|
SHELL MULTIHOLE ACETABULAR
|
Facility
|
IP
|
$10,359.30
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001798
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,143.72 |
| Max. Negotiated Rate |
$9,841.33 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8,287.44
|
| Rate for Payer: Cash Price |
$6,215.58
|
| Rate for Payer: Cash Price |
$6,215.58
|
| Rate for Payer: Cigna Commercial |
$8,805.41
|
| Rate for Payer: First Health Commercial |
$9,323.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9,323.37
|
| Rate for Payer: GEHA Commercial |
$7,251.51
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9,323.37
|
| Rate for Payer: Multiplan All |
$9,426.96
|
| Rate for Payer: OMNI Networks Commercial |
$7,251.51
|
| Rate for Payer: One Health Plan PPO/POS |
$9,323.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,841.33
|
| Rate for Payer: Three Rivers Provider Network All |
$7,769.48
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,634.15
|
| Rate for Payer: Zelis Auto |
$4,143.72
|
|
|
SHELL MULTIHOLE ACETABULAR
|
Facility
|
OP
|
$10,359.30
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001798
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,589.82 |
| Max. Negotiated Rate |
$9,841.33 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,215.58
|
| Rate for Payer: Cash Price |
$6,215.58
|
| Rate for Payer: Cash Price |
$6,215.58
|
| Rate for Payer: Cigna Commercial |
$8,805.41
|
| Rate for Payer: First Health Commercial |
$9,323.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9,323.37
|
| Rate for Payer: GEHA Commercial |
$8,287.44
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9,323.37
|
| Rate for Payer: Humana ChoiceCare |
$2,693.42
|
| Rate for Payer: Multiplan All |
$9,426.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,215.58
|
| Rate for Payer: OMNI Networks Commercial |
$7,251.51
|
| Rate for Payer: One Health Plan PPO/POS |
$9,323.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,841.33
|
| Rate for Payer: Three Rivers Provider Network All |
$7,769.48
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9,116.18
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,589.82
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,634.15
|
| Rate for Payer: Zelis Auto |
$4,143.72
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,179.65
|
|
|
SHELL MULTIHOLE ACETABULAR 50MM
|
Facility
|
OP
|
$11,344.80
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006458
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,836.20 |
| Max. Negotiated Rate |
$10,777.56 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,806.88
|
| Rate for Payer: Cash Price |
$6,806.88
|
| Rate for Payer: Cash Price |
$6,806.88
|
| Rate for Payer: Cigna Commercial |
$9,643.08
|
| Rate for Payer: First Health Commercial |
$10,210.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,210.32
|
| Rate for Payer: GEHA Commercial |
$9,075.84
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,210.32
|
| Rate for Payer: Humana ChoiceCare |
$2,949.65
|
| Rate for Payer: Multiplan All |
$10,323.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,806.88
|
| Rate for Payer: OMNI Networks Commercial |
$7,941.36
|
| Rate for Payer: One Health Plan PPO/POS |
$10,210.32
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10,777.56
|
| Rate for Payer: Three Rivers Provider Network All |
$8,508.60
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9,983.42
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,836.20
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,550.66
|
| Rate for Payer: Zelis Auto |
$4,537.92
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,672.40
|
|
|
SHELL MULTIHOLE ACETABULAR 50MM
|
Facility
|
IP
|
$11,344.80
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006458
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,537.92 |
| Max. Negotiated Rate |
$10,777.56 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9,075.84
|
| Rate for Payer: Cash Price |
$6,806.88
|
| Rate for Payer: Cash Price |
$6,806.88
|
| Rate for Payer: Cigna Commercial |
$9,643.08
|
| Rate for Payer: First Health Commercial |
$10,210.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,210.32
|
| Rate for Payer: GEHA Commercial |
$7,941.36
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,210.32
|
| Rate for Payer: Multiplan All |
$10,323.77
|
| Rate for Payer: OMNI Networks Commercial |
$7,941.36
|
| Rate for Payer: One Health Plan PPO/POS |
$10,210.32
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10,777.56
|
| Rate for Payer: Three Rivers Provider Network All |
$8,508.60
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,550.66
|
| Rate for Payer: Zelis Auto |
$4,537.92
|
|
|
SHELL MULTIHOLE ACETABULAR 62MM ALPH G
|
Facility
|
OP
|
$10,184.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007048
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,546.00 |
| Max. Negotiated Rate |
$9,674.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,110.40
|
| Rate for Payer: Cash Price |
$6,110.40
|
| Rate for Payer: Cash Price |
$6,110.40
|
| Rate for Payer: Cigna Commercial |
$8,656.40
|
| Rate for Payer: First Health Commercial |
$9,165.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9,165.60
|
| Rate for Payer: GEHA Commercial |
$8,147.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9,165.60
|
| Rate for Payer: Humana ChoiceCare |
$2,647.84
|
| Rate for Payer: Multiplan All |
$9,267.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,110.40
|
| Rate for Payer: OMNI Networks Commercial |
$7,128.80
|
| Rate for Payer: One Health Plan PPO/POS |
$9,165.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,674.80
|
| Rate for Payer: Three Rivers Provider Network All |
$7,638.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,961.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,546.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,471.12
