Three Rivers Provider Network All |
$402.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$184.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$71.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$188.67
|
| Rate for Payer: United Payors & United Providers UP&UP |
$499.41
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$188.67
|
| Rate for Payer: Zelis Auto |
$214.80
|
| Rate for Payer: Zelis Medicare |
$160.37
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$226.40
|
| Rate for Payer: Zelis Worker's Compensation |
$146.60
|
|
|
RMVL DEVITAL TISS N-SLCTV DBRDMT W/O ANE
|
Facility
|
IP
|
$537.00
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
1997602
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$146.60 |
| Max. Negotiated Rate |
$510.15 |
| Rate for Payer: Cash Price |
$322.20
|
| Rate for Payer: Cigna Commercial |
$456.45
|
| Rate for Payer: First Health Commercial |
$483.30
|
| Rate for Payer: First Health Workers Compensation |
$207.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$483.30
|
| Rate for Payer: GEHA Commercial |
$375.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$483.30
|
| Rate for Payer: Multiplan All |
$488.67
|
| Rate for Payer: OMNI Networks Commercial |
$375.90
|
| Rate for Payer: One Health Plan PPO/POS |
$483.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$510.15
|
| Rate for Payer: Three Rivers Provider Network All |
$402.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$499.41
|
| Rate for Payer: Zelis Auto |
$214.80
|
| Rate for Payer: Zelis Worker's Compensation |
$146.60
|
|
|
RMVL DEVITAL TISS N-SLCTV DBRDMT W/O ANE
|
Facility
|
IP
|
$656.00
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
1000050
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$179.09 |
| Max. Negotiated Rate |
$623.20 |
| Rate for Payer: Cash Price |
$393.60
|
| Rate for Payer: Cigna Commercial |
$557.60
|
| Rate for Payer: First Health Commercial |
$590.40
|
| Rate for Payer: First Health Workers Compensation |
$253.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$590.40
|
| Rate for Payer: GEHA Commercial |
$459.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$590.40
|
| Rate for Payer: Multiplan All |
$596.96
|
| Rate for Payer: OMNI Networks Commercial |
$459.20
|
| Rate for Payer: One Health Plan PPO/POS |
$590.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$623.20
|
| Rate for Payer: Three Rivers Provider Network All |
$492.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$610.08
|
| Rate for Payer: Zelis Auto |
$262.40
|
| Rate for Payer: Zelis Worker's Compensation |
$179.09
|
|
|
RMVL DEVITAL TISS N-SLCTV DBRDMT W/O ANE
|
Facility
|
IP
|
$537.00
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
1997604
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$146.60 |
| Max. Negotiated Rate |
$510.15 |
| Rate for Payer: Cash Price |
$322.20
|
| Rate for Payer: Cigna Commercial |
$456.45
|
| Rate for Payer: First Health Commercial |
$483.30
|
| Rate for Payer: First Health Workers Compensation |
$207.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$483.30
|
| Rate for Payer: GEHA Commercial |
$375.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$483.30
|
| Rate for Payer: Multiplan All |
$488.67
|
| Rate for Payer: OMNI Networks Commercial |
$375.90
|
| Rate for Payer: One Health Plan PPO/POS |
$483.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$510.15
|
| Rate for Payer: Three Rivers Provider Network All |
$402.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$499.41
|
| Rate for Payer: Zelis Auto |
$214.80
|
| Rate for Payer: Zelis Worker's Compensation |
$146.60
|
|
|
RMVL DEVITAL TISS N-SLCTV DBRDMT W/O ANE
|
Facility
|
OP
|
$537.00
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
1997602
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.39 |
| Max. Negotiated Rate |
$510.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$88.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$322.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$88.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$70.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$188.67
|
| Rate for Payer: Cash Price |
$322.20
|
| Rate for Payer: Cash Price |
$322.20
|
| Rate for Payer: Cigna Commercial |
$456.45
|
| Rate for Payer: First Health Commercial |
$483.30
|
| Rate for Payer: First Health Workers Compensation |
$207.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$483.30
|
| Rate for Payer: GEHA Commercial |
$429.60
|
| Rate for Payer: GEHA Medicare |
$188.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$483.30
|
| Rate for Payer: Humana ChoiceCare |
$207.54
|
| Rate for Payer: Humana Medicare Advantage |
$188.67
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$316.97
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$71.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$188.67
|
| Rate for Payer: Multiplan All |
$488.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$320.74
|
| Rate for Payer: OMNI Networks Commercial |
$375.90
|
| Rate for Payer: One Health Plan PPO/POS |
$483.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$82.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$71.83
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$188.67
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$510.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$377.34
|
| Rate for Payer: Three Rivers Provider Network All |
$402.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$184.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$71.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$188.67
|
| Rate for Payer: United Payors & United Providers UP&UP |
$499.41
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$188.67
|
| Rate for Payer: Zelis Auto |
$214.80
|
| Rate for Payer: Zelis Medicare |
$160.37
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$226.40
|
| Rate for Payer: Zelis Worker's Compensation |
$146.60
|
|
|
RMVL DEVITAL TISS N-SLCTV DBRDMT W/O ANE
|
Facility
|
IP
|
$436.05
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
1900007
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$119.04 |
| Max. Negotiated Rate |
$414.25 |
| Rate for Payer: Cash Price |
$261.63
|
| Rate for Payer: Cigna Commercial |
$370.64
|
| Rate for Payer: First Health Commercial |
$392.44
|
| Rate for Payer: First Health Workers Compensation |
$168.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$392.44
|
| Rate for Payer: GEHA Commercial |
$305.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$392.44
|
| Rate for Payer: Multiplan All |
$396.81
|
| Rate for Payer: OMNI Networks Commercial |
$305.24
|
| Rate for Payer: One Health Plan PPO/POS |
$392.44
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$414.25
|
| Rate for Payer: Three Rivers Provider Network All |
$327.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$405.53
|
| Rate for Payer: Zelis Auto |
$174.42
|
| Rate for Payer: Zelis Worker's Compensation |
$119.04
|
|
|
RMVL DEVITAL TISS N-SLCTV DBRDMT W/O ANE
|
Facility
|
OP
|
$436.05
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
1900007
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.39 |
| Max. Negotiated Rate |
$414.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$88.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$261.63
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$88.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$70.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$188.67
|
| Rate for Payer: Cash Price |
$261.63
|
| Rate for Payer: Cash Price |
$261.63
|
| Rate for Payer: Cigna Commercial |
$370.64
|
| Rate for Payer: First Health Commercial |
$392.44
|
| Rate for Payer: First Health Workers Compensation |
$168.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$392.44
|
| Rate for Payer: GEHA Commercial |
$348.84
|
| Rate for Payer: GEHA Medicare |
$188.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$392.44
|
| Rate for Payer: Humana ChoiceCare |
$207.54
|
| Rate for Payer: Humana Medicare Advantage |
$188.67
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$316.97
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$71.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$188.67
|
| Rate for Payer: Multiplan All |
$396.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$320.74
|
| Rate for Payer: OMNI Networks Commercial |
$305.24
|
| Rate for Payer: One Health Plan PPO/POS |
$392.44
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$82.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$71.83
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$188.67
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$414.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$377.34
|
| Rate for Payer: Three Rivers Provider Network All |
$327.04
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$184.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$71.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$188.67
|
| Rate for Payer: United Payors & United Providers UP&UP |
$405.53
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$188.67
|
| Rate for Payer: Zelis Auto |
$174.42
|
| Rate for Payer: Zelis Medicare |
$160.37
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$226.40
|
| Rate for Payer: Zelis Worker's Compensation |
$119.04
|
|
|
RMVL EMBEDDED FB FROM DENTALVLR STRUXS S
|
Facility
|
IP
|
$857.00
|
|
|
Service Code
|
CPT 41805
|
| Hospital Charge Code |
21600480
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$233.96 |
| Max. Negotiated Rate |
$814.15 |
| Rate for Payer: Cash Price |
$514.20
|
| Rate for Payer: Cigna Commercial |
$728.45
|
| Rate for Payer: First Health Commercial |
$771.30
|
| Rate for Payer: First Health Workers Compensation |
$330.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$771.30
|