|
| Rate for Payer: Zelis Auto |
$4,073.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,092.00
|
|
|
SHELL MULTIHOLE ACETABULAR 62MM ALPH G
|
Facility
|
IP
|
$10,184.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007048
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,073.60 |
| Max. Negotiated Rate |
$9,674.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8,147.20
|
| Rate for Payer: Cash Price |
$6,110.40
|
| Rate for Payer: Cash Price |
$6,110.40
|
| Rate for Payer: Cigna Commercial |
$8,656.40
|
| Rate for Payer: First Health Commercial |
$9,165.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9,165.60
|
| Rate for Payer: GEHA Commercial |
$7,128.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9,165.60
|
| Rate for Payer: Multiplan All |
$9,267.44
|
| Rate for Payer: OMNI Networks Commercial |
$7,128.80
|
| Rate for Payer: One Health Plan PPO/POS |
$9,165.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,674.80
|
| Rate for Payer: Three Rivers Provider Network All |
$7,638.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,471.12
|
| Rate for Payer: Zelis Auto |
$4,073.60
|
|
|
SHELL MULTIHOLE ACETABULAR 64MM ALPH H
|
Facility
|
IP
|
$9,928.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003396
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,971.20 |
| Max. Negotiated Rate |
$9,431.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,942.40
|
| Rate for Payer: Cash Price |
$5,956.80
|
| Rate for Payer: Cash Price |
$5,956.80
|
| Rate for Payer: Cigna Commercial |
$8,438.80
|
| Rate for Payer: First Health Commercial |
$8,935.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,935.20
|
| Rate for Payer: GEHA Commercial |
$6,949.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,935.20
|
| Rate for Payer: Multiplan All |
$9,034.48
|
| Rate for Payer: OMNI Networks Commercial |
$6,949.60
|
| Rate for Payer: One Health Plan PPO/POS |
$8,935.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,431.60
|
| Rate for Payer: Three Rivers Provider Network All |
$7,446.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,233.04
|
| Rate for Payer: Zelis Auto |
$3,971.20
|
|
|
SHELL MULTIHOLE ACETABULAR 64MM ALPH H
|
Facility
|
OP
|
$9,928.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003396
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,482.00 |
| Max. Negotiated Rate |
$9,431.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,956.80
|
| Rate for Payer: Cash Price |
$5,956.80
|
| Rate for Payer: Cash Price |
$5,956.80
|
| Rate for Payer: Cigna Commercial |
$8,438.80
|
| Rate for Payer: First Health Commercial |
$8,935.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,935.20
|
| Rate for Payer: GEHA Commercial |
$7,942.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,935.20
|
| Rate for Payer: Humana ChoiceCare |
$2,581.28
|
| Rate for Payer: Multiplan All |
$9,034.48
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,956.80
|
| Rate for Payer: OMNI Networks Commercial |
$6,949.60
|
| Rate for Payer: One Health Plan PPO/POS |
$8,935.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,431.60
|
| Rate for Payer: Three Rivers Provider Network All |
$7,446.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,736.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,482.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,233.04
|
| Rate for Payer: Zelis Auto |
$3,971.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,964.00
|
|
|
SHORT ARM CAST, ADULT (11+YRS)
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
CPT Q4010
|
| Hospital Charge Code |
8804010
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.25 |
| Max. Negotiated Rate |
$57.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$36.60
|
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Cigna Commercial |
$51.85
|
| Rate for Payer: First Health Commercial |
$54.90
|
| Rate for Payer: First Health Workers Compensation |
$23.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$54.90
|
| Rate for Payer: GEHA Commercial |
$48.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$54.90
|
| Rate for Payer: Humana ChoiceCare |
$15.86
|
| Rate for Payer: Multiplan All |
$55.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$36.60
|
| Rate for Payer: OMNI Networks Commercial |
$42.70
|
| Rate for Payer: One Health Plan PPO/POS |
$54.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$57.95
|
| Rate for Payer: Three Rivers Provider Network All |
$45.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$53.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$15.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$56.73
|
| Rate for Payer: Zelis Auto |
$24.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$30.50
|
| Rate for Payer: Zelis Worker's Compensation |
$16.65
|
|
|
SHORT ARM CAST, ADULT (11+YRS)
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
CPT Q4010
|
| Hospital Charge Code |
8804010
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$16.65 |
| Max. Negotiated Rate |
$57.95 |
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Cigna Commercial |
$51.85
|
| Rate for Payer: First Health Commercial |
$54.90
|
| Rate for Payer: First Health Workers Compensation |
$23.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$54.90
|
| Rate for Payer: GEHA Commercial |
$42.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$54.90
|
| Rate for Payer: Multiplan All |
$55.51
|
| Rate for Payer: OMNI Networks Commercial |
$42.70
|
| Rate for Payer: One Health Plan PPO/POS |
$54.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$57.95
|
| Rate for Payer: Three Rivers Provider Network All |
$45.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$56.73
|
| Rate for Payer: Zelis Auto |
$24.40
|
| Rate for Payer: Zelis Worker's Compensation |
$16.65
|
|
|
SHORT ARM CAST, ADULT (11+YRS)
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
CPT Q4010
|
| Hospital Charge Code |
8204010
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.25 |
| Max. Negotiated Rate |
$57.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$36.60
|
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Cigna Commercial |
$51.85
|
| Rate for Payer: First Health Commercial |
$54.90
|
| Rate for Payer: First Health Workers Compensation |
$23.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$54.90
|
| Rate for Payer: GEHA Commercial |
$48.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$54.90
|
| Rate for Payer: Humana ChoiceCare |
$15.86
|
| Rate for Payer: Multiplan All |
$55.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$36.60
|
| Rate for Payer: OMNI Networks Commercial |
$42.70
|
| Rate for Payer: One Health Plan PPO/POS |
$54.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$57.95
|
| Rate for Payer: Three Rivers Provider Network All |
$45.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$53.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$15.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$56.73
|
| Rate for Payer: Zelis Auto |
$24.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$30.50
|
| Rate for Payer: Zelis Worker's Compensation |
$16.65
|
|
|
SHORT ARM CAST, ADULT (11+YRS)
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
CPT Q4010
|
| Hospital Charge Code |
8204010
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$16.65 |
| Max. Negotiated Rate |
$57.95 |
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Cigna Commercial |
$51.85
|
| Rate for Payer: First Health Commercial |
$54.90
|
| Rate for Payer: First Health Workers Compensation |
$23.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$54.90
|
| Rate for Payer: GEHA Commercial |
$42.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$54.90
|
| Rate for Payer: Multiplan All |
$55.51
|
| Rate for Payer: OMNI Networks Commercial |
$42.70
|
| Rate for Payer: One Health Plan PPO/POS |
$54.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$57.95
|
| Rate for Payer: Three Rivers Provider Network All |
$45.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$56.73
|
| Rate for Payer: Zelis Auto |
$24.40
|
| Rate for Payer: Zelis Worker's Compensation |
$16.65
|
|
|
SHORT ARM CAST, PED (0-10 YRS)
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT Q4012
|
| Hospital Charge Code |
8804012
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$28.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$25.50
|
| Rate for Payer: First Health Commercial |
$27.00
|
| Rate for Payer: First Health Workers Compensation |
$11.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.00
|
| Rate for Payer: GEHA Commercial |
$24.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.00
|
| Rate for Payer: Humana ChoiceCare |
$7.80
|
| Rate for Payer: Multiplan All |
$27.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$18.00
|
| Rate for Payer: OMNI Networks Commercial |
$21.00
|
| Rate for Payer: One Health Plan PPO/POS |
$27.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$28.50
|
| Rate for Payer: Three Rivers Provider Network All |
$22.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$26.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$27.90
|
| Rate for Payer: Zelis Auto |
$12.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.19
|
|
|
SHORT ARM CAST, PED (0-10 YRS)
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT Q4012
|
| Hospital Charge Code |
8804012
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.19 |
| Max. Negotiated Rate |
$28.50 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$25.50
|
| Rate for Payer: First Health Commercial |
$27.00
|
| Rate for Payer: First Health Workers Compensation |
$11.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.00
|
| Rate for Payer: GEHA Commercial |
$21.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.00
|
| Rate for Payer: Multiplan All |
$27.30
|
| Rate for Payer: OMNI Networks Commercial |
$21.00
|
| Rate for Payer: One Health Plan PPO/POS |
$27.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$28.50
|
| Rate for Payer: Three Rivers Provider Network All |
$22.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$27.90
|
| Rate for Payer: Zelis Auto |
$12.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.19
|
|
|
SHORT ARM CAST, PED (0-10 YRS)
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT Q4012
|
| Hospital Charge Code |
8204012
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$28.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$25.50
|
| Rate for Payer: First Health Commercial |
$27.00
|
| Rate for Payer: First Health Workers Compensation |
$11.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.00
|
| Rate for Payer: GEHA Commercial |
$24.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.00
|
| Rate for Payer: Humana ChoiceCare |
$7.80
|
| Rate for Payer: Multiplan All |
$27.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$18.00
|
| Rate for Payer: OMNI Networks Commercial |
$21.00
|
| Rate for Payer: One Health Plan PPO/POS |
$27.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$28.50
|
| Rate for Payer: Three Rivers Provider Network All |
$22.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$26.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$27.90
|
| Rate for Payer: Zelis Auto |
$12.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.19
|
|
|
SHORT ARM CAST, PED (0-10 YRS)
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT Q4012
|
| Hospital Charge Code |
8204012
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.19 |
| Max. Negotiated Rate |
$28.50 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$25.50
|
| Rate for Payer: First Health Commercial |
$27.00
|
| Rate for Payer: First Health Workers Compensation |
$11.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$27.00
|
| Rate for Payer: GEHA Commercial |