| Rate for Payer: GEHA Commercial |
$599.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$771.30
|
| Rate for Payer: Multiplan All |
$779.87
|
| Rate for Payer: OMNI Networks Commercial |
$599.90
|
| Rate for Payer: One Health Plan PPO/POS |
$771.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$814.15
|
| Rate for Payer: Three Rivers Provider Network All |
$642.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$797.01
|
| Rate for Payer: Zelis Auto |
$342.80
|
| Rate for Payer: Zelis Worker's Compensation |
$233.96
|
|
|
RMVL EMBEDDED FB FROM DENTALVLR STRUXS S
|
Facility
|
OP
|
$857.00
|
|
|
Service Code
|
CPT 41805
|
| Hospital Charge Code |
21600480
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$233.96 |
| Max. Negotiated Rate |
$2,813.06 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,524.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$514.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,524.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,999.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,406.53
|
| Rate for Payer: Cash Price |
$514.20
|
| Rate for Payer: Cash Price |
$514.20
|
| Rate for Payer: Cigna Commercial |
$728.45
|
| Rate for Payer: First Health Commercial |
$771.30
|
| Rate for Payer: First Health Workers Compensation |
$330.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$771.30
|
| Rate for Payer: GEHA Commercial |
$685.60
|
| Rate for Payer: GEHA Medicare |
$1,406.53
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$771.30
|
| Rate for Payer: Humana ChoiceCare |
$1,547.18
|
| Rate for Payer: Humana Medicare Advantage |
$1,406.53
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,362.97
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,040.27
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,406.53
|
| Rate for Payer: Multiplan All |
$779.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,391.10
|
| Rate for Payer: OMNI Networks Commercial |
$599.90
|
| Rate for Payer: One Health Plan PPO/POS |
$771.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,355.78
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,040.27
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,406.53
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$814.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$2,813.06
|
| Rate for Payer: Three Rivers Provider Network All |
$642.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,378.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,040.27
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,406.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$797.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,406.53
|
| Rate for Payer: Zelis Auto |
$342.80
|
| Rate for Payer: Zelis Medicare |
$1,195.55
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,687.84
|
| Rate for Payer: Zelis Worker's Compensation |
$233.96
|
|
|
RMVL EMBEDDED FB VESTIBULE MOUTH COMP
|
Facility
|
OP
|
$942.00
|
|
|
Service Code
|
CPT 40805
|
| Hospital Charge Code |
21600490
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$257.17 |
| Max. Negotiated Rate |
$967.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$770.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$565.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$770.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$610.32
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$483.55
|
| Rate for Payer: Cash Price |
$565.20
|
| Rate for Payer: Cash Price |
$565.20
|
| Rate for Payer: Cigna Commercial |
$800.70
|
| Rate for Payer: First Health Commercial |
$847.80
|
| Rate for Payer: First Health Workers Compensation |
$363.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$847.80
|
| Rate for Payer: GEHA Commercial |
$753.60
|
| Rate for Payer: GEHA Medicare |
$483.55
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$847.80
|
| Rate for Payer: Humana ChoiceCare |
$531.90
|
| Rate for Payer: Humana Medicare Advantage |
$483.55
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$812.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$622.75
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$483.55
|
| Rate for Payer: Multiplan All |
$857.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$822.03
|
| Rate for Payer: OMNI Networks Commercial |
$659.40
|
| Rate for Payer: One Health Plan PPO/POS |
$847.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$719.05
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$622.75
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$483.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$894.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$967.10
|
| Rate for Payer: Three Rivers Provider Network All |
$706.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$473.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$622.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$483.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$876.06