$21.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$27.00
|
| Rate for Payer: Multiplan All |
$27.30
|
| Rate for Payer: OMNI Networks Commercial |
$21.00
|
| Rate for Payer: One Health Plan PPO/POS |
$27.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$28.50
|
| Rate for Payer: Three Rivers Provider Network All |
$22.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$27.90
|
| Rate for Payer: Zelis Auto |
$12.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.19
|
|
|
SHORT ARM SPLINT, ADULT (11+YRS)
|
Facility
|
OP
|
$41.00
|
|
|
Service Code
|
CPT Q4022
|
| Hospital Charge Code |
8804022
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$32.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Humana ChoiceCare |
$10.66
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.60
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$36.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.50
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
SHORT ARM SPLINT, ADULT (11+YRS)
|
Facility
|
IP
|
$41.00
|
|
|
Service Code
|
CPT Q4022
|
| Hospital Charge Code |
8204022
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$28.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
SHORT ARM SPLINT, ADULT (11+YRS)
|
Facility
|
IP
|
$41.00
|
|
|
Service Code
|
CPT Q4022
|
| Hospital Charge Code |
8804022
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$28.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
SHORT ARM SPLINT, ADULT (11+YRS)
|
Facility
|
OP
|
$41.00
|
|
|
Service Code
|
CPT Q4022
|
| Hospital Charge Code |
8204022
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$32.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Humana ChoiceCare |
$10.66
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.60
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$36.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.50
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
SHORT ARM SPLINT, PED (0-10 YRS)
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
CPT Q4024
|
| Hospital Charge Code |
8204024
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$16.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Humana ChoiceCare |
$5.20
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.00
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
|
SHORT ARM SPLINT, PED (0-10 YRS)
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
CPT Q4024
|
| Hospital Charge Code |
8804024
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$14.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
|
SHORT ARM SPLINT, PED (0-10 YRS)
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
CPT Q4024
|
| Hospital Charge Code |
8804024
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$16.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Humana ChoiceCare |
$5.20
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.00
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
|
SHORT ARM SPLINT, PED (0-10 YRS)
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
CPT Q4024
|
| Hospital Charge Code |
8204024
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$17.00
|
| Rate for Payer: First Health Commercial |
$18.00
|
| Rate for Payer: First Health Workers Compensation |
$7.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.00
|
| Rate for Payer: GEHA Commercial |
$14.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.00
|
| Rate for Payer: Multiplan All |
$18.20
|
| Rate for Payer: OMNI Networks Commercial |
$14.00
|
| Rate for Payer: One Health Plan PPO/POS |
$18.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.00
|
| Rate for Payer: Three Rivers Provider Network All |
$15.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18.60
|
| Rate for Payer: Zelis Auto |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$5.46
|
|
|
SHORTENING OF HAND TENDON
|
Facility
|
OP
|
$1,202.00
|
|
|
Service Code
|
CPT 26479
|
| Hospital Charge Code |
6126479
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$328.15 |
| Max. Negotiated Rate |
$6,161.78 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,723.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$721.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,723.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,365.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,080.89
|
| Rate for Payer: Cash Price |
$721.20
|
| Rate for Payer: Cash Price |
$721.20
|
| Rate for Payer: Cigna Commercial |
$1,021.70
|
| Rate for Payer: First Health Commercial |
$1,081.80
|
| Rate for Payer: First Health Workers Compensation |
$464.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,081.80
|
| Rate for Payer: GEHA Commercial |
$961.60
|
| Rate for Payer: GEHA Medicare |
$3,080.89
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,081.80
|
| 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 |
$1,392.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,080.89
|
| Rate for Payer: Multiplan All |
$1,093.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,237.51
|
| Rate for Payer: OMNI Networks Commercial |
$841.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,081.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,608.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,392.84
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,080.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,141.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,161.78
|
| Rate for Payer: Three Rivers Provider Network All |
$901.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,019.27
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,392.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,080.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,117.86
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,080.89
|
| Rate for Payer: Zelis Auto |
$480.80
|
| 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 |
$328.15
|
|