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$483.55
|
| Rate for Payer: Zelis Auto |
$376.80
|
| Rate for Payer: Zelis Medicare |
$411.02
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$580.26
|
| Rate for Payer: Zelis Worker's Compensation |
$257.17
|
|
|
RMVL EMBEDDED FB VESTIBULE MOUTH COMP
|
Facility
|
IP
|
$942.00
|
|
|
Service Code
|
CPT 40805
|
| Hospital Charge Code |
21600490
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$257.17 |
| Max. Negotiated Rate |
$894.90 |
| Rate for Payer: Cash Price |
$565.20
|
| Rate for Payer: Cigna Commercial |
$800.70
|
| Rate for Payer: First Health Commercial |
$847.80
|
| Rate for Payer: First Health Workers Compensation |
$363.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$847.80
|
| Rate for Payer: GEHA Commercial |
$659.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$847.80
|
| Rate for Payer: Multiplan All |
$857.22
|
| Rate for Payer: OMNI Networks Commercial |
$659.40
|
| Rate for Payer: One Health Plan PPO/POS |
$847.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$894.90
|
| Rate for Payer: Three Rivers Provider Network All |
$706.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$876.06
|
| Rate for Payer: Zelis Auto |
$376.80
|
| Rate for Payer: Zelis Worker's Compensation |
$257.17
|
|
|
RMVL EMBEDDED FB VESTIBULE MOUTH SMPL
|
Facility
|
OP
|
$537.57
|
|
|
Service Code
|
CPT 40804
|
| Hospital Charge Code |
8540804
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$146.76 |
| Max. Negotiated Rate |
$1,780.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$197.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$322.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$197.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$156.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$890.25
|
| Rate for Payer: Cash Price |
$322.54
|
| Rate for Payer: Cash Price |
$322.54
|
| Rate for Payer: Cigna Commercial |
$456.93
|
| Rate for Payer: First Health Commercial |
$483.81
|
| Rate for Payer: First Health Workers Compensation |
$207.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$483.81
|
| Rate for Payer: GEHA Commercial |
$430.06
|
| Rate for Payer: GEHA Medicare |
$890.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$483.81
|
| Rate for Payer: Humana ChoiceCare |
$979.27
|
| Rate for Payer: Humana Medicare Advantage |
$890.25
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,495.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$159.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$890.25
|
| Rate for Payer: Multiplan All |
$489.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,513.42
|
| Rate for Payer: OMNI Networks Commercial |
$376.30
|
| Rate for Payer: One Health Plan PPO/POS |
$483.81
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$184.37
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$159.67
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$890.25
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$510.69
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,780.50
|
| Rate for Payer: Three Rivers Provider Network All |
$403.18
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$872.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$159.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$890.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$499.94
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$890.25
|
| Rate for Payer: Zelis Auto |
$215.03
|
| Rate for Payer: Zelis Medicare |
$756.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,068.30
|
| Rate for Payer: Zelis Worker's Compensation |
$146.76
|
|
|
RMVL EMBEDDED FB VESTIBULE MOUTH SMPL
|
Facility
|
OP
|
$550.00
|
|
|
Service Code
|
CPT 40804
|
| Hospital Charge Code |
21600163
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$150.15 |
| Max. Negotiated Rate |
$1,780.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$197.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$330.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$197.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$156.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$890.25
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$467.50
|
| Rate for Payer: First Health Commercial |
$495.00
|
| Rate for Payer: First Health Workers Compensation |
$212.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$495.00
|
| Rate for Payer: GEHA Commercial |
$440.00
|
| Rate for Payer: GEHA Medicare |
$890.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$495.00
|
| Rate for Payer: Humana ChoiceCare |
$979.27
|
| Rate for Payer: Humana Medicare Advantage |
$890.25
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,495.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$159.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$890.25
|
| Rate for Payer: Multiplan All |
$500.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,513.42
|
| Rate for Payer: OMNI Networks Commercial |
$385.00
|
| Rate for Payer: One Health Plan PPO/POS |
$495.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$184.37
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$159.67
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$890.25
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$522.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,780.50
|
| Rate for Payer: Three Rivers Provider Network All |
$412.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$872.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$159.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$890.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$511.50
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$890.25
|
| Rate for Payer: Zelis Auto |
$220.00
|
| Rate for Payer: Zelis Medicare |
$756.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,068.30
|
| Rate for Payer: Zelis Worker's Compensation |
$150.15
|
|
|
RMVL EMBEDDED FB VESTIBULE MOUTH SMPL
|
Facility
|
IP
|
$537.57
|
|
|
Service Code
|
CPT 40804
|
| Hospital Charge Code |
7240804
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$146.76 |
| Max. Negotiated Rate |
$510.69 |
| Rate for Payer: Cash Price |
$322.54
|
| Rate for Payer: Cigna Commercial |
$456.93
|
| Rate for Payer: First Health Commercial |
$483.81
|
| Rate for Payer: First Health Workers Compensation |
$207.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$483.81
|
| Rate for Payer: GEHA Commercial |
$376.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$483.81
|
| Rate for Payer: Multiplan All |
$489.19
|
| Rate for Payer: OMNI Networks Commercial |
$376.30
|
| Rate for Payer: One Health Plan PPO/POS |
$483.81
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$510.69
|
| Rate for Payer: Three Rivers Provider Network All |
$403.18
|
| Rate for Payer: United Payors & United Providers UP&UP |
$499.94
|
| Rate for Payer: Zelis Auto |
$215.03
|
| Rate for Payer: Zelis Worker's Compensation |
$146.76
|
|
|
RMVL EMBEDDED FB VESTIBULE MOUTH SMPL
|
Facility
|
OP
|
$537.57
|
|
|
Service Code
|
CPT 40804
|
| Hospital Charge Code |
7240804
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$146.76 |
| Max. Negotiated Rate |
$1,780.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$197.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$322.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$197.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$156.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$890.25
|
| Rate for Payer: Cash Price |
$322.54
|
| Rate for Payer: Cash Price |
$322.54
|
| Rate for Payer: Cigna Commercial |
$456.93
|
| Rate for Payer: First Health Commercial |
$483.81
|
| Rate for Payer: First Health Workers Compensation |
$207.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$483.81
|
| Rate for Payer: GEHA Commercial |
$430.06
|
| Rate for Payer: GEHA Medicare |
$890.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$483.81
|
| Rate for Payer: Humana ChoiceCare |
$979.27
|
| Rate for Payer: Humana Medicare Advantage |
$890.25
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,495.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$159.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$890.25
|
| Rate for Payer: Multiplan All |
$489.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,513.42
|
| Rate for Payer: OMNI Networks Commercial |
$376.30
|
| Rate for Payer: One Health Plan PPO/POS |
$483.81
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$184.37
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$159.67
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$890.25
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$510.69
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,780.50
|
| Rate for Payer: Three Rivers Provider Network All |
$403.18
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$872.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$159.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$890.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$499.94
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$890.25
|
| Rate for Payer: Zelis Auto |
$215.03
|
| Rate for Payer: Zelis Medicare |
$756.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,068.30
|
| Rate for Payer: Zelis Worker's Compensation |
$146.76
|
|
|
RMVL EMBEDDED FB VESTIBULE MOUTH SMPL
|
Facility
|
IP
|
$550.00
|
|
|
Service Code
|
CPT 40804
|
| Hospital Charge Code |
21600163
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$150.15 |
| Max. Negotiated Rate |
$522.50 |
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$467.50
|
| Rate for Payer: First Health Commercial |
$495.00
|
| Rate for Payer: First Health Workers Compensation |
$212.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$495.00
|
| Rate for Payer: GEHA Commercial |
$385.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$495.00
|
| Rate for Payer: Multiplan All |
$500.50
|
| Rate for Payer: OMNI Networks Commercial |
$385.00
|
| Rate for Payer: One Health Plan PPO/POS |
$495.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$522.50
|
| Rate for Payer: Three Rivers Provider Network All |
$412.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$511.50
|
| Rate for Payer: Zelis Auto |
$220.00
|
| Rate for Payer: Zelis Worker's Compensation |
$150.15
|
|
|
RMVL EMBEDDED FB VESTIBULE MOUTH SMPL
|
Facility
|
IP
|
$537.57
|
|
|
Service Code
|
CPT 40804
|
| Hospital Charge Code |
8540804
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$146.76 |
| Max. Negotiated Rate |
$510.69 |
| Rate for Payer: Cash Price |
$322.54
|
| Rate for Payer: Cigna Commercial |
$456.93
|
| Rate for Payer: First Health Commercial |
$483.81
|
| Rate for Payer: First Health Workers Compensation |
$207.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$483.81
|
| Rate for Payer: GEHA Commercial |
$376.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$483.81
|
| Rate for Payer: Multiplan All |
$489.19
|
| Rate for Payer: OMNI Networks Commercial |
$376.30
|
| Rate for Payer: One Health Plan PPO/POS |
$483.81
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$510.69
|
| Rate for Payer: Three Rivers Provider Network All |
$403.18
|
| Rate for Payer: United Payors & United Providers UP&UP |
$499.94
|
| Rate for Payer: Zelis Auto |
$215.03
|
| Rate for Payer: Zelis Worker's Compensation |
$146.76
|
|
|
RMVL ESOPHGL SPHNCTR DEV
|
Facility
|
IP
|
$6,390.00
|
|
|
Service Code
|
CPT 43285
|
| Hospital Charge Code |
6191089
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,744.47 |
| Max. Negotiated Rate |
$6,070.50 |
| Rate for Payer: Cash Price |
$3,834.00
|
| Rate for Payer: Cigna Commercial |
$5,431.50
|
| Rate for Payer: First Health Commercial |
$5,751.00
|
| Rate for Payer: First Health Workers Compensation |
$2,467.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,751.00
|
| Rate for Payer: GEHA Commercial |
$4,473.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,751.00
|
| Rate for Payer: Multiplan All |
$5,814.90
|
| Rate for Payer: OMNI Networks Commercial |
$4,473.00
|
| Rate for Payer: One Health Plan PPO/POS |
$5,751.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,070.50
|
| Rate for Payer: Three Rivers Provider Network All |
$4,792.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,942.70
|
| Rate for Payer: Zelis Auto |
$2,556.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,744.47
|
|
|
RMVL ESOPHGL SPHNCTR DEV
|
Facility
|
OP
|
$6,390.00
|
|
|
Service Code
|
CPT 43285
|
| Hospital Charge Code |
6191089
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,744.47 |
| Max. Negotiated Rate |
$11,079.92 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$6,296.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,834.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$6,296.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$4,987.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5,539.96
|
| Rate for Payer: Cash Price |
$3,834.00
|
| Rate for Payer: Cash Price |
$3,834.00
|
| Rate for Payer: Cigna Commercial |
$5,431.50
|
| Rate for Payer: First Health Commercial |
$5,751.00
|
| Rate for Payer: First Health Workers Compensation |
$2,467.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,751.00
|
| Rate for Payer: GEHA Commercial |
$5,112.00
|
| Rate for Payer: GEHA Medicare |
$5,539.96
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,751.00
|
| Rate for Payer: Humana ChoiceCare |
$6,093.96
|
| Rate for Payer: Humana Medicare Advantage |
$5,539.96
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$9,307.13
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$5,089.30
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5,539.96
|
| Rate for Payer: Multiplan All |
$5,814.90
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9,417.93
|
| Rate for Payer: OMNI Networks Commercial |
$4,473.00
|
| Rate for Payer: One Health Plan PPO/POS |
$5,751.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$5,876.30
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$5,089.30
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5,539.96
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,070.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11,079.92
|
| Rate for Payer: Three Rivers Provider Network All |
$4,792.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,429.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5,089.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,539.96
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,942.70
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5,539.96
|
| Rate for Payer: Zelis Auto |
$2,556.00
|
| Rate for Payer: Zelis Medicare |
$4,708.97
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,647.95
|
| Rate for Payer: Zelis Worker's Compensation |
$1,744.47
|
|
